Potential countries for testing eHealth programs

SevagKechichian

We are so grateful for the insights previously shared around potential locations for the competition. We would appreciate your help in curating a “Top 3” and “Bottom 3” based upon our current sorting of potential countries.

The countries below have been prioritized through a quantitative and qualitative analytical approach. The countries listed in the left column have received an endorsement from experts through this online community or in multiple expert interviews. The countries on the right have not been mentioned, however we would like to hear your thoughts on both lists, before eliminating countries from consideration.

We would like to hear your thoughts. Please comment and share your list for a “Top 3” and “Bottom 3” as well as a rationale for why you made your selections. The best comment wins a $100 gift card.

Shashi

Hello @ajchenx, @RahulJindal, @SArora, @ymedan, @CHardaker, @anaconnav, @shamakarkal, @bngejane, @Nvargas2, @JohnParrishSprowl, @biki, @rajpanda, @a1m2r3h4, @jonc101, @marschenrj - Win a gift card by sharing your thoughts on potential countries for testing an eHealth solutions.

ajchenx

India, Bangladesh, Indonesia would be my top 3 places to test ehealth solutions. Larger population, larger impact. also more stable countries providing the security needed.

Shashi

Thanks @ajchenx for sharing your thoughts on the top three countries. It would be great to hear from you the list of bottom three countries as well along with the rational behind it.

Shashi

Hi @tylerbn, @namkugkim, @Shabbir, @Lizzy_2020, @LeeStein, @Riika, @drdavewinkler, @kenjisuzuki, @dpatterson22 and @Ewunate - What according to you would be the top 3 countries from the above list to pilot test a digital health solution? Also which 3 countries we should avoid?

Shabbir

I have a different opinion. Humans are humans no matter in which country they born or living. So I really don't see any logic in prioritising any particular country, and on what basis? The fundamental issues related to the adoption of new technologies in healthcare will be the healthcare system of that particular country we want to introduce digital health. If a country has adequate infrastructure to implement any digital solution we should and must use it.
Another important issue will be the mindset and literacy level of the population if they are open and willing to adopt DH, we have to do it.

Shashi

@Shabbir - Thanks Dr. Shabbir for sharing your thoughts. We welcome diverse points of view. We are considering various criteria's like connectivity, legality, data security etc. to narrow down on the potential countries for this competition.

tylerbn

While countries with more diverse economies like Nigeria, India, Kenya, Ghana, would be where I would make the strongest recommendations - stronger political infrastructure and more of a middle class and growing private sector, which diversifies financing models for trying a new technology. In a country that depends primarily on a single health systems structure, an innovation has to fit into the existing system (i.e. in Rwanda if you can't establish a clear pricing model that will function within the national health insurance scheme, you're unlikely to get a large enough user or patient base to make a new innovation sustainably float).
There is so much saturation in Nigeria, India and Kenya, however, that Ghana stands out to me as an interesting option. Senegal and El Salvador as well.
Stability is critical, and advancement of digital health policies is an important factor to consider.
Rwanda is a strong leader in policy and stability, as well as infrastructure, it is also densely populated, and has a strong level of homogeneity which makes it a good candidate for testing things that are new, though comes with other challenges.

scveena

I would recommend testing in top 3 countries on high priority due to the population density and the large spectrum of social, economic background. Also for the affordability of the advanced technology in urban cities atleast.
Also in these countries, the healthcare policies are getting defined, it make sense to give right inputs to incorporate them into the policy.
Thanks

Shashi

@tylerbn and @scveena - Thanks Tyler and Dr. Veena for sharing insights on this important topic.
Dr. Veena, it would be nice if you could name the countries you feel are of high priority.

Nitesh

Following are my recommendations:
Assumption: Digital health here does not limit to software apps only. It also includes electromechanical tools like breathing support devices (especially in COVID, monitoring tools etc. )
Bias: Even though my recommendations are based on the data and facts but Personal experience of working in some countries and understanding of their healthcare system can influence my recommendations.

