Key Points in Kenya’s new e-Health Strategy

During the month of August 2011, one of the many developments in the national Health and ICT scene was the launch of Kenya\’s National e-Health Strategy 2011-2017. The vision of the strategy is “To develop efficient, accessible, equitable, secure and consumer friendly health care services enabled by ICT”. The strategy also outlines a mission to “promote and deliver efficient healthcare services to Kenyans and consumers beyond our borders, using ICT”.

Hon. Peter Anyang Ngong\’o – Kenya\’s Minister for Medical Services officially launched the strategy on 11th August 2011.

Hon. Peter Anyang\’ Nyongo – Kenya\’s Minister for Medical Services

Calling for a paradigm shift

The newly launched strategy seeks to set in motion a process of compensating for the shortage of skilled health care professionals by harnessing ICT for improved healthcare delivery. It also aims to tap into the latent capacity of healthcare consumers to play an active role in the protection and management of their personal health. The strategy also leverages the imperative for the government to provide quality healthcare for all its citizens to build a nation with increased economic and social productivity.

These underlying themes constitute a requisite mindset to begin addressing the failures of the country\’s National Health Sector Strategic Plan – NHSSP I (1999 – 2004) and NHSSP II (2005 – 2010).

The Real Challenges

Challenges of the health care sector in Kenya are highlighted for attention in the strategy are

• A shortage of healthcare professionals   
• Emerging threats to public heath such as H1N1 ad H5N1 flu
• Expectation of equality in service deliver among rural and urban populations
• Silos of care resulting in duplication and difficulties for national health management     information systems
• Inadequate health infrastructure and equipment

Strategic areas of intervention

To address the above challenges the strategy isolates five key areas of intervention forming a five pillar conceptual framework approach as follows:

1. Telemedicine
2. Health Information Systems
3. Information for citizens
4. mHealth
5. eLearning

Although the document does not take time to elaborate specific roles and expectations for these pillars in the conceptual framework, the strategy acknowledges that the pillar will include technology service overlaps and that interventions might cut across pillars.

Implementation

Stakeholders involved in development of the strategy prioritised the Health Information Systems Pillar for implementation. Indeed this is a clever move because it targets to build on progress made by the Ministry of Health’s division of health information systems to access some low hanging fruits. Arguably it appears to be a politically clever move to focus the Division of eHealth and Continuous Professional Development (CPD) and the Division of Health Information systems on the same objectives.

The Health Information Systems pillar was further subdivided for implementation in the strategy into various functional domains as  follows :-

• Patient Centric Information
• Pharmacy and Medical Supply Chain Information System
• Financial Information, including insurance and payments
• Health Workforce Management and Training
• Regulation

Curiously, this subdivision of functional domains seems to relegate health management information systems (HMIS) in which significant progress has been achieved with the ongoing national roll-out of DHIS2 (username and password available from HIS division).

One more notable inclusion in the strategy is a phase to design the Enterprise Architecture for e-Health Strategy implementation. Depending on how well this is done, persistent concerns among stakeholders such as effort replication, implementation silos and unproductive undercurrents on tools selection should be a thing of the past.

The strategy was developed by the Ministry of Medical services in conjunction with the Ministry of Public Health and Sanitation and with the support of the World Bank Country Office. There also seems to have been a fair attempt to make the strategy development participatory. This was championed by Dr. Esther Ogara, Head of the eHealth and CPD division. Listed contributors to the strategy included physicians, pharmacists, ICT experts, supply chain experts, economists and development workers.

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Child Count for A growing mHealth scene in Kenya

As the pivot25 competition progresses,  I have been getting curious over the nature of applications coming up in the category for mHealth. I thought to myself that perhaps an analysis of locally existing albeit underutilised mHealth applications will help to manage my curiosity.

Useful perspective

For some reason a lot of my last 8 years was spent working on information systems to improve community based health services. It is a shame that I did not get myself interested enough in SMS based data collection platforms for health service delivery  until recently. Earlier in the year, while reading through @mberg\’s blog post I was even surprised by a prediction to see a lot less discussion about the differences in particular platforms (CommCare, ChildCount+, FrontlineSMS:Medic, Mwana, MoTeCH). I could be excused for my apparently slow uptake of these tools because the Kenyan Health IT scene to which I vainly contributed has over the years been mark-timing. The apparent stalling of Health IT in Kenya seems to be caused by a 7+ year old inconclusive debate of which tools are best for electronic medical records (EMR) systems.

First encounter

Great initiatives like ChildCount have a way of eventually popping up the stack despite being implemented with muted marketing effort. I first heard about ChildCount in one of the annual OpenMRS meetings. I was not only impressed that ChildCount seamlessly integrates with OpenMRS for its master database. The SMS based platform impressed me further with its easy application in Kenya’s remote areas empowering communities to improve child survival and maternal health.

