Leveraging information technology to bridge the health workforce gap
Robert Bollinger a, Larry Chang a, Reza Jafari b, Thomas O’Callaghan c, Peter Ngatia d, Dykki Settle e, Jane McKenzie-White a, Kunal Patel c, Amir Dossal f & Najeeb Al Shorbaji g
a. Johns Hopkins University School of Medicine, Phipps 540, 600 N. Wolfe St, Baltimore, Maryland 21287, United States of America (USA).
b. E-Development International, Baltimore, USA.
c. iHeed Institute, Mitcheltown, Ireland.
d. African Medical and Research Foundation, Nairobi, Kenya.
e. CapacityPlus, Intrahealth International, Chapel Hill, USA.
f. Global Partnerships Forum, New York, USA.
g. World Health Organization, Geneva, Switzerland.
Correspondence to Robert Bollinger (e-mail: email@example.com).
(Submitted: 15 April 2013 – Revised version received: 04 August 2013 – Accepted: 06 August 2013.)
Bulletin of the World Health Organization 2013;91:890-891. doi: http://dx.doi.org/10.2471/BLT.13.118737
According to some estimates, the world needs more than 4 million additional physicians, nurses, pharmacists, laboratory technicians, midwives, community health workers (CHWs) and other front-line health workers.1 However, there is also a shortage of faculty that can provide high-quality training and mentorship for current training programmes2 and continuing education opportunities for health workers. The use of new information and communication technologies (ICTs) can help to overcome these challenges.3,4
Recent global investments in fibre and wireless infrastructure, as well as innovations in e-learning, electronic health (eHealth) and mobile health (mHealth) and in the social media, can be leveraged to train, deploy, support and empower health workers.4–8 The International Telecommunication Union estimates that, in only four years (2007–2011), mobile broadband subscriptions in the developing world increased by more than tenfold: from 43 million to 458 million. Mobile devices and internet access are becoming increasingly necessary professional tools for health-care workers at all levels in developing countries. New fibre and wireless infrastructure, as well as the rapid growth of computer processing power, provide an unprecedented opportunity to scale up health worker training and improve its quality, as well as to optimize health service delivery and strengthen health systems.
Over the past 20 years, learning management systems have contributed greatly to the tremendous expansion of e-learning. The past five years have also seen an increase in massive open online courses. eHealth technologies, including electronic medical records, laboratory and pharmacy information systems, along with disease surveillance and supply chain information systems, are transforming health care. Mobile health (mHealth), which is the practice of medicine and public health supported by mobile devices, extends these systems to the most remote and inaccessible parts of the developing world. In addition, the same mobile devices used to optimize communication and support front-line health-care workers can be used to deploy multimedia training programmes and clinical decision support tools. The social media and the development of communities of practice have yet to be fully mobilized to support health workforce capacity building. The use of the social media by health workers has several potential benefits. Some examples are crowdsourcing of educational content, translations and localization (i.e. adaptation of the content to a particular region), peer-to-peer learning, joint problem solving and reflective practice. In addition, ICTs can strengthen communication between providers and patients, increase community support for health worker capacity building and heighten the demand for high-quality clinical services.
E-learning tools can support curriculum development and course scheduling and management in ways that are conducive to blended learning approaches and that take advantage of multiple learning environments. Such tools can also be linked with national health professional registration and licensure systems, as well as with health workforce planning, management and in-service training systems, to provide information and support to the health workforce throughout the health worker lifecycle. Following pre-service training, ICTs can be used to optimize the work of a health-care provider – the use of electronic health records, clinical decision-making, supply chain management and service quality control are examples – and to facilitate mHealth communications, continuing education and the establishment of professional social networks.