1. Rwanda
Reason: A getaway to digital health base intervention in the African region. Government and legal procedures are in place. WHO, WEF and many other international organizations are working in Rwanda to do pilots for Africa. I have a lot of experience in working in the African health system and found that any digital health intervention can here lead to a big impact which is not just an incremental impact but if sustained can save lives at a scale.
2. India
India is 2nd most populist country in the world with one of the lowest health outcomes and limited resources both physical and human resources. India has multiple organizations to design and execute a strong pilot. Pilots in India also becomes a path to the whole of South Asia and with the patient numbers and diversity, it is fast to complete a pilot and prove the efficacy of the intervention.

3. Philippines:
I choose it for the number 3 spot because doing a pilot in the Philippines can give insights about the East Asian healthcare system. It has a fairly clean system and policies in place to implement a digital health system.

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Bottom 3:
Sudan: Corruption and armed conflicts make it difficult to deploy any solution.
Ukraine: Similar corruption and conflicts makes it difficult to implement things operationally.
Sudan: Again operationally it is difficult to roll out something fast and safely to the bottom of the pyramid.

I hope this is useful.

bngejane

Hello @XPRIZE

There you have it, Bill' (Avatar) suggests we choose as follows:
Community Health Workers | Frontline Health
1. Brazil,
2. Liberia,
3. Ethopia,
4. Bangladesh,

Vaccine Delivery
1. Senegal,
2. Zambia,
3. Nepal

See details: https://drive.google.com/file/d/1-gYNkS4xeowfIZd4PPUY6U9H-wfbOHNS/view?usp=sharing

boblf029

I nominate Bolivia, India and Rwanda. Choosing three countries is desirable methodologically because it allows for diversity and the results from studying three very different societies greatly enhance the external validity of the study--assuming the three are very different from one another in theoretically meaningful ways. India in South Asia is on a different continent from the other two, in some ways is highly developed (it possesses nuclear weapons) and in other ways still a developing country in rural areas especially. It is huge in area, and with over a billion people is the second most populous nation in the world. Rwanda in Africa, was formerly a Belgian protectorate, is a developing country that is politically stable and fairly prosperous. Bolivia in South America ,has a population that is mostly indigenous people of Amerindian stock, mainly is dependent on tin, but has prospered. All three countries share an interest in technological improvement. Bolivia modernized its urban transportation in La Paz , for example, with gondolas! A major consideration to my mind is whether you can recruite foreign technical experts to work in the country. Om ,u p[onion recruiting foreign health workers should be fairly easy for these countries. For instance, in India, besides their native languages. large numbers of people speak English, and possibly French, and Portuguese because of the country's colonial heritage In Rwanda, probably French is widely spoken and in Bolivia, probably Spanish is spoken by large numbers of people. The advantage of having French as one of the languages understood is that respected organizations such as Medecins sans Frontieres can work there, The advantage of picking a country where English is widely spoken is that Oxfam an work there and most countries in the world have an intelligentsia that is competent in English. So you can draw from countries other than the United States and still get highly qualified people including Israelis, Germans, Koreans, and Malaysians or Singaporean Chinese etc. Spanish is widely spoken in the United States because it is the language of Puerto Rico. But it is also the language of Spain. And Brazilians may also understand a lot of Spanish because their neighboring countries speak it and it is not too different from Portuguese.

Shashi

Thanks @Nitesh, @bngejane and @boblf029 for sharing insights. All good points.

@Fractalman, @vipat, @DrAhimsa, @DanielaHaluza, @Stefania, @siimsaare, @stepet, @alafiasam, @dokgva, @jda, @ClaireM - Curious if you might have any input on the optimal location to pilot test digital health solution?

addy_kulkarni

Top 3 on the list:

