ICTs and Health Technology
at the Grassroots Level inAfricaMargaret Nyambura Ndung’u

ATPS SPECIAL PAPER SERIES No. 33

Published by the African Technology Policy Studies Network, P.O. Box 10081, 00100
General Post Office, Nairobi, Kenya.

© 2007 African Technology Policy Studies Network (ATPS)

PUBLISHED BY ATPS COMMUNICATIONS DEPARTMENTABOUT THE AFRICAN TECHNOLOGY POLICY STUDIES NETWORKThe African Technology Policy Studies Network (ATPS) is a multi-disciplinary network of researchers,
policy makers, actors in the private sector and other end users interested in generating, promoting
and strengthening innovative science and technology policies in Africa. With a regional secretariat in
Nairobi, the network operates through national chapters in 23 countries, with an expansion plan tocover the entire sub-Saharan Africa.
One of the objectives of the network is to disseminate research results to policy makers, legislators,
the organized private sector, civil society, mass media and farmers’ groups through publications,dialogue and advocacy. Among its range of publications are the Working Paper Series (WPS),
Research Paper Series (RPS), Special Paper Series (SPS) and the Technopolicy Briefs.
Papers published under the ATPS Special Paper Series are those commissioned as concept
papers, think pieces, leading conference papers and keynote addresses. In keeping with
our knowledge brokerage function, ATPS publishes, with permission of the author(s) or
journal editors, papers (published or unpublished) produced by distinguished academics/
researchers for a different purpose but judged by ATPS to be of excellent quality. Thesepapers address significant policy questions relevant to the work of ATPS and/or support
the Southern voice or an African perspective. We also consider theoretical papers that
advance our knowledge of science and technology policy issues.
ATPS is supported by a growing number of donors including the International Development ResearchCentre (IDRC), the Carnegie Corporation of New York, the Rockefeller Foundation, the World Bank,
the OPEC Fund, Ford Foundation, Coca-Cola Eastern Africa, the African Development Bank, InfoDev,
European Union and the Royal Dutch Government.

Table of Contents

1.

Introduction

1

2.

What are ICTs?

2

3.

The Case of AfriAfya

3

4

Role of ICTs in e-health at the Grassroots Level

5

5

Grassroots Connectivity Initiatives: The Major Challenges

8

6

Key Lesson

11

7

Tips on ICTs Introduction at the Grassroots

12

8

Recommendations to Policy Makers

139Conclusion

14

References15

Acronyms

DRC
GDP
HCPs
HR
ILO
MDGs
OECD
R&D
RN
RSA
UK
UNECA
USA
WHO

Democratic Republic of Congo
Gross Domestic Product
Health Care Professionals
Human Resource
International Labour Organization
Millennium Development Goals
Organisation for Economic Co-operation and Development
Research and Development
Registered Nurse
Republic of South Africa
United Kingdom
United Nations Economic Commission for Africa
United States of America
World Health Organization

Introduction

One of the central questions of the 21st century is how technology is producing a change in our modeof operation and how its benefits can be used and applied positively. Today’s communications
technology has enormous potential for helping people and communities improve their circumstances.
The communications environment in which most people live has changed radically over the last
decade, both in relation to the information people have access to, and the opportunities people haveto communicate their own perspectives on issues that concern them.
Knowledge transfer should not be a one-way street. Too little regard is being given to the role andpotential of local, traditional and indigenous knowledge, especially from rural communities, in the
global equation. Efforts to reverse the situation have faced several challenges.
The difference in opportunities to access information has been referred to as the “digital divide”.
This term has become widely used to denote the inequity in the opportunities presented by the newtechnologies commonly known as Information and Communication Technologies (ICTs). The
expanding digital divide is making a new dimension of poverty (information poverty), which is highly
significant and visible. The potential levels of impact (both present and future) derived from thistechnology-related gap are fairly serious.
With scarce resources available for very basic development needs, such as water and sanitation,
education, food security, and income generation, one may wonder why countries should then botherto provide these new technologies, and whether they are not unnecessary luxuries in many contexts.
It should be realized that these technologies are nothing more than advanced information tools to be
used if and when their use is beneficial. Among a poor farmer’s first priorities is to get sufficient foodfor his family. ICTs can help him find better prices for his produce and enable him to buy more andhigher quality food. The issue of ICTs and the digital divide is ultimately about greater choices. New
technologies are not a solution by themselves.

