The development of the South African ehealth Strategy assessed against the recommendations of the WHO/ITU ehealth Strategy Toolkit

Transcription

1 The development of the South African ehealth Strategy aeed againt the recommendation of the WHO/ITU ehealth Strategy Toolkit Roemary Foter PhD a,b a ehealth Strategy and Policy Diviion, Medical Reearch Council, South Africa b Faculty of Engineering and the Built Environment and Information Technology, Nelon Mandela Metropolitan Univerity Abtract Purpoe: The purpoe of thi review i to etablih the extent to which procee followed in the development of the South African ehealth Strategy conform to the recommendation provided in the National ehealth Strategy Toolkit publihed by the World Health Organiation (WHO) and the International Telecommunication Union (ITU) in. Method: For each of the tep recommended by the Toolkit, the procee followed in the development of the South African ehealth Strategy are rated againt the recommended procee. Reult: Overall, the procee followed in the development of the South African ehealth Strategy conform well to the recommended procee. Weaknee were found with repect to management and reourcing of the development proce and the engagement of multiectoral takeholder. Keyword: ehealth, ehealth trategy, ehealth trategy toolkit, ehealth viion, ehealth planning, health information ytem Introduction The word trategy wa originally ued to decribe the art of planning and directing high-level military operation and movement in a war or battle. Simply put, a trategy i nothing more than a high-level plan to achieve one or more goal within the context of given contraint. [] The word trategy i now applied in all phere of life and ha come to be broadly ued in two way: to decribe a high level plan or to decribe a hybrid that i a high level plan combined with a framework for implementation. In the development of country ehealth trategie, the word i ued in both way. For example the Scottih ehealth Strategy (-7) i a high level document that focue on the benefit and outcome experienced by the people of Scotland flowing from ehealth enabled ervice re-deign and quality improvement.[] The Autralian ehealth Strategy publihed in 8 wa a much longer document, including a detailed definition of the propoed ehealth architecture model. [3] The term ehealth blueprint, ehealth trategic framework or ehealth trategic plan tend to be ued when the plan goe into ome detail regarding the realization of the trategy, e.g. Ontario ehealth Blueprint. [4] The National ehealth Strategy Toolkit publihed in by the World Health Organiation (WHO) and the International Telecommunication Union (ITU) [5] eek to provide a practical guide for government, their relevant minitrie and department for the development of a national ehealth viion, action plan and monitoring framework. Although it i called an ehealth Strategy Toolkit, the Toolkit doe not guide it uer toward the creation of a eparate document called an ehealth trategy. The Toolkit i deigned in three part, with Part and 3 building progreively on the output of Part : Part : Etablihing a national ehealth viion. Part. Developing a national ehealth action plan. Part 3. Developing a plan for monitoring and evaluation of implementation of the action plan. The ue of the word viion in the Toolkit may be mileading to thoe intending to apply the guideline. Textbook methodologie for trategy development include the development of a miion tatement and a viion tatement which hould decribe in a few word what the organiation i doing and why. According to the Toolkit, the national ehealth viion to be etablihed through Part i much broader than a viion tatement and hould anwer the following quetion: Why doe the country need a national approach to ehealth? What will a national ehealth plan achieve? What are the component required in order to achieve the deired outcome? Thee are the anwer that countrie eek to addre when they et about developing a high-level plan or trategy for ehealth. For the purpoe of thi review, it will therefore be aumed that Part provide guideline for the development of a national ehealth trategy or high-level plan, which the Toolkit ha called a viion. Part, an action plan decribing the comprehenive et of activitie, required reource and trategic phae for implementing the national ehealth viion, i equivalent to a plan for the realization of a national ehealth trategy. Thi paper examine the procee followed and the output produced in the development of the South African ehealth Strategy 6 [6] in order to determine the extent to which thee conform to the guideline provided in Part of the Toolkit. Part provide guidance on developing a national ehealth trategy that repond to health and development goal. The trategy hould be developed through an iterative approach to enure that it i grounded in the current context. Nine tep are recommended:

2 . Managing the proce The proce hould have a clear plan with well-defined governance mechanim for conultation, communication and approval. In addition, a core team with ufficient technical knowledge, analytical ability and communication kill hould be engaged.. Engaging with takeholder The involvement of a range of multiectoral takeholder hould be enured in order to gain perpective on what ehealth i expected to deliver in the country. Engagement with takeholder hould be continued throughout the entire trategy development proce. 3. Etablihing trategic context The trategic context mut be etablihed early on in order to identify the goal and challenge of the health ytem, epecially thoe that ehealth can help to addre. Broader ocial and development goal hould alo be taken into account. 4. Learning from trend and experience It i recommended that time i inveted in reearching the ehealth uccee and failure of other countrie in order to undertand trend and bet practice. In addition, reearch mut be done to identify available technologie, potential outcome that can be achieved and the challenge and rik that hould be taken into account in planning. 5. Drafting initial trategy Once the trategic context ha been defined and trend and experience have been reviewed, an uncontrained trategy hould be drafted expreing an ideal national ehealth environment. Thi will include a comprehenive view of opportunitie that can be purued in future and will give an indication of the degree of change that will be required in order to develop the ehealth environment. 6. Identifying required component Building block that will be required in order to deliver on the goal of the trategy mut be identified. The Toolkit include even component that hould be addreed. 7. Gathering information on ehealth environment Information mut be collected to determine to what extent the building block referred to above already exit, can be re-ued or expanded. 8. Aeing opportunitie and gap The gap between what i required and what already exit mut be decribed o that opportunitie for re-ue or haring can be identified and the gap can be addreed. Rik and barrier hould alo be identified at thi tage. 9. Refining trategy and develop recommendation The initial trategy i refined baed on the output of tep 6, 7 and 8. A et of recommendation i developed which i ued to develop the action plan (covered in Part ). Thi tage alo include endorement of the trategy and it communication to the broader takeholder community. When the Toolkit wa publihed, the proce for development of the ehealth Strategy for South Africa wa already at the tage where endorement wa being ought. The purpoe of thi review i to etablih to what extent the procee followed in the development of the South African ehealth Strategy conform to the recommendation provided in the Toolkit. Material and Method Thi review will go through the nine tep recommended by the Toolkit and compare the activitie and output recommended in thee to the procee followed in the development of the South African ehealth Strategy. The author, a a member of the core team that developed the trategy, ha rated element within each recommended tep from to, where indicate Wa not done, indicate Wa partially done and indicate Wa done. Explanatory comment are added for each element and, where applicable, the relevant ection of the trategy document are referred to. Reult Step : Managing the proce. Element High-level health ector leaderhip and upport Appropriate governance tructure and mechanim Multi-diciplinary project team with requiite kill and expertie Agreed timeline and reource for completing the work Rating The proce benefited from the ongoing upport of the chairperon of the National Health Information Sytem South Africa (NHISSA) Committee who alo kept the leaderhip appried of the proce. However, a NHISSA only meet quarterly there were extended period without engagement. There wa no formalized governance tructure and mechanim put in place pecifically for thi proce. Regular progre report were made to the NHISSA Committee. The proce benefited from input from ehealth ubject matter expert. The development of the trategy wa not project-baed but had acce to a mall but capable core team with health ytem and public health expertie a well a a broad knowledge of ehealth and ICT. There wa no project plan and therefore no agreed timeline for the work. No budget or other reource were aigned for the proce. Step : Engaging with takeholder Clarify the role of government in national ehealth development The development of the trategy wa directed by government. A thi wa the country firt ehealth trategy, the deciion wa made to limit the cope to the public-ector in order etablih a trong national framework on which to build more incluive trategie in future.