Training methods based on video conferencing, webcasting, recording, localization and playback of training can enable global access to the very best educators and are more cost-effective than standard face-to-face educational programmes. Interactive content programmes that incorporate gaming and adaptive learning tools can also be used.9 By enabling the development of virtual networks of learners, e-learning makes learning a community effort and facilitates the sharing of training content. Furthermore, since e-learning can take place in the community, at the point of care or at other convenient points, training costs are reduced and health-care providers can remain in their clinics and communities, where they are most needed, without disruption of health-care delivery.10
E-learning is not a second-rate alternative to traditional health worker education. It adds value and makes it possible to overcome the limitations of existing educational strategies. The goal of any health education strategy or curriculum should be to present the educational content and conduct the training in a manner that will enable all learners to acquire the clinical competencies they need. A blended learning strategy based on the use of ICTs, e-learning and other educational methods can achieve this objective.
Despite the potential and opportunities described herein, several challenges must be addressed before ITCs and e-learning can be fully employed to build health-care worker capacity globally. Some of them have to do with the limitations of the ICT infrastructure and of the ICT and e-learning technologies themselves; others are cultural, societal and regulatory barriers.
Despite recent investments in fibre and wireless network infrastructure, two thirds of the world’s population still lacks internet access and, even in communities with new network architecture, the cost of connectivity remains prohibitively high.11 The number of highly trained ICT experts is also insufficient for health programmes and institutions to adequately staff their own network support teams. In addition, in many communities a lack of electric power is the main obstacle to the use of ICTs and mHealth tools. The use and scale up of ICTs in health programmes are also hindered by the absence of appropriate and enabling strategies, policies and standards, the lack of harmonization across communication systems and the poor interoperability of technologies and platforms.
Many medical faculty members and health programme staff are reluctant to modify or abandon traditional teaching and learning methods that have been essentially unchanged for decades. Incentives may be required to promote the uptake of e-learning strategies among these professionals, in addition to training in computers and e-learning tools. Furthermore, since women represent the majority of health-care providers, efforts to leverage ICTs to train health workers will have little impact unless computer literacy and access to ICTs are promoted among women.12 Various ministries, especially the ministries of information technologies, education, finance and health, will need to better coordinate and synergize their missions in connection with the use of ICTs among health workers. In addition, several issues need to be addressed with respect to regulation on content sharing and the use of e-learning platforms for the certification and accreditation of health professionals. Use of the internet to share content, faculty members, lessons and best practices, as well as to build social networks of learners, could bring down the regulatory silos that limit cross-border collaboration in health education.
Governments and donors will need to be shown evidence that investments in ICTs and e-learning for health workers lead to programmatic cost savings, increased productivity and improved health outcomes. New models of public–private partnership are needed to ensure the scalability and sustainability of investments in ICTs for the support of health-care workers. Governments and donors will need to recognize that corporate partners expect public–private partnerships to lead to new business and new markets. Similarly, private sector partners will need to recognize that governments, donors, health programmes, institutions and communities will expect public–private partnerships to lead to sustainable improvements in programmatic efficiency, productivity and improved health outcomes.
We recommend several measures to train, empower and support health workers in resource-limited settings in Africa, Asia and Latin America through the use of ICTs (Box 1). ICTs are a global transformative force. E-learning and other ICT tools offer ways of bridging the global health workforce gap, but several challenges must be overcome. The ICT “train” has left the station. It remains to be seen whether the global health workforce will ride along or remain behind.
Box 1. Recommendations for training, empowering and supporting health workers in resource-limited settings through the use of information and communication technologies (ICTs)
- Ministries of health, education, finance and information technologies and communications must coordinate efforts to improve ICT infrastructure, expand broadband access and support e-learning initiatives in health professional institutions and health programmes.
- Ministries of health and health professional organizations must fully embrace e-learning through the establishment of standards and accreditation procedures that facilitate the certification and sharing of training programmes for students and of continuing education initiatives for health-care providers.
- Health professional institutions and health programmes should fully embrace e-learning and ICT innovations in training, supporting and empowering health workers at all levels.
- Computer literacy, particularly for women, should be a high-priority competency in all training programmes for health-care workers.
- Specific training of faculty and students in the use of e-learning platforms should be a priority for health professional schools.
- E-learning tools should be blended with other educational approaches designed to help all students achieve the necessary competencies.
- The full range of e-learning tools – learning management systems, massive open online courses, mHealth, the social media, webcasts, decision support tools, simulation training, adaptive learning platforms, etc. – should be utilized in the training of health professionals.