1

2.

What are ICTs?

ICTs is an acronym for Information and Communication Technologies. It is a technology that has
revolutionized communication for the past two decades. It is a term used to describe bothmodern and old forms of communication ranging from the radios and telephones to the modern
technologies such as the Internet and mobile communications. There is a convergence1 of allthese technologies. In health, various systems have been developed with a view to effectively andefficiently delivering health services. ICTs have been used in various e-health initiatives such as
telemedicine2, electronic data records, e-learning and in health management information
systems.

1

A term applied to the way in which computing, telecommunications and, more recently, television are moving towards acommon technological basis characterized by the use of digital systems.
2
A term applied to the way in which com
puting, telecommunications and, more recently, television are moving towards a common technological basis characterized by
the use of digital systems.

2

3.

The Case of AfriAfya

AfriAfya is a consortium of seven health NGOs (partner agencies) in Kenya, together with the Ministryof Health. The partner Agencies are: Aga Khan Health Services, Kenya; AMREF (African Medical
and Research Foundation); CARE Kenya; Christian Health Association of Kenya (CHAK); HealthNet
Kenya; Plan Kenya; World Vision Kenya; Ministry of Health, Kenya.
The idea for AfriAfya was based on the realization that while modern ICTs had provided commercial
entities, universities, ministries, research institutions and big hospitals with information for theiractivities, it had done little for rural communities in the area of health. Rural and poor communities
missed the benefits that arise from these modern communications, in both giving and receiving
information. The agencies involved recognized that these new communication methods were notunderstood sufficiently well to be put into practice in much of the African continent.
It was noted that while there is severe shortage of up-to-date health information in rural settings, there
is an abundance of health information in the various forms of ICTs especially the Internet, and yet the
ICTs were not impacting rural communities.
AfriAfya was thus inaugurated to explore possible ways of improving communications for health andsocial development.

3.1

How ICTs have been used in AfriAfya

AfriAfya has used a range of ICTs. It attempts to combine modern and traditional communication
methods. Some of the ICTs that have been used include:
q Audio programmes and video shows
q Diskettes, CD-ROMs and memory sticks with adapted health information in local languages
q Pamphlets, flyers and print-outs of desired information
q Mobile phones for both voice and data – bulk SMS using a customized softwareq World Space radios – downloading selected Internet information
q Incorporating messages into traditional communication channels – drama, plays and songs
ICTs have generally been used to repackage health and development information. They have beenused to link and dialogue with communities, researchers, and academia as well as to collaborate
with partner organizations to implement health information systems.

3

4

ATPS SPECIAL PAPER SERIES NO. 33

Communication of up-to-date relevant health information to rural communities, production andsharing of local content and community mobilization has been done using ICTs.

4.

Role of ICTs in E-health at the Grassroots Level

At the level of community participation in the development arena, experience indicates that while therhetoric is very much present, the structures to ensure a circular flow of information between andwithin local communities or between local communities, development workers and policy-makers
are lacking. This is both at the national and international levels. A lot of valuable information, whichis generated at the higher level rarely gets to the intended beneficiaries. In return, feedback fromlocal communities on their own interpretations and solutions based on the impact of information or
programmes intended to alleviate local problems scarcely ever gets back to the designers at themacro level, or to other communities with similar problems.
There are various e-health projects that have been started, aimed at making use of ICTs to benefit
the rural communities. Some of the projects are described as follows:

