JMIR Publications

ABSTRACT

Background:

Background The advent of eHealth solutions demonstrated the capability of information and communication technologies (ICTs) to improve health and the healthcare system. By definition of Lewis et al (2012) ,“eHealth is the cost-effective and secure use of information communication technology in support of health and health-related fields, including health-care services, health surveillance, health literature, and health education, knowledge and research” [1]. It includes clinical, administrative, and research-oriented areas [2]. It has been well stated that eHealth solutions contribute to more effective and efficient healthcare services by improving diagnosis accuracy, optimizing clinical pathways, avoiding duplicate examinations or treatments, and fostering collaboration among healthcare stakeholders [3]. The WHO 58th assembly urged countries to develop ICTs for health as deemed appropriate to promote equitable, affordable, and universal access to their benefits [4]. Thus, eHealth requires the use of appropriate hardware, software, and connectivity technologies for successful use [5]. Digital health should be an integral part of health priorities, benefiting people in ways that are ethical, safe, secure, dependable, equitable, and sustainable. Transparency, accessibility, scalability, replicability, interoperability, privacy, security, and confidentiality should all be considered when addressing eHealth solutions [6]. The successful use of eHealth technologies is thought to improve healthcare services delivery by improving healthcare data management, lowering costs, and decreasing medical errors [7, 8]. The long-term sustainability of eHealth technology is dependent on the economic, social, and organizational attributes in which the technology is embedded [9]. Sustainability is defined as the capacity to maintain or improve the state and availability of desirable materials or conditions over a long period of time. It is a normative and fuzzy concept that is determined by the users’ preferences [10]. Similarly, sustainable infrastructure refers to infrastructure projects that are planned, designed, constructed, operated, and decommissioned in a manner that ensures economic and financial, social, environmental, and institutional sustainability throughout the project’s entire life cycle [11]. Despite the fact that eHealth technology is regarded as a very useful technological approach to addressing many challenges (such as disease burden, scarcity of healthcare professionals, inequity of healthcare service delivery, and shortage of healthcare budget) [9, 12], investment in ICT in many African countries is limited and has the lowest ICT development Index for its successful use [13]. In addition, the financing strategies at regional and national level are found to be affecting the sustainability of eHealth [14]. Despite the widely anticipated benefits of eHealth technologies in improving healthcare service delivery, eHealth sustainability use in developing countries is low [15]. Investigating the facilitators and barriers to sustain eHealth solutions would aid in the design, development, and use of these solutions in resource-constrained settings. However, evidence on the barriers and facilitators for the sustainable use of eHealth solutions in the context of LMICs is scarce.

Objective:

This study aimed to explore the attributes for sustainable use of eHealth solutions in LMICs

Methods:

Methods It was a qualitative study conducted from September to December 2021 in four LMICs, Ethiopia, Tunisia, Malawi and Ghana from September to November 2021 as part of the EU-funded project BETTEReHEALTH. A qualitative study was conducted to investigate the attributes of sustainability of eHealth use in the study settings. Program implementers at various levels, developers of eHealth solutions, government officials (ministries, regional, or county leaders), facility administrators, and service providers were the study participants. Thus 49 study participants were identified purposively using maximum variation techniques in four countries. A total sample size, however, was determined based on information saturation, and data were collected via a face-to-face interview using a semi-structured interview guide with multiple probes. The interview guide was developed by the research team using published studies [9, 16] and adapted to local contexts. Data collectors were trained on the interview guide. We examined the tool's content and comprehensiveness to determine whether it would address the research questions. All the collected data was tape recorded. The data collection took on average 21 days. Similarly the average minimum and maximum times were 42.5 minutes and 116.75 minutes respectively. Field notes were also taken to supplement the audio recording. Data Analysis The recorded data was transcribed to verbatim and returned back to the interviewee for feedback. The transcription was translated to English from any native languages. Multiple readings were carried out in order to grasp the overall meaning of the data. Additionally, a line number was given for each sentence, and codes were created in order to identify patterns of ideas. The data was scoured for notable patterns and common themes. Themes and subthemes were thus developed based on emergent ideas, and data was analyzed thematically using OpenCode software [17]. Ethics approval The study was carried out in accordance with the WHO Declaration on Ethical Principles [18]. Besides, we have received ethical clearance from the respective participating countries not only for its ethical appropriateness but also for methodological soundness. Informed consent was taken from the study participants, and the information was gathered anonymously with no personal identifiers. To refer to the direct quotations, non-personal identifiers were used.