- All health training programmes should include self-evaluation and regular curricular updates to ensure that all students achieve the necessary clinical competencies, regardless of the educational strategies used.
- Support for innovative and sustainable e-learning programmes for health workers should be established through new public–private partnership models that engage the full range of stakeholders.
- The ICT workforce available in resource-limited communities needs to be greatly expanded to provide health programmes with highly qualified, affordable and innovative ICT support.
The authors gratefully acknowledge the participants, speakers and moderators of the 2013 GETHealth Summit and particularly thank Kate Tulenko, Director of CapacityPlus IntraHealth International, for her suggestions. The opinions expressed in this paper are those of the authors alone and do not necessarily reflect the opinions of Kate Tulenko or of GETHealth participants, speakers or moderators.
Robert Bollinger and Amir Dossal were co-leaders of the 2013 GETHealth Summit that took place at the United Nations on 6–7 February 2013. They received no direct financial support for their role in the Summit. However, the GETHealth Summit was supported by The US National Institutes of Health Office of AIDS Research, the Norwegian Agency for Development Cooperation, Hewlett-Packard, My Two Sons Fund, The Verizon Foundation, InPractice, Intel and the Gilead Foundation.
- The world health report 2006: working together for health. Geneva: World Health Organization; 2006. Available from: http://www.who.int/whr/2006/en/index.html. [accessed 11 September 2013].
- Mullan F, Frehywot S, Omaswa F, Buch E, Chen C, Greysen SR, et al., et al. Medical schools in sub-Saharan Africa. Lancet 2011; 377: 1113-21 http://dx.doi.org/10.1016/S0140-6736(10)61961-7 pmid: 21074256.
- GETHealth [Internet]. New York: Global Education and Technology for Health Summit; 2011 [updated 2013]. Available from: http://www.gethealthsummit.org/ [accessed 11 September 2013].
- Frehywot S, Vovides Y, Talib Z, Mikhail N, Ross H, Wohltjen H, et al., et al. E-learning in medical education in resource constrained low- and middle-income countries. Hum Resour Health 2013; 11: 4-11 http://dx.doi.org/10.1186/1478-4491-11-4 pmid: 23379467.
- Resolution WHA58.28. eHealth. In: World Health Organization [Internet]. Fifty-eighth World Health Assembly, Geneva, 16–25 May 2005. Resolutions and decisions. Geneva: WHO; 2005. Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA58-REC1/english/Resolutions.pdf [accessed 11 September 2013].
- Broadband Commission for Digital Development Working Group on Education. Technology, broadband and education: advancing the education for all agenda. Paris: United Nations Educational, Scientific and Cultural Organization; 2013. Available from: http://www.broadbandcommission.org/work/working-groups/education/BD_bbcomm-education_2013.pdf [accessed 11 September 2013].
- Key global telecom indicators for the world telecommunication service sector. Geneva: International Telecommunication Union; 2013. Available from: http://www.itu.int/net/itu_search/index.aspx [accessed 11 September 2013].
- Kaplan WA. Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? Global Health 2006; 2: 9-14 http://dx.doi.org/10.1186/1744-8603-2-9 pmid: 16719925.
- Erhel S, Jamet E. Digital game-based learning: impact of instructions and feedback on motivation and learning effectiveness. Comput Educ 2013; 67: 156-67 http://dx.doi.org/10.1016/j.compedu.2013.02.019.
- Funes R, Hausman V, Rastegar A. Preparing the next generation of community health workers: the power of technology for training. New York: Dalberg Global Development Advisors; 2012. Available from: http://hetv.org/pdf/power-of-technology-for-training.pdf [accessed 11 September 2013].
- Farhan H, D’Agostino D, Worthington H. WebIndex 2012. Geneva: World Wide Web Foundation & Oxford Economics; 2012. Available from: http://thewebindex.org/2012/10/2012-Web-Index-Key-Findings.pdf [accessed 11 September 2013].
- Tella A, Mutula SM. Gender differences in computer literacy among undergraduate students at the University of Botswana: implications for library use. Malays J Libr Inf Sci 2008; 13: 59-76.