Most developing countries, including Uganda, have embraced the use of e-Health and m-Health applications as a means to improve primary healthcare delivery and public health for their populace. In Uganda, the growth in the information and communications technology industry has benefited the rural communities and also created opportunities for new innovations, and their application into healthcare has reported positive results, especially in the areas of disease control and prevention through disease surveillance. However, most are mere proof-of-concepts, only demonstrated in use within a small context and lack sustainability. This study reviews the literature to understand e-Health’s current implementation status within Uganda and documents the barriers and opportunities to sustainable e-Health intervention programmes in Uganda.
A structured literature review of e-Health in Uganda was undertaken between May and December 2015 and was complemented with hand searching and a document review of grey literature in the form of policy documents and reports obtained online or from the Ministry of Health’s Resource Centre.
The searches identified a total of 293 resources of which 48 articles met the inclusion criteria of being in English and describing e-Health implementation in Uganda. These were included in the study and were examined in detail.
Uganda has trialled several e-Health and m-Health solutions to address healthcare challenges. Most were donor funded, operated in silos and lacked sustainability. Various barriers have been identified. Evidence has shown that e-Health implementations in Uganda have lacked prior planning stages that the literature notes as essential, for example strategy and need readiness assessment. Future research should address these shortcomings prior to introduction of e-Health innovations.
The World Health Organization (WHO) defines e-Health as the use of information and communication technologies (ICTs) for health.
e-Health tools [mobile and fixed phones, voice over internet protocol, text and multimedia messaging] encourage communication between healthcare providers and their clients, sharing of information and knowledge among healthcare providers and establishing of better healthcare for patients.
While the potential of e-Health for sub-Saharan Africa is great, its uptake has been poor. A number of factors have been identified for this. These include: the excessive burden of disease in Africa
Uganda is a landlocked country with a population of 41.2 million people, 85% of whom live in rural areas. The median age is 15 years. There are only eight physicians per 100 000 people who work in a pluralistic health system with a government-funded public sector, and private for profit and not for profit sectors supplemented by traditional and complementary medicine.
The public system is decentralised at district and sub-district levels ranging from national referral hospitals (NRHs), regional referral hospitals, general hospitals, health centres, to village health teams. The referral systems from lower to higher levels do not work well, due in part to poor transport and communication systems and staff shortages, with 44% of the established positions within the healthcare system vacant. The majority of the population is reliant on nurses, aid workers and traditional birth attendants for healthcare.
The Government of Uganda recognises e-Health as an enabling platform to improve healthcare delivery by allowing doctors to consult and diagnose remotely, access patients’ medical information, provide district health information surveillance data and in addition facilitate research studies.
Internet penetration in Uganda is steadily growing – now estimated at 31%.
Several studies conducted in developing countries, including Uganda, have demonstrated an increasing application of e-Health systems for healthcare delivery.
A structured search of peer-reviewed literature on e-Health in Uganda was undertaken between May and December 2015, and complemented with hand searching and a document review of grey literature in the form of policy documents and reports online or from the Ministry of Health’s (MoH’s) Resource Centre.
The online databases, PubMed, Google Scholar, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, EBSCO Health and Lilacs (Virtual Health Library) were searched. Published articles were complemented with a desk review of unpublished documents: reports and policies related to e-Health implementation in Uganda obtained from the MoH library. In PubMed, the following search string was used: ‘Uganda’ [Mesh] AND (‘Telemedicine’ [MeSH] OR ‘telemedicine’ [Text word] OR ‘telemedicine’ [All fields] OR ‘e-Health’ [All fields] OR ‘e-Health’ [Text word] OR ‘cell phones’ [Mesh] OR ‘Cell phones’ [All fields] OR ‘Electronic Medical Records’ [Mesh] OR ‘Electronic Medical Records’ [All fields]). For Google Scholar, the search was performed using four key phrases; e-Health in Uganda, telemedicine in Uganda, electronic medical records (EMRs) in Uganda and m-Health in Uganda (only the first 100 resources from each of the four Google Scholar searches were reviewed). These searches were supplemented by search of conference proceedings from ISTAfrica and Med-e-Tel [all conference years, in two thematic areas (e-Health and m-Health)], and hand searching of unpublished documents, including reports and policies obtained from the MoH Resource Centre. Titles and abstracts were reviewed to determine inclusion or exclusion. Inclusion criteria were broad: the document reported on e-Health activities in Uganda, and was in English.