4.1

Telemedicine projectThis project was founded in 2004 by the African Medical and Research Foundation in partnershipwith the ministries of health in Kenya and Tanzania. This was after the realization that health careand technology were converging fast in Africa. The majority of people in Africa remain rural based
and their health care is minimal. In contrast, the epicentre of health care expertise and resources inAfrica remains in the cities. AMREF noted that health care had not physically expanded to the rural
areas despite the efforts of both government and international organizations. This is because of theenormous logistical costs and social change needed to make this both effective and efficient.
AMREF realized that if modern ICTs are innovatively and appropriately used, they would improveaccess, quality and cost of health care for rural populations. AMREF developed a concept to connectrural health care facilities to the centres of excellence in the cities electronically in a regional ‘healthintranet’ and in turn to the world, enabling access to bodies of medical knowledge hitherto
inaccessible. In this way health care is taken to the patient rather than the other way round.
AMREF has been in the medical field since 1957 and they have been using voice radio equipment
to communicate. This had its own limitations ranging from unreliability, lack of accuracy andreliance on memory without much documentation. Also, given that some hospitals are in very rural
set-ups, patient follow-up faced many challenges. Medical staff also faced some challenges which
included:q Poor infrastructure and austere logistics when performing operations

5

ATPS SPECIAL PAPER SERIES NO. 33

6qProfessional and social isolation which resulted in poor morale and staff turnover

The telemedicine project is perceived to address these problems. In addition, AMREF has started
a distance e-learning programme that aims at upgrading the skills of 26,000 nurses through distancelearning.

4.2

Community health information systems

There are a number of projects working to develop community information systems, as well as tostrengthen existing health information systems that are being funded by the Rockefeller Foundation(RF). These projects are run by AfriAfya, AMREF Kenya, Aga Khan Health Services (Community
Health Department), Tropical Institute of Community Health (TICH) in Africa, and Moi University.
The first project was designed to forge linkages with these other RF-funded projects to complement
them and to harness the learning that has taken place and allow its application elsewhere. The
project also aims at allowing the outcomes of sharing community information to be monitored andthe impact to be evaluated.
AfriAfya works with Aga Khan Health Services (AKHS) in the coast region, AMREF Kenya in Eastern
Province, Moi University in Eldoret and Tropical Institute of Community Health and Development(TICH) in Nyanza region. The project areas are Kwale, Kilifi, Makueni, Kisumu, Siaya and Homa Bay
districts. These are rural districts located in the Coast, Nyanza and Eastern provinces that have highlevels of poverty and HIV/AIDS prevalence, and where the Rockefeller Foundation grantees alreadyhave other ongoing projects.
The RF-funded project is aimed at strengthening health information systems and health care delivery
through provision of relevant, reliable, usable and accessible information in a sustainable andappropriate manner in the selected target communities. The development partners have predesigned forms used for data collection by the community members. Data are then fed into a
computer for level one analysis by the community own resource persons (CORPS). At the partner
agency level, they have a data base using Ms Access. Further analysis is then done using SPSS and
Epi-Info.
The projects are mainly dealing with Health Management Information Systems (HMIS) andCommunity Based Health Information Systems (CBHIS). The project’s goal is to harness ICTs forcommunity health and development. The information generated by the communities and facilities
is used for decision making and planning at their level.
There is also focus on strengthening community-based information systems, and ensuring linkages
between these and the formal information system. The projects aim at providing a voice for theserural communities, as well as improved access to health and other development information in aneffort to reduce the causes and effects of ill health and poverty.