How it works

ChildCount uses  uses SMS text messages to facilitate and coordinate the activities of community health care workers (CHWs). CHWs are community based health care providers. Any standard phone can be used by CHWs to register patients and report their health status to a central web dashboard for as long as there is a slight mobile carrier signal. The system supports messaging features for communication between members of the health service provision system alongside an automated alert system which all combine to reduce gaps in treatment for local communities. By providing a central web dashboard with information based on the processed SMS messages, ChildCount also provides a real-time view of health of in a community.

The new improved ChildCount+ works slightly differently from the initial deployment but the overall approach remains fundamentally the same.

A combination of noble efforts

The ChildCount platform is developed by the Earth Institute in collaboration with the UNICEF Innovation Team for the Millennium Villages Project. ChildCount is now free and open-source software available under the GPL License. It is build on yet another open source framework – RapidSMS. An important provision of phone handsets for CHWs to initially launch the service was facilitated by Sony Ericsson in early 2009. Airtel Kenya, then known as Zain also assisted in setting up a toll free number for the project . The project has also benefited from having in its team Matt Berg, as its Technology Director. Matt was in the 2010 list of Time’s top 100 influential people of the world

Deployments

Like many other open-source platforms, it is difficult to know how many installations of ChildCount exist across the globe. For sure though, after interacting with some good people at the millenium villages project like Maurice Baraza, I know that ChildCount is instrumental to their exemplary service delivery at their project in Sauri in Kenya’s Siaya County. At Sauri, the project covers over 65,000 people  with child and maternal health care services. They have also deployed the system at the Dertu millenium village project in Kenya’s Garissa County.

In the larger East Africa, ChildCount is deployed in at least one millennium village in Tanzania. In regional health informatics circles, word has it that the Rwanda government is considering a national deployment of ChildCount to support its community based health service delivery system. This does not come in as a surprise as the Rwanda government has recently been a regional leader in taking up ICT to improve its service delivery with more action than speak.

Less speak for more action

More information on ChildCount can be found on the project’s website. This pdf report might be useful for those wishing to dig deeper into the rationale behind the project and its initial success as a pilot. It should interest local mobile application developers and mHealth enthusiasts to consider building on ChildCount’s successes as they seek to further innovate mobile solutions in health services. RapidAndroid is definitely a natural platform to look at in keeping this innovation wheel spinning. We can only hope that pivot25, the Android Developer Challenge and other developer competitions will spur innovation in this direction. I shall leave readers with a video of the health care service delivery works going on at Sauri Millenium Village that I found useful

Time to Comply with EMR Systems Standards and Guidelines in Kenya

A week ago I wrote about the then imminent launch of the Standards and Guidelines for electronic medical record systems in Kenya. The document was signed by both the Director of Medical Services (Dr. Francis M. Kimani) and the Director of Public Health and Sanitation (Dr. Shahnaz Kassam Shari). Another week has passed and the document has since been officially launched. It was the Director of Medical Services who launched the document on 3rd November at the Kenyatta International Conference Center on behalf of the Government of Kenya.

It has been argued that the existence of two Ministries of Health in Kenya has not been worked well for the country. However, it should be reassuring to note that the document is a product of collaborative efforts between the Ministry of Medical Services and the Ministry of Public Health and Sanitation. National AIDS and STI Control Program (NASCOP) which is placed in the Public Health and Sanitation Ministry was a key contributor to the document’s development. The Division of Health Information Systems (HIS) has been the leader of the effort as it pursues its vision to “Be a centre of excellence for quality health and health-related data and information for use by all.” For more on the division’s strategic plan see an older article I wrote in 2009. The Division of HIS is placed in the Ministry of Medical Services.

It is noteworthy that the EMR implementation initiatives have been driven largely by a need to run the country’s Anti-Retroviral Treatment (ART) programs more efficiently. Development of EMR systems has however grown beyond merely addressing ART programs.

The Division of HIS also envisions a country health care system with “EMR systems that support the provision of holistic health care while improving on health records management and contributing to improved quality of patient care.”

It should be noteworthy therefore that the Division of HIS has taken the lead in championing implementation of EMR systems, not only for clinics with specific disease programs but also for an entire health facilities medical interactions.

In the previous post I highlighted some of the benefits of the standards and guidelines as well as some of the document’s weaker areas. A wide circulation of the document should in itself be a milestone for the government which is often accused of producing documents it fails to distribute widely for implementation and reference. In this post I shall rest at providing readers with a link to the actual document

Hopefully all stakeholders will start referring to it and complying appropriately – this is the line where I get to force relevance to this article’s title.