The online searches identified 426 articles of which 146 articles were excluded as duplicates. In total, 293 unique resources were identified and reviewed: 280 from the database searches and 13 grey literature resources in the form of policy documents, reports and web articles. Inclusion criteria were not met by 245 articles and the remaining 48 articles were included in the study.
These 48 articles were classified according to the themes represented by the subject matter of the paper, thesis or report. The thematic areas were: m-Health – 23, electronic records systems – 8, telemedicine – 6, ICT – 6 and government policy documents and reports – 5 (
A summary of articles and reports that met the inclusion criteria.
Articles, theses, and reports | Author name, year | Findings |
---|---|---|
Into Africa: The telemedicine links between Canada, Kenya and Uganda. | House et al. (1987) | Study confirmed that new approaches to education and consultation can effectively be applied through ICT. |
The Nakaseke multipurpose community telecentre in Uganda. | Mayanja (2001) | A telecentre was designed to provide a test bed for future investment in ICT for rural development. |
Tele-dermatology web consultation and e-learning project Kampala-Mbarara, Uganda and Graz, Austria. | Kaddu (2007) | Despite being deemed successful, challenges encountered included technical and systems problems, plus economic and cultural limitations. |
Factors affecting adoption, implementation and sustainability of telemedicine information systems in Uganda. | Isabalija et al. (2011) | Innovations around telemedicine are persistently being hindered by the lack of policy on use of telemedicine, insufficient knowledge and skills among health workers and resistance to change. |
Feasibility and diagnostic accuracy of Internet-based dynamic telepathology between Uganda and Germany. | Wamala et al. (2011) | Internet-based conferencing systems offer an inexpensive method of obtaining a primary diagnosis by telepathology and consulting on cases that require subspecialty expertise. |
A framework for designing sustainable telemedicine information systems in developing countries. | Kituyi et al. (2012) | The key requirements for designing sustainable telemedicine information systems in developing countries were identified as the need for speed, ease of use and affordability. |
Using HMIS for monitoring and planning: The experience of Uganda Catholic Medical Bureau. | Mandelli and Giusti (2005) | The existing HMIS can be used as a tool to monitor the effects of managerial decisions. |
Creation and evaluation of EMR-based paper clinical summaries to support HIV-care in Uganda, Africa. | Were et al. (2010) | By taking advantage of data stored in EMRs, efficiency and quality of care can be improved through clinical summaries, even in settings with limited resources. |
Use of an innovative, affordable, and open-source short message service-based tool to monitor malaria in remote areas of Uganda. | Asiimwe et al. (2011) | Use of SMS-based reporting systems have the potential to improve timeliness in reporting of specific, time-sensitive metrics at modest cost, while bypassing current bottlenecks in the flow of data. |
Electronic medical records and same day patient tracing improves clinic efficiency and adherence to appointments in a community-based HIV/AIDS care programme, in Uganda. | Alamo et al. (2012) | EMR and same day patient tracing can significantly reduce missed appointments (LTFU) and improve clinic efficiency. |
Review of developing country health information systems. | Foster (2012) | Uganda has strong evidence of planning and implementation of adequate ICT infrastructure for health facilities. |
A study of the preconditions for a sustainable implementation of a digital health system in Uganda. | Gårdstedt et. al. (2013) | There is no need for sophisticated technologies for Uganda to achieve sustainable ICT projects within healthcare. |
e-Health at outpatient clinics in Uganda. | Hindemark (2013) | Because of the multitude of non-compatible e-Health projects in Uganda, the report calls for a consolidation of efforts and sharing of information among the e-Health application developers of Uganda. |
Designing an architecture for secure sharing of personal health records – A case of developing countries. | Ssembatya (2014) | Identity-based encryption can be extended to mobile phones to secure patient health records beyond the hospital server domain. |
Responding to the human resource crisis: Peer health workers, mobile phones, and HIV care in Rakai, Uganda. AIDS Patient Care. | Chang et al. (2008) | A simple and inexpensive clinical and adherence monitoring intervention leveraging PHWs empowered with mobile phones can successfully be implemented in a rural resource limited setting. |
m-Health: Mobile phones in HIV prevention in Uganda. | Salomonsson (2010) | Mobile phones can be both feasible and effective in HIV prevention campaigns in east African settings despite structural constraints such as lack of electrical power and illiteracy. |