3 Identify takeholder group that need to be involved Develop approach to managing thee group Define and communicate point of conultation The development of the trategy did not include a broad takeholder group. However, the NHISSA Committee include relevant takeholder from within the public-ector and input into the trategy wa olicited from them a well a from manager within the national Department of Health. No pecific approach wa developed. No pecific conultation point were defined. upport thee goal and challenge enable and upport ervice delivery intervention were identified and decribed. Step 4: Learning from trend and experience Reearch national ehealth viion, trategie and programme Reearch international ehealth trend, bet practice and outcome Reearch wa done in order to learn about ehealth trategie and programme in other countrie. Reearch wa done in order to learn about ehealth trend, bet practice and outcome in other countrie. Step 3: Etablihing trategic context Reearch population health and demographic Decribe the health ytem Review national health trategy, goal and prioritie Identify economic and ocial development goal relevant to health Identify work already done on trategie for ehealth, ICT and HIS Identify the trategic goal and challenge mot directly affected by the ehealth viion Decribe how a national ehealth environment can Thi wa done to ome extent and i reflected in Section 5: ehealth contribution to NDoH trategic aim. Thi wa done to ome extent and touched on throughout the document. A review of the national health trategy a expreed in the Negotiated Service Delivery Agreement -4 (NSDA) [7] and the Point Plan for 9-4 [8] wa done. Although the document take into account the health context in South Africa, it doe not identify relevant economic and ocial development. The proce took into account previou attempt to develop an ehealth trategy and alo the National Healthcare Management Information Sytem (NHC/MIS) drawn up in 994. Each ervice delivery intervention identified in the Negotiated Service Delivery Agreement -4 (NSDA) and the Point Plan for 9-4 wa aeed in order to identify opportunitie where ehealth could enable and upport the intervention. Opportunitie where ehealth could Step 5: Drafting an initial viion Agree time horizon for the ehealth trategy Define deired ehealth outcome baed on health goal and challenge Decribe rationale for each outcome ought; link outcome to the trategic context Develop an initial viion tatement Decribe what delivering the national ehealth viion will mean for the takeholder Develop one or more cenario that put ehealth viion in practice Target delivery date were included, aligned with the NSDA and Point Plan. The deired ehealth outcome were defined within the country context. The deired ehealth outcome were linked to the health ytem goal. An initial viion tatement, linked to the health viion, i articulated. It i ehealth: enabling a long and healthy life for all South African. The viion tatement of the national Department of Health a expreed in the NSDA i A long and healthy life for all South African. Thi i done to ome extent and reflected in Section 5.3: Leveraging ehealth to upport NDoH trategic aim. Specific initiative are referred to, e.g. the propoed National Health Inurance Scheme. Opportunitie where ehealth could enable and upport ervice delivery intervention of the NSDA and the Point Plan were identified and decribed.

4 Step 6: Identify required component Leaderhip and governance Strategy and invetment Service and application Identified within Strategic Priority : Strategy and Leaderhip. Identified within Strategic Priority : Strategy and Leaderhip. Invetment, Affordability and Sutainability. ehealth Foundation. Identified within Strategic Priority 9: Application and Tool to upport Healthcare Delivery. Infratructure ehealth Foundation. Standard and interoperability Legilation, policy and compliance Identified within Strategic Priority 3: Standard and Interoperability. Workforce Identified within Strategic Priority 7: Capacity and Workforce. Step 7: Gather information on the ehealth environment Leaderhip and governance Strategy and invetment Service and application in Section 4.: Structural, Policy and Legilative Context. Identified within Strategic Priority : Strategy and Leaderhip. in Section 4.: The requirement for a National ehealth Strategy and in Section 4.3: ehealth funding and expenditure. Identified within Strategic Priority : Strategy and Leaderhip. Invetment, Affordability and Sutainability. in Section 4.6: Telemedicine, Section 4.7: mhealth, Section 4.4: Notable current initiative in ehealth. ehealth Foundation. Identified within Strategic Priority 9: Application and Tool to upport Healthcare Delivery. Infratructure in Section 4.4: ehealth Maturity, Section 4.5: NHC/MIS and Section 4.3: ehealth funding and expenditure. ehealth Foundation. Standard and interoperability Legilation, policy and compliance in Section 4.8: ehealth Standard. Identified within Strategic Priority 3: Standard and Interoperability. in Section 4.9: Policie and Regulation affecting ehealth. Workforce in Section 4.: ehealth Capacity Building, Section 4.: ehealth Aociation and Conference. Identified within Strategic Priority 7: Capacity and Workforce. Step 8: Ae opportunitie and gap Leaderhip and governance Strategy and invetment Service and application Strategic Priority : Strategy and Leaderhip. Strategic Priority 4: Governance and Regulation. Strategic Priority : Strategy and Leaderhip. Strategic Priority 4: Invetment, Affordability and Sutainability.