ICTS AND HEALTH TECHNOLOGY AT THE GRASSROOTS LEVEL IN AFRICA

4.3

7

Mosoriot medical record systems

In a unique collaboration, the departments of Medicine at Moi University, Kenya, and Indiana
Universities in the USA established the Academic Model for the Prevention and Treatment of HIV/AIDS (AMPATH). Since 2001, AMPATH has been providing care for HIV-infected patients in Kenya’
second national referral hospital and a series of rural health centres in western Kenya.
According to the writers of an electronic medical record system for ambulatory care of HIV-infectedpatients in Kenya, “the AMPATH Medical Record System” (AMRS) is the core to the HIV Clinic Care
Service. Clinicians enter data into an 8-page initial encounter patient record and a 2-page return visit
patient record. Data are entered into a central electronic data repository for HIV infected patients only
programmed in MS Access. After data entry, a summary report is printed that becomes part of thepaper record and contains selected clinical data and evidence-based, patient-specific computer
reminders for antiretroviral treatment, drug monitoring, and preventive care. Separate modules havebeen created for the antenatal clinic and the pharmacy. The design of the AMRS has input from thephysicians in the HIV clinics who are knowledgeable about the local community and the constraintsof a resource-poor setting. To date, the AMRS contains more than 20,000 visit records for more than
3,000 patients, almost half on antiretroviral therapy. Future development includes using wirelessconnections, tablet computers, and migrating to a Web-based platform.
The writers further state that, “the AMRS is the first functioning comprehensive electronic medical
record system committed to managing and improving the quality and efficiency of care for patientswith HIV/AIDS in sub-Saharan Africa. It has played a significant role in patient care at all AMPATH
sites. It has standardized patient data collection and made data retrieval much faster than the traditional
paper-based record. It has enabled evidence-based decision-making for patient encounters and forthe health system. The AMRS is affordable and represents a model system for recording critical HIV/AIDS data in resource-poor settings that will be delivering an increasing amount of HIV care. It willallow those funding the rapid increase in highly active antiretroviral therapy (HAART) to know the
return they are getting on their investment and hopefully encourage continued treatment of the worst
medical disaster to ever befall humanity.”

5.

Grassroots Connectivity Initiatives: The Major
Challenges

The deployment of ICTs at the grassroots level presents a number of major challenges. Given thepresent physical, financial and linguistic access constraints, there is urgent need to improve theconditions for equitable and affordable access, through which the benefits of the information age
are distributed. Some of the challenges faced in implementing ICTs at the grassroots level include
the following:
Policy and legal structures are lacking
Issues regarding legislation and regulation pose mounting challenges, as ICT applications continue
to be developed in many areas of the world. In most developing countries, the formulation andimplementation of policies in the ICT sector is still very rudimentary, and the situation calls for an
integrated set of laws, regulations and guidelines that shape the generation, acquisition and utilizationof ICTs. Most countries lack policies and strategies that facilitate the harnessing of new ICTs forrural development, and where policies have been formulated, proper implementation plans andreview strategies are often lacking.
High telecommunication costs in most developing countries have been a challenge
There are no telephones in rural areas hence alternative technologies have to be looked into. This
makes the cost of basic Internet a strong deterrent in many rural areas. Alternative communicationequipment such as the HF radio is very expensive in initial investment, installation and subsequentmonthly charges. Although market liberalization has led to the entry of several private sector ISPs,
service provision is through government telephone companies, of which service is inadequate interms of robustness, low band width, congestion and noisy lines. This adds to the cost of connection.
The telecommunication and electricity infrastructure in developing countries is lacking or
is poorly developed in rural areas
Satellite and wireless technologies are now in use in some developing countries, but these arelargely developed around urban cities. The initial capital for using these alternative technologies isvery high.
Lack of local content and language barrier
Information available through ICTs is mostly in English, which the majority of rural communities indeveloping countries cannot read. There is a marked shortage of relevant material in local languages