Using mobile phones to improve clinic attendance amongst an antiretroviral treatment cohort in rural Uganda: A cross-sectional and prospective study. | Kunutsor et al.(2010) | Mobile phones have a potential for use in resource-constrained settings to substantially improve the clinical management of HIV/AIDs. |
Using SMS for HIV/AIDS education and to expand the use of HIV testing and counselling services at the AIDS Information Centre (AIC) Uganda. | Hoefman and Apunyu (2010) | Study outcome saw a high acceptance rate of the SMS survey and increase in the number of people accessing HCT. |
Using personal digital assistants to improve healthcare delivery in Uganda (Doctoral dissertation, Malmo University, Sweden). | Kirunda (2010) | The use of PDAs can improve healthcare delivery in rural health facilities. |
Impact of an m-Health intervention for peer health workers on AIDS care in rural Uganda: A mixed methods evaluation of a cluster-randomised trial. | Chang et al. (2011) | Interventions for m-Health registered improvements in patient care, logistics and broad support among patients, clinic staff and PHWs. |
Cell phone usage among adolescents in Uganda: Acceptability for relaying health information. | Mitchell et al. (2011) | Need for effective HIV prevention programmes that can reach large audiences at low cost and are culturally relevant for the Ugandan context. |
You have an important message! Evaluating the effectiveness of a text message HIV/AIDS campaign in Northwest Uganda. | Chib et al. (2012) | Potential of m-Health tools when extended to millions of mobile phone users as part of an integrated health campaign approach. |
Mobile phones in health care in Uganda: The Applab study. | Nchise et al. (2012) | A need to integrate a referral system to registered health professionals and their facilities, and the need for education and/or marketing strategy with an indigenous branding to address the misconception of the brand name ‘Google SMS’. |
m-Health and developing countries: A successful obstetric care model in Uganda. | DeStigter (2012) | Uganda still experiences challenges due to expensive equipment and high electrical power requirements hindering developments in e-Health. |
Usability testing of a prototype phone oximeter with healthcare providers in high- and low-medical resource environments. | Hudson et al. (2012) | User feedback was positive and the overall usability was high. |
High acceptability for cell phone text messages to improve communication of laboratory results with HIV-infected patients in rural Uganda: A cross-sectional survey study. | Siedner et al. (2012) | Cell phone text messaging for communication of abnormal laboratory results is highly acceptable in a cohort of HIV-infected patients in rural Uganda. |
Optimising network connectivity for mobile health technologies in sub-Saharan Africa. | Siedner et al. (2012) | Addition of SMS to standard GPRS cellular network connectivity can significantly reduce network connection failures for mobile health applications in remote areas. |
Perceptions and acceptability of m-Health interventions for improving patient care at a community-based HIV/AIDS clinic in Uganda: A mixed methods study. | Chang et al. (2013) | Study findings were vital to guide future design and implementation of m-Health interventions in this setting, optimising their chances for success. |
Cost analyses of PHW and m-Health support interventions for improving AIDS care in Rakai, Uganda. | Chang et al. (2013) | The PHW intervention (m-Health) was found to be cost saving. |
Vulnerabilities in m-Health implementation: A Ugandan HIV/AIDS SMS campaign. | Chib et al. (2013) | Interactive SMS quiz design motivated recipients with the correct HIV/AIDS knowledge to respond (and thus become eligible for free HIV screening). |
The role of m-Health in Uganda: A tool to reach development. | Mattsson and Sabuni (2013) | ICT tools such as m-Health were identified. However, collaboration between NGOs and government must exist to build communication and organisational structure. |
Response patterns to interactive SMS health education quizzes at two sites in Uganda: A cohort study. | Lepper et al. (2013) | Future research should focus on developing evidence-based guidelines for the design, implementation and evaluation of SMS-based interventions. |
The role of mobile health technologies in improving community health seeking practices in rural Uganda. | Liu and Lin (2014) | Study showed a critical gap in the local healthcare infrastructure that needs to be addressed in order to establish more efficient delivery of healthcare services. |
A pilot study on mobile phones as a means to access maternal health education in eastern rural Uganda. | Roberts et al. (2014) | Providing local communities with mobile maternal health education offers a new potential method of reducing maternal mortality. |
Demographic and psychosocial characteristics of mobile phone ownership and usage among youth living in the slums of Kampala, Uganda. | Swahn et al. (2014) | Given that nearly half of the youth own and use phones daily, new research is needed to determine next steps for mobile health (m-Health). |
