South African policy relating to digital communication and its use for

During the Vutivi study there was policy debate about the implementation of eHealth and mHealth in South Africa.

The following national policies are relevant to eHealth and mHealth implementation.

 The National eHealth Strategy (2012–2017)

 The National mHealth Strategy (2015-2019)

 National Health Normative Standards Framework for Interoperability in eHealth in South Africa (2014)

 The National Integrated ICT Policy Green Paper (2014)

 The South African Connect Broadband Strategy (2013)

 National Health Insurance Green Paper (2011) & White Paper (2015)

 District Health Management Information System Policy

 The National Health Act (2003)

The National eHealth Strategy 2012–2017

The aim of the National eHealth Strategy is to leverage eHealth to support the broader transformation of the health sector. In July 2015 the NDOH published a notice in the Government Gazette on the establishment of the ‘Ministerial Advisory Committee on eHealth’. The Minister of Health suggests that the government will ‘closely monitor the implementation, to ensure that previous errors do not revisit us’ (NDOH, 2012b:5). One of the major principles of the eHealth Strategy is to constantly evaluate any eHealth initiative. This will measure improvements in health outcomes to build an evidence-base that demonstrates the net benefits of eHealth to ‘guide planning and decision- making’ (NDOH, 2012b:8). There are widely differing levels of eHealth maturity across and within the nine South African provinces. Several previous initiatives have not reached completion due to issues of poor planning, management or lack of funding (NDOH, 2012b:10). For example, telemedicine projects have failed to survive past the pilot phase, resulting in the NDOH placing a moratorium on their implementation (Leon et al., 2012). While the development of the eHealth Strategy was an important milestone, its actual impact will depend on effective implementation monitoring and evaluation (Masilela, 2014).

The National mHealth Strategy (2015-2019)

A sub-component of the eHealth Strategy is the mHealth Strategy published in 2015. The government’s mission is to apply mHealth as an integral part of delivery of healthcare services in order to ‘empower patients with information, improving access to health services and real-time data management to assist in addressing the current inefficiencies in service delivery’ (NDOH, 2015a:6). South Africa lacks an overarching legal framework for eHealth and mHealth necessary to govern and regulate when and how technology is utilised. Nevertheless, South Africa has legislation to protect patients’ health records (The National Health Act 61 of 2003) that includes the electronic transmission of personal medical information networks (Broomhead, 2015). The Protection of Personal Information Act (POPI) (NDOH, 2013) supports this.

mHealth Strategy Roadmap

In order to deliver the mHealth implementation plan, the government has set out ten interdependent priority areas and foreseeable challenges of mHealth projects.

mHealth Strategy priority areas: 1. Strategy and Leadership 2. Stakeholder Engagement 3. Standards and Interoperability

7. Capacity and Workforce

8. eHealth and mHealth Foundations

9. Applications and Tools to support Healthcare Delivery 10. Monitoring and Evaluation of the mHealth Strategy

Challenges encountered in mHealth projects:

 Lack of alignment and integration of the interventions into health

plans, strategies and systems

 Absence of government leadership and coordination

 Poor documentation and learning from best practices

 Lack of use of open-source options

 Absence of practical approaches to privacy and security

 Lack of interoperability

 Absence of a single framework within which to evaluate the role

of mHealth and eHealth tools in strengthening the health system

Box 3. mHealth Strategy Roadmap with priority areas and challenges encountered (NDOH, 2015a:11)

Government mHealth initiative: MomConnect

This section briefly describes the first major government-initiated scaled-up mHealth programme to date: MomConnect (discussed in-depth in Chapter 7). It aims to improve pregnancy registration and client empowerment through increased knowledge and access to services and outcomes during the antenatal and postnatal period for mother and child (Massyn, 2015). Mothers receive stage-based messaging during pregnancy and up to one-year after the child’s birth. The goal is for all 1.2 million women who become pregnant annually to be registered (van Shaik, 2015). ‘MomConnect illustrates the strong desire and political pressure to take advantage of ICT and to benefit from improved health messaging’ (Waldman & Stevens, 2015:34). South Africa’s Health Minister praised its initial success ‘in only eight months we

have been able to register 383,354 pregnant women. It is regarded as the largest number in the world’ (Motsoaledi, 2015:1).