5 Infratructure Standard and interoperability Legilation, poli- cy and compli- ance Workforce Strategic Priority 8: ehealth Founopportunitie dation. Activitie to leverage Strategic Priority 9: Application and Tool to upport Healthcare Delivery. Strategic Priority 8: ehealth Foun- dation. Strategic Priority 3: Standard andd Interoperability. Strategic Priority 4: Governance and Regulation. Strategic Priority 7: Capacity and Workforce. ment and publih The trategy wa preented to the ehealth trategy National Health Council which, chaired by the Miniter of Health, conit of the leaderhip of the National Department of Health. The trategy wa igned by the Miniter of Health and the Director General of the Department of Health. The core for each tep were addedd and the compari- followed by the South African ehealth Strategy team i on between the recommendation and the procee graphically diplayed in Figure. Refining trategy and Aeing opportunitie Gathering information Identifying required Drafting initial trategy Learning fromm trend and Etablihing trategic Engaging with Managingg the proce 5 5 Step 9: Refine the trategy and develop recommen- dation Element Rating Adjut cope and focu Refinee initial vi- recom- ion Develop mendation Gain endore- Opportunitie identified for ehealth to upport and enablee healthcare ervice delivery intervention weree orted into three group of objec- exit tive:. Build on what. New and extended work requiring ignificant pro curement and implemen further planning i equired tation 3. Work for which The initial draft trategy wa re- wa achiev-- able in the hort, medium and long term. In addition, ten priority area were identified in order to facilitatee the coordination of effort and in- fined in term of whatt vetment. The recommendation are grouped within the ten priority area and key activitie with clear output and target date are identified. Toolkitt Guideline SA ehealth Strategy Figure. Comparion of South African procee and Toolkit recommendation Dicuion n Managing thee proce Low compliance (37.5%) with the Toolkit recommenda- core tion wa recorded here. Although a competent team worked on development of the ehealth trategy, there wa no formal plan n or reourcee allocation for the proce. Governance wa limited to the overight role played by the National Health Information Sytem South Africa (NHISSA) Committee. The NHISSA Committee conit of enior manager in the National Department of Health reponible for health information, monitoring and evaluation, epidemiology, and reearch; enior manager reponible forr imilar function in the prov- and ince, and invited repreentative from partner other organiation. Thee NHISSA Committee meet quarterly and report to thee Director-General of Health. Engaging with takeholder Low compliance (37.5%) with the Toolkit recommenda- en- tion wa aloo recorded with repect to takeholder gagement. A range of multiectoral takeholder wa not involved a the deciion wa taken to focu the cope of thi firt national ehealth trategy only on the public-ector. 83% of the population ha no medical in- for urance [9] and a i dependent on the public-ector health ervice. Etablihing the neceary ehealth foundation inn the public-ector wa therefore een a a

6 priority. Although input from multiectoral takeholder could have been beneficial to development of the trategy, previou effort to involve a broader group in trategic planning for ehealth had not reulted in much ucce. Thi could due to the lack of a dedicated, wellreourced tructure to manage the proce. Etablihing trategic context Although compliance with the Toolkit recommendation wa fairly good (7%), the South African ehealth trategy doe not identify relevant economic and ocial development or include thee in the trategic context. The goal and challenge of the health ytem were taken into account, although thee could have been addreed in more depth. Learning from trend and experience Compliance wa %. Reearch wa done in order to learn about ehealth trategie, programme, trend, bet practice and outcome in other countrie. The ten trategic prioritie were informed by leon learned a well a the challenge and rik that had been identified in thi reearch. Drafting initial trategy Compliance wa 9%. An uncontrained trategy wa drafted, expreing an ideal national ehealth environment within the given contraint. The initial draft pragmatically included three level of opportunitie, expreed a objective: Building on what exit, new or extended work, and work that could be planned for in the future. The trategy articulated the change that would be required to develop the South African ehealth environment from the current tatu quo. Due to limited takeholder involvement, it did not adequately