8

ICTS AND HEALTH TECHNOLOGY AT THE GRASSROOTS LEVEL IN AFRICA

9that responds to their needs, and this calls for significant investment and support for local content
that can address the local needs.
High rate of illiteracy in rural areas“Illiteracy is a fundamental barrier to participation in knowledge societies” (Mansell, 1998). A large
proportion of the rural population of developing country nations, the majority of who are women, is
illiterate. Most pictographic and audio-visual information has some text that goes with it. Thismeans that these individuals are disadvantaged and lack the basic skills required to harness thebenefits of ICTs. The assistance of intermediaries may thus be required.
Gender insensitivity has been a major challenge
Men and women in developing countries play different productive and community roles in ruraldevelopment and have different needs and preferences. Women have wisdom and indigenous
knowledge that is rooted in culture, traditions, values and experience. They produce more than half
the world’s food (World Bank, 2000) and face many problems in addressing food security and ruraldevelopment. When new technologies are introduced, they are seen as a domain for men. Women
have often been left out of initiatives associated with new ICTs. Their methods of communicationand information exchange should thus be harnessed and be complemented with new ICTs (FAO,
1999). Women also spend most of their income on family welfare and have a greater impact on
increasing agricultural productivity and improving the quality of family life.
The youth are another special group that deserves to be integrated in the ICTs projects
The youth have been given little opportunity to contribute to rural development issues, despite their
numbers and fresh and innovative ideas. It is only by giving them these opportunities that a criticalmass of information-aware people and leaders of tomorrow can be developed to ensure that theircountries realize food security and rural development goals.
Inadequate human resources have been a hindrance. To ensure more meaningful participation inrural development and to pave way for the creation of a critical mass of people that effectively
harness ICTs in developing countries, training and capacity building must be an integral part of all
ICT projects. To help in ensuring food security in Africa, human resource development throughknowledge building and information sharing is very crucial. Users of ICTs have to be trained in theuse, application and maintenance of ICTs before they become confident and comfortable enoughto use them.
There is lack of localized technical know how. Most staff managing ICT-based projects in rural
areas lack adequate training that would enable them to take full advantage of the new technologies.
There is need to invest in training and advisory services for information intermediaries, telecentre
staff, frontline workers and women’s groups. There is need to identify the best training approaches
for rural communities, targeting different user categories and different technologies. Such training
could be done through conferences, workshops or training of trainers’ courses. Introductory and10

ATPS SPECIAL PAPER SERIES NO. 33

sensitizing workshops could be organized for different categories of users, and local experts could
provide ongoing on-line support.
Sustainability of projects is often not given much consideration. Most projects established withexternal funding face major challenges after the project period has ended. Sustainability of theseprojects should be considered right from the onset and, where possible, should have government,
private sector and community support. Users should also pay for services at a subsidized rate. There
are as yet few examples of success in attaining such sustainability, and there is urgent need for
viable models to be developed and tested. For the success of any ICT project in the rural areas,
communities should be ready, willing and capable of taking the initiatives and responsibilities tomake them sustainable. Once the project life is over a method should be devised to ensure that it isable to generate money and possibly give employment to the local community. It should supplement
activities such as farming, agriculture and health issues within the area.
In some projects, emphasis has been more on the technology than the people. Uses that thetechnology will be put to are never given any consideration. As a result, participation and support
often come from a small group of people that in turn remains the only group benefiting from thefacility. In many projects, the problem is the information itself because the kind of information thatsuits the needs of the community and the suitable form through which to convey such information is
ignored.
Institutional management and policies have been a challenge to ICT implementation. This is bothat the level of the implementing organization, the donor and the target community. Participatory
management is very crucial at every level of project implementation.

6.

Key Lessons

Experience in information and communication technologies for development (ICT4D) projects has
shown that ICTs have to address practical problems to be relevant. It is important to have a two-way
communication process and share information that users can identify with. Community informationneeds must be researched on and appropriate materials and content developed.
The implementers must understand local power dynamics, minimize social exclusion and endeavour
to strengthen the social capital. Building relationships to improve livelihoods and economic
development is key. A project must focus on community priorities and not the technology. It is
important to plan for financial sustainability. Social and institutional sustainability must be incorporated.
Lessons from the project must be shared with practitioners, researchers and donors. Monitoring andevaluations must be continuous.
Experience has proved that ICT skills transfer is relatively easy. However, this is subject to the way it
is done. There must be an attempt to adapt to local infrastructure and choose appropriatetechnologies. ICTs must be blended with traditional information systems and be built on existing
information systems.
It has become increasingly clear over the past two years that offering the whole world a phone and acomputer screen will not in itself help bridge the digital divide. The new technology is practicallyworthless unless people are equipped with the know-how, and the willingness, to use it. Those who
cannot use it confidently will become increasingly marginalized within the modern world. As Edwyn
James (2000) clearly states in his article ‘Learning to Bridge the Digital Divide’, “It is not enough toequip people with computers. It is necessary but not sufficient to provide avenues to information andknowledge. What is more important is to empower people with appropriate educational, cognitiveand behavioral skills and tools.”
There are some arguments and beliefs that new technology would soon be widely available toindividuals and communities worldwide. However, there are also doubts that technology would be acure for all of today’s problems. Merely because people have access to the Internet does not mean
their lives will improve. In addition, emerging economies might not compete in the capital-intensive
world of information technology and are in danger of being left behind in the information revolution.