1. India (and Bangladesh):- India possess extreme diversity of healthcare system (out-of-pocket + government + private insurance) with inadequate healthcare infrastructure to suffice the healthcare needs. It accounts for over 2 million+ front line healthcare staff with e-health solution and thus they could be empowered to reach out to resource constrained settings which accounts for more than 50% of the population. India's national health mission policy is well aligned with global SDG and thus offers a nurturing context for new innovations to try, test and scale. As health is a state government's topic of decision, its possible to pilot various forms of e-health solutions in one go. India also offers unprecedented scale, enormous smartphone penetration and decent level of english speaking population.
2. Tanzania:- Tanzania, situated on the eastern side of Africa, is a country faced with major challenges such as poor infrastructure, low education levels, poverty, and diseases exacerbate the extent of these challenges. The bold attempt, in the form of the Millennium Development Goals (MDG) set by the United Nations (UN), to eradicate poverty, mortality, and combat diseases remains important for countries striving to improve the overall state of wellness of their societies. The country has recognized the shortages of health professionals as impacting very negatively on its ability to make progress in achieving health-related MDGs. In an attempt to fill the gap of health professionals, Tanzania has implemented a system of mid-level health workers (MLHWs) in relation to specific health service needs. The Tanzanian health system is decentralized, and framed most explicitly by its National Health Policy. The Tanzanian National Health Policy appears to be driven primarily by the objective to provide access to quality primary health care for all citizens.
3. El Salvador:- El Salvador is in the paradoxical situation of producing a relatively large overall number of health workers, yet not being able to meet population needs within the context of the country’s universal health care coverage and the new national health strategy of comprehensive primary health care. Hence it offers a great scope of e-health innovation unlike most other countries. Primary challenges include: a) Unemployment and under-employment due to overproduction of health workers in certain categories, financial inability of the health sector to recruit, and inequitable distribution of health workers at different levels of service b) A 43% deficit of health workers for primary care services coupled with inequitable geographic, demographic, and institutional distribution of existing resources c) Lack of health workers adequately trained for implementation of the current comprehensive health care strategy based on primary care d) Lack of an information system that allows timely HRH decision-making to solve problems and generate personnel actions oriented to the development and quality of care.

Bottom 3 on the list:

1. Pakistan (and Afghanistan, Nigeria):- These countries are not-so-safe when it comes to implementing healthcare solutions. The local government support will be limited and high level of malpractices adds to the extra trouble. It is advisable to work with support from global developmental agencies to thwart some of these aspects.
2. Rwanda (and Kenya):- Many developmental agencies and global organizations have already tried out various innovations across Rwanda and Kenya. These countries have become a battleground for innovations to secure funding and roll out projects for pilots. I find it bit hard to imagine extra efforts as a part of Xprize competition will help alleviate the situation for better.
3. Nepal (and Bhutan):- Vicinity to India, Bangladesh etc. and similarity in context with these countries takes away an explicit need of testing solutions here. Proven innovations from these huge countries will typically scale in Nepal and Bhutan without much challenges. Both governments are also supportive of innovations from neighbouring countries.

bngejane

Liberia

1. Has had a stressor in the form of an Ebola outbreak, which has helped to accelerate a robust public health system.
2. Makes a solid case for a country with little resources and a rural population.
3. Strong donor management system & a government vision.
4. Has invested in data-driven systems.
5. Has developed its own financial costing and sustainability model that helps government track and study three key variables: potential costs, potential benefits, and potential funding for each program.
6. Has a track record of an iterative approach to public health systems.

bngejane

Ethopia

1. Has some 40,000 trained community health workers.
2. Has a problem-driven approach to program design.
3. Has political leadership that seeks to strengthen its primary health care system.
4. Ethiopia’s strong coordination of donors aligned donors’ traditionally vertical, disease-specific funding with government’s horizontal primary healthcare priorities to address the systemic failure of the health system.
5. Starting with a single province Tigray, they experimented with innovations, tested global best practices locally, and developed frameworks and policies that would eventually guide scaling.
6. Has shown a commitment to program evaluation and adaptation.

bngejane

Bangladesh

1. Has some 130 000 community health workers, serving a 100 m rural population.
2. Uses data to ensure their CHW programming has responded to clearly identified health challenges.
3. Leverages of icddr,b, (an international research organisation). The organization’s Matlab—the longest-running demographic surveillance site in the Global South—continuously experiments, thoroughly tests innovations, and heavily informs and influences government and NGO policies and programs.
4. Sustained political will for over 50 years.
5. Leverages of the robust NGO sector and its resources.
6. Commitment to evaluation and adaptation including community ownership.

bngejane

Thank you @SevagKechichian @Nitesh @boblf029 @Fractalman, @vipat, @DrAhimsa, @DanielaHaluza, @Stefania, @siimsaare, @stepet, @alafiasam, @dokgva, @jda, @ClaireM - for your insights.