Along Came Standards and Guidelines for EMR Systems in Kenya

An Electronic Medical Record (EMR) is defined as a computerized  medical record created in an organization that delivers care, such as a hospital and doctor\’s surgery – (in wikipedia). EMR systems, information systems used in health facilities to manage EMRs have remained a popular topic of discussion among Kenya\’s eHealth initiative\’s over the last five years.  

A knowledge-based economy

A nation wide adoption of EMR systems in Kenya promises to increase effectiveness of the national health care system from policy making, to financing,  and to service  delivery at health facilities. This is by strengthening the practice of knowledge management in health care. Among other things, it would support evidence-informed decision making at the various service delivery levels of the national health system.  

A health care system in Kenya with efficient knowledge management and decision making will not only create a healthier and more economically productive Nation. It will also foster development and harnessing of such knowledge as a resource for wealth creation within and across Kenya’s borders.

Entrenched Fragmentation

A significant number of fragmented, strongly entrenched and donor funded EMR systems have come into existence at our health facilities over the last decade. The fragmented initiatives have diverse approaches to issues like stakeholder inclusiveness, health data ownership, systems development and support, systems ownership and sustainability. The total cost of ownership (TCO) profiles of the fragmented initiatives are also diverse. They range from low cost open source community supported systems to high cost vendor supported systems thriving on the occasional waves of donor funding.

With the fairly uncoordinated setting above, the debate on a road-map for nationwide adoption of EMR systems has been emotive if not controversial over the years. About 6 years ago, in August 2004 to be specific, the World Health Organization (WHO) convened a meeting of EMR systems stakeholders in Nairobi.  The stakeholders included National AIDS Control Programs of five African countries, clinicians and developers of EMR sytems and learning experts.

Delayed conclusion of matters

The WHO meeting of August 2004 recognised among other things that “development and implementation of EMRs in Africa has resulted in numerous small projects without data content or data exchange standards, running the risk of creating a fragmented and chaotic information environment in which national data reporting and mobile patient tracking would be severely impaired;”

In recognising the above challenge, the same meeting also called upon the WHO to “work with partners including African Ministries of Health, the CDC, developers of EMR systems used for Africa, and clinicians to establish basic standards to allow interoperability, mobile patient tracking, and the possibility of national and cross national data mining.” To further quote the meeting’s report, The WHO’s support was also to recognize the fact that “These standards include electronic information exchange standards, agreement on the approach to core minimal data sets, and the establishment of a common data dictionary”.

The state of affairs

6 years later, Kenya has continued suffer an unduly protracted debate on EMR initiatives whose systems are nowhere near nationwide, cannot inter-change data and are without a common concept dictionary. More information on the August 2004 meeting and some of WHOs initiatives on Knowledge management platforms for clinical care can be found here. It remains difficult to understand why it has taken long to confront the challenges highlighted in the meeting. The explanation can get as complex as the stakeholder’s interests.

Major strides forward

It should be with some relief that stakeholders will be seeing the official launch of the \’Standards and Guidelines for EMR systems in Kenya\’ this November. The standard and guidelines document has been developed with the support of PEPFAR through I-TECH, a collaboration between the University of Washington and the University of California, San Francisco. Development of the document has also benefited extensively from the leadership of the government’s Division of Health Information Systems and the National STI and AIDS Control Program (NASCOP).

The document should go a long way to improve the framework and environment for development, deployment and implementation of EMR systems in Kenya. It attempts to leverage on recognized national and international standards for health informatics. The document also attempts to build on learning from experiences of historical EMR system implementations.

In the document’s section two, it sets national standards for information interchange and interoperability. This will help to foster information exchange between EMR systems at different health facilities. This should address among other issues mobility of health care clients.  The interoperability standards will help foster a deliberate awareness among EMR systems of pharmacy information systems, district health information systems, financial management systems and other subsystems in a health facility’s enterprise architecture.

The document’s section 4 on governance and policy attempts to set standards for systems ownership, TCO profiles and sustainability. It also goes further to set a standard for health data ownership. The document also spells out the responsibility of the Division of Health Information Systems to ensure the standards are enforced.  The possibility of this responsibility being delagated to NASCOP and other disease programs is also specified in the document.

Areas of improvement

As with a majority of standards documents, The ‘Standards and Guidelines for EMR systems in Kenya’ still has much room for improvement. One of the weakness could be how the document addresses “the approach to core minimal data sets, and the establishment of a common data dictionary” – identified in the August 2004 WHO meeting. A gray area remains on how well the use of medical concepts and terminologies can be standardised for uniformity and comparability of data held or shared across computer systems.