Results:

Results Participants’ demographic characteristics A total of 49 key informant interviews were conducted as part of the study (10 from Tunisia, 15 from Ethiopia, 13 from Ghana, and 11 from Malawi). Of those participants, 20 (40.8 %) of them were between the ages of 26 and 35. 36 (73.5%) of them were male participants, and 35 (71.4%) have MSc or above. Furthermore, the work experiences of the participants ranged from 2 to 35 years (Appendix A). The data collection took an average of 21 days. Similarly the average minimum and maximum times were 42.5 minutes and 116.75 minutes respectively (Appendix B). Theme formation We identified five themes which were related to human factors, economy or funding, organizational factors, technology and technological infrastructures, and policy and regulations. Theme 1: Human factors User-related attributes such as being younger, having a higher education level, good awareness, exposure to digital literacy, and commitment were identified as facilitators for the sustainable use of eHealth solutions. This was resounded by: “Those in the older age brackets are less likely to use it compared to the younger one. They pushed their tablet to the young Nexus to demonstrate and I asked them whether they were not part of their training. So the young ones should use and demonstrate to me how the system works” (Male, PG03) Additionally, positive attitudes, willingness, prior exposure, and acceptability of the eHealth solution by end-users were identified as major contributors to the long-term use of digital health applications. Participants in the study also stated that incentivized employees were more likely to use eHealth solutions than non-incentivized ones. Even though many attributes have been mentioned by study participants as contributing to sustainable use of eHealth solutions, there are a few that have a significant impact on the technology's viability. Lack of trained manpower, low digital literacy, lack of commitment and motivation, skill gap, a lack of trust in technology, resistance to change, a negative attitude, and fear of technology were mentioned as potential barriers to the sustainability of eHealth solutions in healthcare. This idea was expressed by: “No one maintains our medical technologies like CT Scan when stop working, but are maintained by someone who comes from other areas, which are the sources of our threat and difficult to trust the care organization that provides the technology since they don’t want to give full responsibility for us” (Male, PE10) Theme 2: Economy or funding According to the findings, adequate budget allocation, affordability, and profitability of technologies were key enablers of the long-term sustainability of eHealth solutions. This idea was echoed by: “The availability of sustainable funding and solid sponsoring are major facilitators for the implementation of sustainable eHealth solutions. Sufficient budget should cover the implementation of appropriate ICT infrastructure including software, equipment, network, maintenance, updating and end users training” (Female, PT09) However, we identified that lack of adequate funding, high startup cost, and reliance on donors were the major barriers to the sustainability of eHealth solutions. “….it is difficult to allocate sufficient budget to invest in the implementation of eHealth solutions. This always depends on external funding because we don't have a clear eHealth strategy and we don't set aside enough money and funds for this.”” (Male, PT02) Theme 3: Organizational attributes The availability of adequate human resources, technical personnel, IT experts, and skill training were all significant facilitators of the sustainable use of eHealth solutions. Furthermore, the availability of partners' involvement to cover financial issues, as well as the availability of capacity-building activities such as supportive supervision, mentorship, and conducting review meetings, was identified as potential enablers for the use of sustainable eHealth solutions. Additionally, having ongoing conversations with staff members, developing a sense of ownership, creating a supportive environment, and encouraging end-user participation were noted as crucial facilitators. Organizations with material and management support, leadership engagement, necessary infrastructure, and good workflow were also among the facilitators. We also discovered that the availability of leaders' support, organizational readiness, and organizational structure were reported as reliable facilitators of sustainable eHealth solutions. This was resounded by: “The eHealth solutions don't exist independently, it is the organizations that provide the eHealth solutions. The call managers or the topmost hierarchy of the organization must see health as a priority. Then that would trickle down to the ordinary worker” (Male, PG02) Contrarily, lack of manpower, staff turnover, lack of technical support, lack of digital literacy, and insufficient capacity-building activities were identified as critical challenges to the sustainability of eHealth solutions. Besides, participants added that lack of home-grown systems, lack of system integration, delayed bidding and procurement processes, lack of leadership support, and lack of incentives as major barriers to sustainable use of eHealth solutions. “It is good to use and integrate open sources with our homegrown software. It is dangerous to rely on open source alone because one day when things go the wrong way, it can lead to a devastating outcome. So in-house developed eHealth solutions are more trustable than open-source and partner-based systems” (Male, PE11) Theme 4: Technology and technological infrastructures System user-friendliness, system ownership, availability of strong data security, availability of data privacy, and confidentiality were all mentioned as important factors in the success of the eHealth solution. Furthermore, the usefulness, user-friendliness, and quality of digital solutions have all been identified as facilitators of sustainable use of eHealth solutions. In addition, reliable internet and LAN connectivity, backup and recovery tools, and larger storage and memory capacity of computers were reported as technology-related facilitators for sustained use of eHealth solutions. Furthermore, adequate power backups, adequate electricity, and infrastructure accessibility were described as prerequisites related to infrastructure for the long-term use of eHealth solutions. Among the many barriers, poor data security and privacy, software complexity, poor information exchange among users and systems, and lack of system maintenance were frequently mentioned as technology-related barriers. Furthermore, digital solutions that