Brazil

1. Has the largest public health program in the world with some 238 000 health workers.
2. It's health care system is largely fragmented and decentralised.
3. The community health system is a gateway to broader wellbeing and government social services.
4. It's primary health care program is a result of a Heath Research from the 80s which aligns with its Constitution of 1988 and a has a strong coalition with union leaders, democracy activists, health professionals, and anti-poverty campaigners.
5. Has a Universal Health System and its healthcare is decentralised.
6. Leverages of Innovative Funding Models.
7. Has developed a robust Family Health Strategy.
8. Once a month CHWs visit the 100–150 households they serve to educate patients on best health and hygiene practices, encourage health-seeking behaviour and preventive care, follow up with sick patients after medical appointments, and help address challenges in accessing other government services.

bngejane

@SevagKechichian @Nitesh @boblf029 @Fractalman, @vipat, @DrAhimsa, @DanielaHaluza, @Stefania, @siimsaare, @stepet, @alafiasam, @dokgva, @jda, @ClaireM- kindly note that:

According to Wikipedia "The population of Brazil is very diverse, comprising many races and ethnic groups. In general, Brazilians trace their origins from three sources: Europeans, Amerindians and Africans. Historically, Brazil has experienced large degrees of ethnic and racial admixture, assimilation of cultures and syncretism. The Brazilian population is said to be one of the most mixed in the world".

bngejane

Demographics

@SevagKechichian @Nitesh @boblf029 @Fractalman, @vipat, @DrAhimsa, @DanielaHaluza, @Stefania, @siimsaare, @stepet, @alafiasam, @dokgva, @jda, @ClaireM

1. Brazil_has an urbanisation rate of 86.57% from a 209 million population_and an 8.5m sq km landmass.
2. Liberia_has an urbanisation rate of 51.62% from a 4,8 million population_and a 100k sq km landmass.
3. Ethiopia_has an urbanisation rate of 21.22% from a 109,2 million population_and a 1.1m sq km landmass.
4. Bangladesh_has an urbanisation rate of 36.63% from a 161,4 million population_and a 147k sq landmass.

bngejane

Top 3, in that order:

1. Brazil
2. Bangladesh
3. Ethiopia

Bottom 3 in no particular order:

1. Zimbabwe
2. Siera leone
3. Sudan

*All due to political and security concerns.

dollendorf

Hello, while some considerations will likely vary based on the type of eHealth intervention being considered, here is my top 3 list along with rationale (interestingly, they are all on your "need more information list"):
1. Tunisia: the only country on the African continent with a formalized agency to assess the clinical benefit and cost-effectiveness of new health interventions, reasonably stable and secure governance on international indices, a smaller country with a well-coordinated health system that would make a useful testbed.
2. Vietnam: also a formalized approach to health technology assessment (HTA) within the ministry of health, a well-coordinated health system and communications infrastructure, and a reasonably stable economy and political environment.
3. Egypt: while a bit less stable politically, a robust infrastructure to assess the economic impact of new health interventions, a mature research enterprise to conduct such evaluations, and reasonable economic and communications infrastructure.

My bottom 3, in no particular order (although it was hard to pick 3 given instabilities with many of them):
1. Phillipines: unstable government with demonstrated lack of willingness to thoughtfully consider population-health interventions.
2. Pakistan: concerns with government stability, large country with poor communications infrastructure and many rural areas not reachable by devices.
3. Niger: government stability concerns, political unrest, residual crime and terrorism issues. Concerns exacerbated because of border with Chad, where things are even worse.

SArora

India, Kenya, and the Philippines
Project ECHO is already in many of these countries, but if narrowing this list down to three countries most ready for the adoption and scaling of ehealth initiatives, there are a few questions to consider:
Is the public sector in the country ripe for collaboration and for the adoption of ehealth? To scale across a country and bring access to quality healthcare to rural and underserved communities, it takes engaging the public sector. What does the technology infrastructure look like? What does cell phone penetration look like? Are these countries with both large need and populations? We want to maximize impact.
If Project ECHO is to reach its goal of helping 1 billion people by 2025, we will need to focus on geographies where there’s both need and population - with this in mind, India and Africa, in general, are major priorities for us.
In 2019, ECHO India (Project ECHO’s India operation) signed an MoU with MoHFW to enable National Programs, National Institutes and Hospitals under Ministry of Health and Family Welfare to further benefit from using the ECHO Model. With COVID alone, we have trained over 300,000 clinicians across India using the ECHO Model. This was only made possible by partnering with the public sector. The point being, any country chosen needs to be ripe for public private partnership (PPP) in digital health. Engaging Ministries of Health / the public sector is critical to increasing access to health care for underserved and rural communities.
Kenya is both a hotbed of social entrepreneurship, and a country with a tradition of tech innovation, which makes it a good choice, similar to India, but on the African continent. We feel it’s important to have at least one country of the three be in Africa. With the need for access to quality healthcare across the continent, Kenya could serve as a pilot or model to scale across the African continent.
The Philippines is also a country ready for collaboration and adoption of digital health. As a country with over 7,000 islands, they have always been early adopters of technology, out of necessity.
Our strategy is to partner with local partners on the ground, and engage the public sector. By doing so, we can achieve widespread adoption more efficiently and in a way that considers the cultural context.