The apparent inadequate engagement of stakeholders in the ICT industry in developing the standards and guidelines can also be flagged against the document. For such a document, there would have been a need to seek the views of the ICT private sector – companies and private practitioners.  If the synergies such as those described in my earlier article on EMRs sytems and the Kenya software industry are to be pursued, future enhancements of the document would require a meaningful engagement of the ICT industry. Key players in Kenya’s ICT landscape include the Kenya ICT Board, the Directorate of e-Government and professional communities such as the iHub and KICTANET.

An evolving set of standards and guidelines

Although the document could arguably have some weaknesses, the document was cautious enough to invite readers to view its content as ‘evolving guidelines’. It proposes to be a ‘living document’ and states that  “the process to identify and agree upon EMR requirements and recommendations presented in this document is more important than the guidelines contained in this initial version”. Dr Patrick Odawo, I-TECH’s Country Director also indicated that they would set up an official forum for discussing the document and its continual improvements on the Google Groups platform.


For readers interested in more insights about standards for EMR systems and their practical implications, I shall embed a video of a presentation made by Dr. Paul Biondich of OpenMRS two years ago. http://video.google.com/googleplayer.swf?docid=4292021079657889189&hl=en&fs=true  
The presentation touches on the possibility of having standardized concept dictionaries for vocabulary management. It was made during a WHO conference on data standards in December 2007

Signs of a Growing eHealth Sector in Kenya

Today I had this nice opportunity to partially attend a PEPFAR partners meeting at the Safari Park Hotel. I shall not assume it is obvious that PEPFAR stands for (United States) President\’s Emergency Plan for AIDS Relief. Kenya is said to be one of the countries with the biggest allocation of PEPFAR grants, largely through USAID and CDC. Every year, billions of Kenya Shillings are handled as grants from PEPFAR within the country, so much so that it is almost a sub-economy in itself. PEPFAR, essentially the philanthropy of the American People appears so immense in the health sector that the aid should ideally overflow to the ICT sector through eHealth. For more on related development dynamics see my earlier post on who really are our genuine development partners.

Over time, PEPFAR leadership may have discovered that it is not possible to practice philanthropy in the air – it has to be in someone\’s jurisdiction –  who needs to care that they Americans are being philanthropic. Although the partners meeting I attended was full of representatives of NGOs supported by PEPFAR, it struck me how the agenda and presentations had undertones of leadership and control by the government. It was also impressive to see the relatively young and professional representation from the government.

Perhaps some readers will frown or cringe at the thought of government stewardship of the eHealth agenda. Consider the scenario where donor funded NGOs have to use this nice MS Access Application developed by this wonderful self taught American Programmer. That would be a self made \’geek\’ sitting at some place in the US offering great support and maintenance whenever MS Access bugs crop up or whenever the dismal functionality MS Access must be pushed to some impossible limits. Of course once in a while there is also a need for them to offer support on matters like \’which Microsoft Office 2003 service pack to install\’ and so on. You might also say that I am not the greatest fun of Microsoft products or proprietary systems. However Kenya is a country with quite a wealth of job seeking, highly skilled, economically frustrated software developers – some of them quite accomplished. The picture appears wrong for huge sums of donor aid to a country with jobless software software developers having  their \’donor aid\’ monitored through what might appears to be a makeshift MS Access application managed overseas.

The above picture has been possible because the government of Kenya and its economic sectors have not been keen enough to take full ownership of the aid given to the country. However, the increasing government stewardship of the eHealth agenda in Kenya promises to help in ensuring that its people and its economic sectors directly benefit from the very aid that donor initiatives purport to give. It might be fair enough for donor money to bounce back to its origin through purchase of anti-retro-viral drugs, bed nets,  condoms, computers and mobile phones. However, it appears unfair for the aid to dodge our fledgling software development talent, bouncing back through the so-called technical assistance expenses like developing and supporting an MS Access application.

During the meeting which had a lot of eHealth talk, I was particularly impressed by presentations delivered by government officials. The presentations outlined progress made and planned initiatives around eHealth which included :-

1. A presentation of plans to rollout a District Health Information System to replace the existing MS Excel Based FTP site for health facility reporting – I gladly observed a silent drift towards DHIS2 – an open source platform that could challenge the use of  the KePMS system. A proposed overall initial implementation budget of Ksh 54M appeared realistic to me (peanuts for donors).
2. A presentation and demonstration of  the Community Based Program Activity Reporting (COBPAR) system – developed in-house at the National AIDS Control Council on an Open Source Platform (currently only available through their VPN).
3. A presentation on the almost ready standards for EMR systems in the country (with functional/ interoperability profiles and guidelines for implementation and human resource capacity building). Government seems to have seen the sense that it only needs to encourage an environment of efficient interoperability – away from an earlier drift to push for a default national EMR system (read controversial).
4.  A clarification that the division of Health Information Systems is pursuing ideas around building an enterprise architecture (EA) for systems in the the health sector – see my earlier post on the importance of EA
5. Some profound thoughts on NASCOP\’s strategy for HIV/AIDS and STI disease surveillance (to be supported by eHealth sub-systems)