11

7.

Tips on ICTs Introduction at the Grassroots

Those introducing the ICTs must engage in ongoing dialogue with local people about the role andimpact of ICTs and the context in which they will be introduced.
The local people and the larger community should identify their needs, which should be the driving
force behind ICTs projects, rather than the projects or the technology.
Awareness should be raised on how ICTs projects may impact the community and affect people’s
lives and livelihoods.
Dialogue and debate on who has control of these new tools and what effect they may have on
community power dynamics should be promoted. Cultural and social sensitivity to the use of ICT
tools for educational and informational purposes should be taken into account.

12

8.

Recommendations to Policy Makers

The Ministry of Health and the ministry concerned with ICTs should work together to put up
infrastructure for health management systems.
More rigorous monitoring and evaluation of projects should be done and frameworks or guidelines
for measuring impact should be developed.
There should be a shift from technology-driven projects to a more holistic approach in which thewider systemic economic, social and communication aspects of communities are central concerns.
Partnerships should be created with public and private institutional infrastructures (universities,
research institutions, schools, libraries, hospitals, NGOs) and built on existing formal and nonformal local organizations and communication networks.
Governments should encourage health workers at the grassroots level to stay long, through incentives
such as appropriate compensation, opportunities for distance learning, and so on.
E-health initiatives should be encouraged and promoted through ensuring that ICT equipment for
health related activities are zero rated.

13

9.

Conclusion

The information revolution has clearly shown that ICTs are very applicable and relevant at thegrassroots level in Africa. However, it is not true that if you give people the computers they will have theneed to access information. It is important to find out what information people have access to, andwhether it empowers poor people and gives them a greater voice.
This follows from the fact that knowledge is socially distributed. Information by itself is insufficient.
Maintenance of the information systems resources should also be given the necessary consideration.
To ensure sustainability of new communication technology at the grassroots level, there is need toensure that ownership of both the message and the medium, the content and the process resides
with the individuals or communities affected. New technologies should have a bias towards
communication that gives voice to the previously unheard, and that has a bias towards local content
and ownership.

14

References
Dzidonu C.K. (2002). A Framework for Guiding the Development of ICT-led Socio-Economic
Development Policies, Strategies and Plans, Africa Technology Policy Study (ATPS), Special
Working Paper Series No.5, Nairobi, Kenya (2002).
Edwyn, J. (2000). Information and Communication Technology (ICT) in Education
and Training – the Route to an Inclusive Society, OECD/CERI.
FAO report (1999/2000).
Rotich J.K., Hannan T.J., Smith F.E., Bii J., Odero W.W., Vu N., Mamlin B.W., Mamlin J.J., Einterz
R.M., Tierney W.M. Installing and implementing a computer-based patient record system in
sub-Saharan Africa: The Mosoriot Medical Record System. J. Am. Med. Inform. Assoc. 10 (2003)
293-303.
Ndung’u M. N. (2002). Uses of new technologies for social change: A paper presented at the Global
Community Journalism: Developing guidelines for covering and participating in communication
for social change.
Ndung’u M. N. (2002). Deployment of rural community based information and communication
technologies (ICTs) networks.
Mansell R. and Utah When. (1998). Knowledge societies: Information technology for sustainable
development. For United Nations Commission on Science and Technology for Development.
World Bank Development Report. (2000).

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ATPS SPECIAL PAPER SERIES NO. 33

Margaret Nyambura Ndung’u is with African Health Network for Knowledge Management andCommunications - AfriAfya.

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