A model of e-Health acceptance and usage in Uganda: The perspective of online social networks. | Miiro and Maiga (2014) | A generic social networked model was developed that can be adopted for use by other transitioning countries. |
Introduction of mobile phones for use by volunteer community health workers in support of integrated Community Case Management (iCCM) in Bushenyi District, Uganda: Development and implementation process. | Tumusiime et al. (2014) | Robust mobile phone–based system may contribute to efficient delivery of iCCM by trained volunteer CHWs in rural settings in Uganda. |
Application of information and communication technology (ICT) in health information access and dissemination in Uganda. | Omona and Ikoja-Odongo (2006) | All stakeholders in the health sector need to support and promote ICT as the most effective tool for health information access and dissemination. In addition, a number of challenges must be addressed if full benefit of the use and application of ICT is to be realised in Uganda. |
ICTs and health in Uganda: Benefits, challenges and contradictions. | Litho (2007) | Development in ICTs for health creates opportunities and benefits for Uganda to step up and embrace sophisticated modes of healthcare delivery. |
Information and communication technology and community-based health sciences training in Uganda: Perceptions and experiences of educators and students. | Chang et al. (2012) | Internet access in rural educational sites is still lacking, but students and educators appear eager to utilise this resource if availability improves. |
A framework for sustainable implementation of e-medicine in transitioning countries. | Isabalija et al. (2013) | e-Medicine sustainability in sub-Saharan Africa is affected by institutional factors. |
Understanding ICT behaviours among health workers in sub-Saharan Africa: A cross-sectional study for laboratory persons in Uganda. | Kasusse et al. (2014) | It is viable/feasible to pilot informatics projects as strategies to build bridges and develop skills for an e-Health landscape in laboratory services with a bigger financial muscle. |
A structured approach for evaluating ICT contributions to development. PhD Thesis. Stockholm University, Faculty of Social Sciences, Department of Computer and Systems Sciences. Makerere University, Uganda. | Kivunike (2015) | Proposes a model and criteria for the evaluation of ICT-related development, recommends complementary qualitative and quantitative approaches and proposes indicators to appropriately evaluate the ICT contribution to development. |
National Health Policy: Reducing poverty through promoting people’s health. | Ministry of Health-Uganda (2009) | Government of Uganda official policy document. |
Health Sector Strategic Investment Plan III. | Ministry of Health-Uganda, (2010) | The health sector strategic plan three for the period 2010/11–2014/15. |
The Second National Health Policy: Promoting people’s health to enhance social-economic development. | Ministry of Health-Uganda, (2010) | Government policy document about the health sector in Uganda. |
Computerised and integrated human resource information system. | Ministry of Health-Uganda, (2011) | Government policy document about human resources in health. |
Uganda Health System Assessment. | Ministry of Health-Uganda (2011) | A report on the five health systems building blocks of the healthcare system in Uganda. |
CHWs, community healthcare workers; EMRs, electronic medical records; HCT, HIV counselling and testing; HMIS, Health Management Information System; LTFU, loss to follow-up; NGO, non-government organisation; PDA, personal digital assistants; PHWs, peer health workers.
e-Health in Uganda started in the 1980s when an audio satellite connection was established between Uganda and Canada for postgraduate education support, to which was added electroencephalogram (EEG) transmission.
Uganda has a fast growing ICT industry, especially in mobile technology. This has enabled innovations around m-Health tools, for instance, the ICT4MPOWER project initiated by the MoH, Uganda Communications Commission (UCC) and the Ministry of ICT (MoICT) aimed at strengthening the flow of information right from community to national levels of the healthcare system. The first site to benefit was Mukono Health Centre IV.
An EMR system was implemented to improve access to antiretroviral treatment at the Reach out Mbuya HIV/AIDs clinic, which reduced missed appointments and improved clinic efficiency.
The Uganda National Drug Authority developed an SMS-based platform (U-reporting) that is used to generate the national procurement and supply management plan.
Uganda’s healthcare system has benefited from donor funding. The Canadian International Development Research Centre funded a telemedicine project based on the East African Telemedicine Project of the 1980s, ‘HealthNet’. The aim was to improve distance education among medical students and to enable resource sharing at Mulago hospital with other health workers in remote areas. In addition, a pilot project strove to enhance data capture, storage, interpretation and retrieval of patients’ information among health workers using a handheld computer (portable digital assistant).