One might say that success of eHealth initiatives is a default expectation and that \’government can only be interfering\’. I would disagree and see the important role of government in  providing the conducive environment for eHealth systems flourishing and efficiently co-existing. Government involvement is also a sure way of ensuring that eHealth initiatives are efficiently tapping from our donor generosity. If the current trend is upheld and protected from adverse political changes, eHealth initiatives including OpenMRS, DHIS2, Child Count, iDart, Jacaranda Health , FrontlineSMS:medic and others are destined for success in Kenya.

Part 2 of Insights from the 5th Annual OpenMRS Meeting

A couple of days back I wrote my first article on the  the fifth annual OpenMRS implementers meeting. Immediately after posting the article I checked my meeting notes and thought I would need to write on a few more insights that appeared equally profound. Consider this a continuation of the lessons I described in the earlier post.

Lesson 4. Open source is great; best with a global community
One of the big debates in many developing countries is whether to adopt an Open Source policy for their e-government initiatives. It appears key decision makers have began to appreciate the benefits of such a policy. However there needs to be further understanding that a mere application of open source technologies for development of government software systems is not enough. There is need to embrace the concept of open source from a global community perspective.  A software expert or two can sit with an health care expert and develop an awesome, robust, feature-rich EMR or Pharmacy system using open source technologies. The system can easily go ahead and be deployed successfully in a health facility or two. The challenge with such an awesome system would revolve around the nature and size of its community of implementers and developers. Such challenges would begin to show when it begins to expand its scope, both in terms of number of installations and scalability of functionality.

During the meeting I confirmed the unparalleled size and diversity of  the OpenMRS community – for an EMR sytem. However, the bigger learning point for me was that indeed a large and diverse community enhances chances of software supporting global best practices.  I may not be placed best to comment on this a the medical or health care point of view. However description of the whole idea of OpenMRS concept collaborative (OCC) and meta-data sharing had strong indications of how powerfully the open source, multi-institution approach can influence harmonization of terminology and adoption of best practices in the health care domain. Dr. Andy Kanter’s presentation did very well to highlight the possibilities and potential around concept sharing.

From the information systems point of view, global best practices on software design and development were an underlying feature of the technical discussions – as a necessity. In this era of globalisation, I was particularly impressed by the approaches to providing services in resource-constrained environments. These I thought in due course can be perfected by developing countries and competitively propagated to developed country settings on relatively  less resource-rich but essential devices like mobile phones.

In general my lesson here was that an open source system built and maintained by a small or closed community can be as inflexible and as expensive as a proprietary system. Any open source software initiative with a national or global ambition should strive to build a large community enough to sustain its growth objectives.

Lesson 5: Enterprise Architecture optimizes on resource use and unifies efforts
During one of those parallel tracks at the meeting there was this intense debate about Enterprise Architecture (EA) and OpenMRS. On my part I had long held this belief that EA was too abstract a concept to be directly relevant to a national health information systems arena. More so for a low-resource, developing country setting, the concept had unfortunately appeared to be ‘too high up there’. The turning point for me was when a participant dared the rest of us to think that “Perhaps EA is NOT too esoteric to be talking about in a low resource setting”. Of course I had to first struggle through the definition of the enterprise itself – noting that the enterprise could be ‘Myself’, a clinic, a Ministry of Health Division, A country’s health sector, or even a countrywide ‘all sectors’ as an entity.

Incidentally I got convinced during this session that a country having EA is one of the biggest success factors for achieving an effective implementation of a nationwide eHealth systems. The simplest benefit of an EA seemed to be its ability to harmonise terminology across the eHealth landscape. For instance it would reduce misunderstandings arising from the lack of a distinction between roles of constituent components such as the EMR, the HMIS system, the Supply chain management system, the Communuty Health Worker system and so on. Where there are many stakeholders, EAs assists every contributor to the national enterprise architecture to focus efforts on the functional and interoperability profiles of envisaged components. Such critical understanding has immense potential to reduce duplication of efforts and wastage of expensive donor money in the developing world.

Furthermore, with EA’s ability to unify national stakeholders around technically sound functional and interoperability profiles, it was regarded in the discussions as an important cushion if not a weapon against the ever looming adverse political changes in our health ministries.

