Potential countries for testing eHealth programs

**Demographics
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@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.

Top 3, in that order:

  • Brazil
  • Bangladesh
  • Ethiopia
  • Bottom 3 in no particular order:

  • Zimbabwe
  • Siera leone
  • Sudan
  • *All due to political and security concerns.

    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.

    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.

    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.

    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.

    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?

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

    I would go with India, Congo, Kenya

    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

    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.
    6. Most important point is to have academic collaboration to test adequacy and feasibility before rolling out large programs and testing with costly experimental designs
    7. 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

    Thanks for giving this chance
    let me point out some points about Ethiopia

    1. in Ethiopia the ratio of doctors to people is about 3 doctors for 100,000 peoples
    2. in Ethiopia about 25 million people (quarter of the total population ) uses uses internet
    3. there is economical and geographical barrier to access health service
      due to these reasons I believe Ethiopia would be one of the best suited country for testing eHealth programs. this is also true for Malawi and Tanzania
      in my opinion Ethiopia, Malawi and Tanzania will be suitable for eHealth programs. these countries are the list countries in doctor to people ratio and health care facilities.

    @supratik12, @rajpanda, @Ewunate - Thank you for sharing your thoughts on this topic. We have taken a note of all points.

    Hi @Lauren, @elekaja, @acavaco, @jenyxp, @krp, @ArdenVent, @nothmany, @Budoff, @timothymusila, @uniyalbandana, @nowellk - What do you think on the best locations to pilot test digital health solution?

    @Shabbir ~ I love your perspective and you are 100% correct. "Humans are humans no matter in which country they born or living.". The reason we are considering partnering with one (or more) specific countries is so that we can co-design a solution with the government so that the likelihood of implementation is higher. Also, while there are many similiarities amongst humans, there are many nuances and intricacies when it comes to public policy and public governance.

    What do you think of the idea of choosing one country as a use case and then (assuming success of the pilot), creating a “playbook” of sorts that other countries can use as a guidepost in case they want to implement similar solutions/technologies?

    @tylerbn ~ Really great insight regarding looking for countries with stronger political infrastructure and more of a middle class and growing private sector, in order to diversify financing models for trying a new technology. This seems like a great criteria for emerging economies. Do you have any suggestions on how we should think about this when it comes to very low income countries that don’t have a strong emerging middle class? While we understand the infrastructure is important (and in many cases essential), we are also trying to weigh those ideal scenarios against wanting to reach the most vulnerable populations in low income countries. Would love your thoughts on how to balance these two competing criteria.

    @Nitesh ~ Brilliant! I love that you also highlight the importance of considering electromechanical tools. We often struggle with our own short-sightedness around emphasizing just the digital aspect. It’s great to be reminded of the importance of physical aspects as well.
    You mention the Philippines as a country that can give insights about the East Asian healthcare system. Do you happen to know what aspects of the health system might be a proxy for the other East Asian countries and their health system?

    @boblf029 - What an insightful post! The idea of testing in 3 different countries as a means to study 3 different types of society is very interesting. This would be quite an endeavor from a prize operations point of view, so I wonder if we could test in a phased approach with multiple competitions (one for each country) to narrow scope, while at the same time validate across multiple contexts. What do you think of that idea?

    Your other suggestion - to also consider countries based on their ability to recruit foreign health workers is also very interesting and I like how you tied this in with countries who speak multiple languages.

    Thank you for that!

    @addy_kulkarni ~ Your suggestions are so helpful! Thank you for this! This is the first time any experts have recommended El Salvador and, based on your outline, it does seem as though that country would be ripe for some e-health innovation. Do you happen to know what enabling structures are in place in El Salvador which allow for such large staffing of health workers? In light of the fact that so many countries struggle with adequately staffing health workers, I wonder what it is that makes El Salvador’s system unique there.

    Massive thanks for also highlighting the challenges in the distribution of existing resources. Gives us much to consider there!

    @bngejane ~ You’ve done an extraordinary job laying out the pros of the top 3 countries. Thank you!!!

    @dollendorf ~ Such an interesting angle! I like that you prioritize counties with a formalized approach to health technology assessment. From what we’ve heard in many expert interviews, many governments struggle to assess different health tech innovations. Do you happen to know if there are any reports or resources we can read to learn more about the assessment criteria of various digital health innovations?