Ugandans seek healthcare through a range of telehealth or m-Health-related means. This includes calling into the local radio medical talk show to get medical advice from the doctor, while those with internet access probably subscribe to daily health tips via their mobile phones and e-mail addresses. In addition, they also use the phone application to diagnose their health conditions, search the internet for health information, post queries for alternative opinions and share experiences on health and illnesses on social networks.
In June 2014, the Government of Uganda commissioned a new building complex for Masaka Referral Hospital that will be fitted with telemedicine related equipment such as televisions/monitors, internet connections, cameras and many others, which will allow patients to link with medical consultants at the NRH – Mulago, minimising physical daily referrals. Similarly, the University of Virginia (USA) and the Mbarara University of Science and Technology link by videoconferencing for interactions in research, education and clinical practices among students at both universities.
The literature identified a spectrum of barriers and opportunities relevant to Uganda. These are discussed below according to the themes previously identified in
According to Uganda’s 2013 national e-Health policy,
Uganda’s National e-Health Policy also identifies the non-existence of e-Health standards and systems as challenges.
e-Health innovations can reduce healthcare costs and enable access to better quality healthcare, provided there is adequate infrastructure. However, consistent power blackouts, loss of internet connectivity and the presence of an unskilled health workforce hinder its uptake.
In the 1980s, the first teleconferencing link established between University of Nairobi, Makerere University and their Canadian counterparts failed because of political turbulence. Meanwhile, the programme provided for personal physician collaboration where faculty from Uganda and Kenya received training in particular fields, while those from Canada served as visiting faculty at the different universities.
Lack of knowledge and skills about telehealth, and the absence of policy and guidelines for the use of telehealth at hospitals, have been cited as major barriers to its adoption in Uganda.
Human resources for e-Health comprise health workers, ICT professionals and electronic content developers. These health cadres have low levels of computer literacy and skills to use ICT equipment and systems, especially those in rural areas.
Countering this reality, ICT development has had a profound impact on Uganda’s economy.
In addition, there is promise for m-Health interventions and increased use of mobile phone technology in Uganda in both rural and urban communities despite the poverty levels.
Uganda has adopted e-Health services such as m-Health programmes to improve healthcare delivery.
Electronic medical records (EMRs) are used for storage, management and retrieval of patients’ data.
Regardless of the presence of a strategy to guide implementation, or an evidence based need, if the setting is not ‘ready’ to use these innovations, they will not succeed.
Opportunities exist to respond to many of the challenges identified. Conventional guidance highlights the requirement for a defensible (health needs based, evidence based and prioritised) e-Health strategy that invokes e-Health only when demonstrated to offer viable solutions.
e-Health is among the building blocks upon which modern health sectors are built. This involves combined use in the health sector of ICTs for learning, research, data acquisition, surveillance, storage and access to patient data and clinical care even at a distance. In developing countries, e-Health solutions have the potential to improve health through enhancing capacity of the health workforce, especially where traditional means are lacking. They may also improve access to relevant information through eliminating constraints like distance and time in accessing information and sharing knowledge.
The literature shows a plethora of e-Health-related activities within Uganda over many years. Uganda has trialled several e-Health and m-Health solutions but most were donor funded, operated in silos and lacked sustainability. Evidence has shown that e-Health implementations in Uganda have lacked prior planning stages of need and readiness assessment, noted in the literature as essential. It is clear that the healthcare system in Uganda has taken the initiative to adopt e-Health programmes such as mobile applications and health information systems. Several barriers have been identified. Furthermore, several ICT infrastructural enhancements geared towards reducing costs of internet bandwidth will contribute to future implementation of more e-Health programmes, enabling teleconsultations, tele-education and teleconferencing activities. However, implementation must lead to sustained programmes. This requires evidence based and defensible strategy, needs based applications, a skilled and a knowledgeable workforce and a ‘ready’ setting. There is no evidence in the literature of a holistic ‘e-Health Readiness Assessment’ having taken place in any of the existing projects prior to implementation. Further research on the development and use of e-Health readiness tools relevant to Uganda is required, and awareness of the need to conduct e-Health readiness assessment during the planning of e-Health programmes needs to be raised.
Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under Award Number D43TW007004. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors declare that they have no competing interests in publishing the piece of work.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
V.M.K., M.M. and R.E.S. conceptualised the study and participated in the literature review. V.M.K. wrote the first draft of the paper; M.M. and R.E.S. revised it. All authors read through and approved the paper for final submission.