There were endless lessons and insights in the meeting and you might guess I still have a couple of more thoughts worth writing about. I shall leave that for yet another blog post.

Insights from the 5th annual OpenMRS meeting

Last week I had this great opportunity to be a participant at the fifth annual OpenMRS implementers meeting in Cape Town. The meeting brought together implementers, developers and the leadership of OpenMRS. The meeting was of the  \’unconference\’ style and being relatively less experienced with OpenMRS,  I found myself simply following through the intense sessions, soaking up a lot of knowledge and insights. There were many lessons and great experiences including ideas on how to actualize the dream in my earlier post on adopting OpenMRS in Kenya. I shall try and describe three of them in this post – based on my personal synthesis.

Lesson 1: Clinical Systems Not Reporting Systems

During one of the evening discussions with Dr. Alvin Marcelo and a few others round a dinner table, I had this bulb light somewhere in my mind that \’Really, medical record systems need not be seen as reporting tools\’. In fact, to some health care practitioners, that the medical records system assists in retrieving a patient\’s medical history and perhaps assists in diagnosis is all that should be expected of the system. To them, other information management issues including aggregation of patient and treatment statistics for what we know as monitoring and evaluation – (read reporting) is almost out of scope for a medical records system. The idea that an EMR system needs to primarily address the health care givers\’ information requirements at their points of care implies that national Monitoring and Evaluation (M&E) and reporting needs become secondary in an EMR. These observations got me thinking that perhaps the efforts to have electronic medical records systems (EMR) in Kenya will not necessarily yield the desired expectations. In Kenya, the National STI and AIDS control program (NASCOP) and the division of Health Information Systems (HIS) in the Ministry of Public Health and Sanitation have over the last couple of years been working hard towards having elaborate EMR systems used at the country\’s public health facilities.  With the  country\’s drive for implementation of EMR systems being \’national reporting\’, it appears NASCOP and the division of HIS might be better off concentrating efforts on district health information systems such as DHIS2. It should be possible to allow for diverse EMR systems that support the SDMX-HD protocol for data exchange with the DHIS system to facilitate upward aggregation of data – hence national reporting. This of-course is not to disregard the need to foster data use and M&E at the administrative level of health facilities.

Lesson 2: Symbiotic Relationships Paramount

It is fairly easy for health experts to say that the field of health information systems (eg medical record systems) is their exclusive domain. Such a perspective can be \’legitimized\’ by many valid arguments to the extent that the relevance of input from other professions can be seriously downplayed.  Conversely, from a different perspective, information systems experts can easily \’justify\’ why health information systems is their domain. When these perspectives are not adequately reconciled, there exists a high probability that in an health information systems implementation, either the health or the information systems aspects will fail to be optimized on. During the meeting, several participants emphasized that the development and implementation of successful medical records system calls for a symbiotic relationship between health care professionals and IT professionals. Moreover, health information systems implementation require meaningful engagement of all would-be beneficiaries. This was well summarized in Chris Bailey\’s observation that \”if you want the truth about an Electronic Health Records system implementation, talk to the nurse\”. 

Lesson 3: Who and What really is OpenMRS?

Am sure this is a lingering question in most readers\’ minds.  To me the question was answered better during the meeting. A plenary session with Dr. Paul Biondich helped to understand the idea that OpenMRS is both a global community and a software platform. It is a non-profit, multi-institution collaborative. Its mission is to improve health care delivery in resource-constrained environments by coordinating a global community that creates a robust, scalable, user driven, open source medical records system platform. From a different perspective, OpenMRS is also a software platform and a reference application which enables design of a customized medical records system. One more related learning point was that there was an on-going undertaking to incorporate a non-profit organization that would facilitate a more proactive pursuit of the community\’s mission.


In general there was a sense that for a health information systems initiative like OpenMRS, maintaining a balance between meeting health care delivery and software evolution objectives is paramount. Some nice photos of the meeting can be found here as posted by John Wesonga

Kenya’s Strategic Plan for Health Information Systems

Kenya has a brand new Strategic Plan for Health Information Systems (HIS) covering the period 2009 to 2014. The new strategic plan also brings along a HIS policy to guide its implementation. The two documents attempt to deliberately address the aspirations of the National Health Strategic Plan II , the Health Sector Monitoring and Evaluation Framework and the country\’s Vision 2030. The documents were prepared with the technical and financial support from the Health Metrics Network (HMN) and UK’s Department for International Development (DfID). Click here to access the two documents on Google Docs

Notably, among government dependent services, the health sector has been at the fore front adopting Information and Communication Technology (ICT) for improved service delivery to Kenyans. The progressiveness on the part of the health sector may be appreciated as a result of good leadership within the government. The same might also be dismissed as a mere side effect of immense donor interest especially with respect to HIV and AIDS. The extreme pessimist might dismiss the same as yet another fantastic set of paperwork that the government produces whose theory will not really be actualized in practice. The extreme pessimist will not be helped to note that whereas there is a very thin line between HIS and eHealth, another set of similar documents on the national eHealth Strategy are being finalised by a different department of the two Ministries of Health.