decribe what delivering the national ehealth viion mean for takeholder. Identifying required component Compliance wa % and building block eential for the delivery of the goal of the trategy were clearly identified. All even component were addreed. Gathering information on ehealth environment Although compliance wa %, only high-level information wa collected to determine to what extent the building block referred to above already exited, could be re-ued or expanded. Thi i becaue the procee decribed in thi tep of the Toolkit are identified in the South African Strategy a part of developing the neceary component for an Enterprie Architecture for health. Thi i one of the key future activitie lited under the Strategic Priority : Strategy and Leaderhip. Aeing opportunitie and gap Although compliance wa %, opportunitie and gap were only identified on a high level. A tated above, the procee decribed in thi tep are identified a part of developing the neceary component for an Enterprie Architecture for health. Thi i one of the key future activitie lited under the Strategic Priority : Strategy and Leaderhip. Refining trategy and develop recommendation Compliance wa %. The initial trategy wa refined baed on the output of tep 6, 7 and 8. The et of recommendation i decribed in Section 7: ehealth Roadmap and delivery on the ehealth Strategy. Although a full core ha been given for thi tep, the Roadmap include a comprehenive lit of key activitie with pecific output and target date. While it i neceary to fix a broad time horizon for a trategy, thi level of detailed planning would be better placed in the ehealth Action Plan that hould now be developed, uing the trategy a input. The trategy wa fully endored by the Miniter and the leaderhip of the Department of Health and publihed on the Departmental webite for public conumption. Concluion It i important to reolve the emantic around ehealth trategie. I a trategy a viion or a imply another word for a high-level plan that include a miion and a viion tatement? The author make the aumption that the ehealth Viion referred to by the Toolkit i eentially the ame a a trategy or high-level plan for national ehealth. While the procee followed in the development of the South African ehealth Strategy generally conformed well to the guideline provided in the Toolkit, there were weaknee noted epecially in the way the work wa managed and the limited incluion of multiectoral takeholder. Although a % core wa aigned for data gathering and analyi of information in order to provide the context for the trategy, the depth, relevance and quality of thi work cannot be aeed in a review of thi nature. Thi alo applie to the reearch into global experience, trend and bet practice. The South African ehealth Strategy contain a Roadmap ection in which key future activitie are outlined and outcome are given target date. Given the definition of a trategy a a high-level plan, thi ection i better placed in the ehealth Action Plan and not in the trategy document. The South African ehealth Strategy 6 can therefore be regarded a a hybrid that i both a high-level plan and a partial implementation plan. The fact that the completion date for many of the activitie have paed before the activitie have been initiated underline the need to keep thi level of detail out of a country trategy. Some of the procee decribed in the Toolkit are part of developing the neceary component for an Enterprie Architecture for health. Thi work could ubtantially delay progre in development of the trategy and it i recommended that a high level approach i followed with the Enterprie Architecture work featuring a a high priority in the Action Plan. Reference [] Definition of trategy. [5 April 3] [] The econd ehealth Strategy for NHS Scotland pdf [6 June 3] [3] Autralian National E-health Strategy, 8. Content/64CF66BE48789DCA575DC5C7/$File

7 /National%eHealth%Strategy%final.pdf [6 June 3] [4] Ontario ehealth Blueprint. ehealth Ontario webite. [ 6 June 3] [5] World Health Organiation and International Telecommunication Union.. National ehealth Strategy Toolkit. [5 April 3] [6] National Department of Health, South Africa.. ehealth Strategy South Africa Strategy_South_Africa_-6.pdf [5 April 3] [7] National Department of Health, South Africa. Negotiated Service Delivery Agreement for Outcome : A long and Health Life for All South African.. /Home/Minitrie/DepartmentofPerformanceMonitori ngandevaluation3/theoutcomeapproach/health%sector% NSDA.pdf [5 April 3] [8] National Department of Health, South Africa. Strategic Plan /-/3. /D5ED79-878C A96BBB6/394.pdf [5 April 3] [9] Health Sytem Trut, Health Indicator Reource. [5 April 3] Addre for correpondence Dr Roemary Foter foter.ehealth@gmail.com