joshnesbit

I'm not sure I understand the proposed/referenced benefits of restricting this challenge to a particular country or small set of countries. It's difficult to weigh in on "optimal" countries or regions or partner institutions (including governments) without the challenge being set... "Where would you propose attempting [some specific and important thing] initially, and why?" is a different question than, "Where should we run a competition?" Also seems unwise to restrict to a country without real and early collaboration with that country's government, including citizens or government leaders helping to define the challenge. Health inequities within countries are larger than inequities across countries, and we may lose (participants, ideas, impact) more than we gain by restricting the challenge in this way. The Frontline Health idea summary says "everyone, everywhere"; I'd open this up and not restrict the challenge in this way.

paulauerbach

I am commenting on countries with which I or trusted friends have experience and where I might be able to assist the winner in making connections. My top choice is Nepal, because (1) it has proven to be resilient, (2) it has a reasonable technology expertise and medical infrastructure, (3) it is a popular destination, particularly for young people, (4) it has a technology-focused disapora, and (5) it has sufficient government obstacles to prove out what will be necessary to accomplish something significant in a struggling country. Rwanda is an interesting choice - terrific because it has some of the best (culturally) that Africa has to offer, but not so good once you dig down into the egotistical behaviors of certain ministry officials. A different approach might be to partner an impoverished nation with a wealthy and well-organized nation, a "sisters country"- sort of method. In that case, Germany, the U.K., or the U.S. could partner with Nepal. Ethiopia seems to be on a path to significant health improvement and would likely work hard to be a decent partner. Bhutan has geographic diversity and wealth disparities, but might be considered too well off to qualify as sufficiently needy for this prize.

Shashi

Thanks @addy_kulkarni, @bngejane, @dollendorf, @SArora, @joshnesbit, @paulauerbach for sharing detailed insights. We highly appreciate your contributions.

Hello @creativiti, @namkugkim, @Haruyo, @barati, @poppyfarrow, @dzera @msrjoy, @gajewski, @andwhite, @angelfoster, @acowlagi, @Sujana - Curious if you might have any input on the best locations to pilot test digital health solution? Any items that jump out at you as key things to explore?

Shashi

Following is the copy-paste from an email sent by Martha on this discussion:

Hi Shashi -

I would go with Indonesia, the Philippines, and Uganda. All have strong national health systems.
Kenya is problematic in that the health system is run by the states. India too big, complex.
Hope this is helpful.

Martha

supratik12

I would go with India, Congo, Kenya

supratik12

I would go with a country with dual benefits: one is to measure the impact on national health. The other is to measure the impact of the deployment on the prevention of possible future pandemic. For this reason Congo is one of my candidates

rajpanda

I would go with India, Nepal ( BANGLADESH) and Indonesia:
1) diverse populations, good penetration of MOBILE HEALTH (m health) and possibility of adding and building on exiting work in the digital health in these countries
2) good record of large number of community health workers and front line health providers
3) interest in using technology for UHC
4) Need based as large parts of countries are still inaccessible for good quality health care that would require tele mentoring , capacity building , tele health and basic digital platform
5) comprehensive digital platforms can target both MCH services as well as the new epidemics of NCDs.
5) Most important point is to have academic collaboration to test adequacy and feasibility before rolling out large programs and testing with costly experimental designs
6) final justification is if you can do multi site country evaluation and establish proof proof of concept they can be expanded anywhere and tested fro effectiveness. The lack of robust evaluation designs and empirical data with costing data is often the make and break in such experiments so would request to integrate this into the testing of the pilots by independent bodies