The strategic plan for HIS has a vision of making Kenya “a centre of excellence for quality health and health related data and information for use by all”. One of the strategic objectives in the document which should interest the local ICT industry is for \’Strengthening use and application of information and communication technology, in data management\’ . Cited strategies for this include enhancing data management functions with hardware and software, developing an integrated web-enabled database system, support for data flow (data connectivity), systems maintenance, data security, and developing capacity of ICT personnel. Given the plan’s budget of Ksh. 1.9 billion, the above strategies if implemented will surely have a spill over effect of further nourishing the country’s fledgeling ICT industry.

The plan aims to directly create jobs for 4,310 more health records and information personnel, 227 ICT officers and 221 statisticians. As meagre as these numbers may look, this should bring a little hope to the disillusioned Kenyan youth studying ICT related degree and diploma courses. Perhaps greater economic impacts will be felt in the ICT industry if affirmative action is enforced to more directly favour local entrepreneurs. Such a protectionist approach will yield even better results in the software industry if local expertise, based on widely tested, global community supported open source approaches, can be developed and tapped. Such an approach will also compare better to acquiring turnkey or off-the-shelf solutions that have dependencies on foreign software vendors with expensive licensing models.

Although it might sound fair enough for the health sector to insist that all they want is a working ICT infrastructure (software and hardware) in pursuit of the HIS strategy, it might help to look beyond an optimal solution for the short term. To gradually build capacity of the local software industry with a reasonable level of tolerance will provide optimal long term solutions in terms of Sustainability, Return On Investment (ROI to the country\’s economy) and the long term Total Cost of Ownership (TCO). Moreover such an approach should eventually improve the country\’s foreign exchange situation by exporting human resources and intellectual property developed throughout HIS implementation. The approach will also be in line with the ICT board\’s vision of making Kenya a top ten global ICT hub.

Lastly, of concern is the apparently dismal engagement of the ICT fraternity in developing the HIS strategic plan. Stronger participation of the ICT board, local solution providers, and associations of ICT practitioners in such an ICT related domain is called for in the future. Such involvement of the domain experts will help to address the economic dimension which exists in the bigger picture of the country’s vision 2030.

Adopting OpenMRS: A kick start to Kenya’s software industry?

Let me first apologies to the faithful readers who have advised to limit the length of posts. I am still learning the art of summary, so please allow the bad old ways for now.

Donor interest

Kenya’s response to HIV and AIDS has over the last decade become a thriving industry in itself. The sustained donor interest and flow of funds to the sector has remained an area of curiosity to many onlookers. A growing school of thought exists; curious why the not-so-meagre funding should not go to fighting Malaria and other diseases with higher mortality rates than AIDS. The donor politics aside, there is a real interest among the so called development partners to finance implementation of Electronic Medical Records (EMR) Systems. Their intention, ostensibly so, is to assist in managing administration of Anti-Retroviral Therapy (ART) among people living with HIV in Kenyan health facilities. The more observant ICT strategist or development minded entrepreneur will hear of a distinct and rare opportunity amidst the noise – a launching pad for a vibrant software industry in Kenya.

Competitive Advantage for ICT in Kenya

ICT and software industry in particular is one of the remaining escape routes that Kenya has, to liberate its people from their economic and social quagmire. Perhaps one only needs to invoke the stereotypical example of the MPESA success to dare the common pessimistic to shrug off the defeatist ‘that is too ambitious‘ attitude. A strategic adoption of the OpenMRS health information system currently implemented by AMPATH at the Moi University Referral and Training Hospital and at the Millenium Villages Project seems a realistic launching pad for a vibrant software industry in Kenya.

Kenya has in the recent past built vast human resource base around ICT ranging from the deeply engaged software developers, systems administrators, trainers and ICT managers. You only need to look around your immediate circle to find a relative or a friend who has undergone some IT related diploma or degree level training. We need not arrange an economic management seminar with Michael Porter to learn that a nation can develop competitive advantages around the skills of its people. Besides in our knowledge economy, traditional factors of production such as land and capital are belittled by the very knowledge-base of a people.