are not adaptable to local contexts were identified as a significant barrier. In line with this, poor data security and privacy were reported as the two main barriers to the sustainability of eHealth solutions. Unlike, lack of infrastructure, limited capacity of ICT infrastructure, frequent power outages, poor electrical installation, and poor internet connectivity are all potential barriers to the long-term viability of eHealth solutions. The idea was reverberated by: “I do not trust the sustainability and trustability of the existing infrastructure (frequent interruption and poor electric installation, no internet connectivity, etc.) to implement eHealth solutions. It needs more strengthening and improving” (Female, PT09) Theme 5: Policy and Regulation The availability of system governance and legislation were identified as key contributors to the sustainability of eHealth solutions. Moreover, lack of policy and legislation, and lack of standards were identified as potential barriers to the sustainability of eHealth solutions. This idea was echoed by: “When there are no well documented, sequential rules and tasks. There could be a barrier to eHealth solutions. The right workflow process that would help and definitely seem to move towards its achievements with regards to eHealth solutions” (Male, PG12) Discussion The varieties of the themes with their numerous sub themes that we have identified indicate that the sustainability of eHealth solutions is a complex topic. In addition, the themes and subthemes that were identified are often closely connected to each other. For example, the theme of economy is also related to issues mentioned in the users, human resources, and infrastructure themes. This study confirmed that end-users’ opinion influenced the use of new eHealth solutions in healthcare settings. This observation is consistent with previous research findings indicating that end-users' negative attitudes and fears about accepting and using new technologies impede the long-term viability of eHealth solutions [19]. On the contrary, current evidence suggests that health professionals' negative perceptions of eHealth solutions are gradually improving [20]. In this study, lack of technical experts with the necessary skills and training was identified as a major barrier to sustain the use of eHealth solutions. Digital illiteracy is still an important inhibitor for the sustainability of eHealth solutions, although its role has been identified for more than decade ago [20]. Many health professionals still lack the necessary skills to use eHealth solutions [16]. As a result, capacitating users through training and frequent support is essential for establishing a stable working environment. Our finding is consistent with existing literature [16, 21]. Economy and financing issues are also related to the workforce shortages in healthcare that also affect the sustainability of eHealth. Our research revealed that the initial cost of creating and deploying eHealth solutions was very expensive, directly affecting the adoption of eHealth technology. This finding is also supported by literature indicating that, long-term financing sources are very crucial for the adoption and successful implementation of new eHealth technologies [1, 22]. Economic issues make it difficult to make eHealth solutions visible, a strategy that is expected to promote acceptance and sustainability. High telecommunications costs and end-user training expenses are all common issues, particularly for developing countries [21, 23, 24]. Because of this, the majority of eHealth systems rely on outside funding to help them overcome budgetary constraints [9, 25]. However, given the limited lifespan of donor-driven eHealth solutions, their long-term viability is still in doubt. The important role of the economy theme is confirming the existing literature, and it seems to be a common issue both in high income countries and LMICs [14]. Findings from an Italian case study [26] indicated that, public strategies for improving eHealth integration and long‐term sustainability in public health care systems. As it has been mentioned by our informants, in LMICs the financing often comes from donors, and this is believed to further challenge sustainability. Donor funding might be short-term or not complying with the country's priorities and needs. National funding needs also to be strategic and long-term oriented otherwise it will impose challenges for the long-term viability of the system [14, 26]. Economy is also related to the infrastructure problems that LMCIs face when it comes to infrastructure for ICT and specifically for eHealth. The complexity of the technology was cited in our study as a barrier to the feasibility of eHealth solutions. On the other hand, it was recognized that the lack of qualified health personnel rather than technology was the limiting factor [5]. Moreover, findings also revealed that political or legislative aspects play a major role for the sustainability of eHealth [22]. However, in our finding, lack of policies and legislations were noticed in all the study areas. Despite the many challenges and barriers related to sustainability for eHealth that we identified, there are also promising approaches for improving sustainability. The scarcity of human resources is a challenge, but it can also be a factor of success. Good eHealth has the potential to increase the efficiency of existing healthcare workers, to improve the quality of the services delivered and to increase their accessibility. The economic issues might be challenging the ability of donors and governments to invest in expensive technology, but this increases the chances of investments in home-grown, open-source solutions that are adapted to the local infrastructure. Those solutions might be easier and cheaper to maintain over time, have easier access to local user support, and improve the capacity and the competence of the national eHealth market. At the same time, policies should ensure that investments have long-term orientation, and conform to standards for security, privacy, and interoperability.

Conclusions:

Conclusion and recommendations Although eHealth has been identified as a promising area of innovation for addressing health system challenges, LMICs continue to face many obstacles to implement new eHealth solutions. Lack of adequate infrastructure, lack of an adequate budget, shortage of technical manpower, and lack of home-grown software were reported amongst the top challenges to implement and sustain eHealth solutions. Donor-driven eHealth solutions face sustainability challenges related to project lifespan; on the other hand, context-based home-grown eHealth solutions were perceived as more sustainable.