An unencumbered software industry

A vibrant software industry will exist only where there is a relevant skilled and motivated human resource base. The challenge however remains that the most highly talented and committed ICT practitioners become increasingly frustrated by an ever nagging glass ceiling – the licensing and intellectual property demands of the foreign software giants. Any efforts to turn Kenya into a net producer of software will be frustrated as long as the software developer\’s successes must be attributed financially to some global software monopoly – call it Microsoft, Oracle, SAP, IBM or Google – whichever.

Apart from a financial ’embargoes’ and ‘dependencies’ on Kenyans derived from ownership of proprietary software, the Software industry continues to suffer from a suppression of creativity. If globalization pays for creative economic value, then globalization tells you that you are too poor to be creative, then globalization has condemned you to poverty. A skilled and talented software developer in Kenya cannot be creative enough for really significant economic value if they cannot tinker with their software application\’s database back-end (eg. Microsoft SQL server, Microsoft Access and Oracle databases).

Currently, in most cases the talented developer may not necessarily need to tinker with the database or operating system back-end. They may only need a reassurance that the software product they are banking their livelihood on will not break helplessly due to a bug or hidden deficiency in the back-end controlled by Microsoft or any other monopolistic manufacturer. The reassurance only, that in a bad case scenario they can tweak the underlying platform themselves is liberating to the would be Kenyan software millionaire. Indeed many back end environments in computers and servers are bulky with unnecessary features for a vast majority of consumers in the developing world. The software implementer will wish to have the ability to cut down on unnecessary functionalities offered in the standard back end or operating system environment. Such reassurance and empowerment in the IT world only comes in the from adherence to the OpenSource software philosophy.

Why OpenSource and OpenMRS?

OpenSource software philosophy encourages ICT specialists to acquire install and use software with licences that do not demand payment for normal use. The licensing structures are such that the software is essentially owned and supported by a global community of self driven ICT specialists and users. Indeed the manufacturer or licensing company may generate revenue from more specialised adaptation of the software where \’more insider\’ support, maintenance and tweaking are required. For software development entities who feel a need to access and tweak the software themselves, the source code for such software is publicly accessible through on-line download or other low cost distribution channels.

Indeed the larger proportion of implementation cost for open source software is largely human capacity building. A structured and elaborate capacity building for software developers and implementers is about all that is required for a large scale adoption of EMR systems based on OpenMRS in Kenya. Of course that should go with a little investment in the not-yet-common foundations of good governance and management practices. Such support could be rendered through some form of facilitating agency; a public or private sector entity or even the donor agency themselves. A well managed facilitating agency should in the long run facilitate export of OpenMRS implementation and support services to the rest of the countries

With development partners wishing to mitigate their risks of project failure, they will rarely go wrong with a larger portion of their investment going into human capacity building. Donor support for adoption of OpenMRS and other OpenSource software projects should offer them a significantly less risk of failure since it is rare to go wrong on human capacity building; the single largest cost component of implementing an OpenSource system. The apparent cost of such capacity building of ICT specialists and health facility staff may be rendered insignificant compared to the opportunity cost of developing or adopting systems based on proprietary technologies; perpetually paying licences and support fees to foreign companies and experts.

Apart from the OpenSource nature of OpenMRS, it has other useful strengths, among them the following:-

1. OpenMRS participated in Google Summer of Code of 2007 and 2008 hence benefits globally from inputs of highly talented and skilled programmers and their mentors
2. OpenMRS has support from a global community with implementations cutting accross continents hence has easily addressing global standards such as HL7
3. OpenMRS has been embraced by the software development community for extended functionalities eg. a)teaming up with Pentaho the data mining and busines intelligence specialist and b) the development of a Google Android application for medical diagnostices using phones based on OpenMRS – to name a few
4. OpenMRS functionality is not limited to HIV related health conditions see abstract on OpenMRS as a key Malaria intervention
5. In early 2009, OpenMRS was ranked by Kenya\’s NASCOP as one of the top three EMR systems being used in Kenya among IQCare and Fuchia which are locked in to Microsoft proprietary technologies and imply payment of expensive Microsoft Licence fees for every extra user or installation. (Note that the reliability of the ranking criteria aside, large scale adoption of such alternative systems as IQcare does not guarantee meaningful opportunities to Kenya job seekers as demonstrated where software development jobs are fashioned for Indian counterparts to \’develop solutions for the developing world\’).

In conclusion, it seems impossible to over-do capacity building among software developers, implementers and entrepreneurs to adapt OpenMRS for public, private and mission hospitals in Kenya that do not have EMR systems. That may be the little investment that development partners in the HIV and AIDS sector need to make in Kenya to address their core interests and whose secondary effects to a fledgling software industry might just be phenomenal.