National Health Normative Standards Framework for Interoperability (2014)

A response to the lack of interoperability listed in the mHealth Roadmap in Box 3, is the ‘National Health Normative Standards Framework for Interoperability’. Those standards include issues such as, data security, access control, safe guards and confidentiality. ‘An interoperable mHealth system needs to ensure that various routine and other information systems are able to connect, communicate and share information’ (Leon et al., 2012:10). The NDOH (2014a) advocated that implementing an open architecture and interoperability framework collaboratively between the public and private health sectors will have benefits. These include ensuring health messaging is consistent and harmonized at the national level, while being adapted and extended for local environments. Another aim of the framework is to align the different service providers to current NDOH objectives such as, primary healthcare strengthening and maternal and child health initiatives.

The National Integrated ICT Policy Green Paper (2014)

The National Integrated ICT Policy Green Paper published in 2014 includes regulation on the distribution of audio-visual, cyber-security/data retention,

Strategy. Both are not directly used in this thesis as they relate to ICT beyond the public health sector.

The South African Connect Broadband Strategy (2013)

The Broadband strategy is called ‘South Africa Connect: Creating

Opportunities, ensuring Inclusion’ (DOC, 2013). The Minster of

Communication said ‘the greatest challenge is how to approach infrastructure development in rural areas where it is clear that the private sector does not show interest to invest in infrastructure capability for Internet connections and high-speed access to data’ (DOC, 2013:21).

One of the reasons the eHealth Strategy has fallen behind schedule is due to poor broadband connectivity. This remains a critical challenge in primary healthcare facilities in rural areas. Telkom and Sentech (state-owned companies) both quoted over five hundred million Rand to provide connectivity to all primary healthcare clinics. Masilela (2014:22) states that exorbitant services charges was ‘a key impediment’ to implementation’. He suggested that the solution is to share costs with other government departments who will also benefit from the required infrastructure.

National Health Insurance (NHI) Green Paper (2011) and White Paper (2015)

South Africa is on the brink of effecting significant changes to its health system financing mechanisms with the recent publication of the NHI white

paper (NDOH, 2015c). The NHI is based on the principles of ‘ensuring the right to health for all, entrenching equity, social solidarity, and efficiency and effectiveness in the health system in order to realise universal health coverage’ (McIntyre, 2012:1). The health system has steadily been undergoing reforms under the umbrella of the NHI since the publication of the Green Paper in 2011 (NDOH, 2011). The purpose of these reforms is to refocus the health system from hospi-centric and curative to a primary healthcare approach. The reforms are underpinned by health promotion, disease prevention and community-centred service delivery. Such reforms aim to radically transform and improve access to healthcare for historically neglected rural communities (Naidoo, 2012). NHI will be phased in over fourteen years to enable universal, equitable and affordable healthcare coverage (Mayosi et al., 2012). This will include training nurses in chronic disease management, equipment and human resources audit, improvement of drug supply, re-organising the patient flow and the establishment of a patient filing system with effective retrieval and storage (NDOH, 2011). The NHI will only be possible, if ‘persistent structural inequity in the distribution of financial, human and material resources such as, medicines, medical equipment and basic infrastructure’ are addressed (RHAP, 2015:2).

services. The Ideal Clinic has been integrated into the clinical guidelines of ‘Primary Healthcare 101’ (NDOH, 2015b).

Figure 7. Graphic representation of the Ideal Clinic (Fryatt & Hunter,

2015:25)

An Ideal Clinic aims to ‘provide a comprehensive range of integrated services’ (Fryatt & Hunter, 2015:23), indicated in Figure 7. Part of the government’s aim is to make health facilities paperless and connected to broadband throughout the country, using a patient information system. The Ideal Clinic includes ‘Ward-Based Primary Healthcare Outreach Teams’: six community health-workers, a professional nurse and one health promotion practitioner. These teams are an effective way of responding to ‘South Africa’s crisis of healthcare’ (Kinkel et al., 2013:8).

Another government aim for the successful implementation of the NHI is to improve the quality of data collected for the District Health Information System (DHIS) and make it web-based. This system was designed to facilitate data collection in public healthcare facilities for quality assurance, monitoring and supervision at the national level (Braa & Hedberg, 2002; Seunanden, 2014). The DHIS contains routine data representing ‘1.4 billion patient encounters’ (Masilela, 2014:17).

National Development Plan (NDP) 2030

The National Development Plan (NDOH, 2012a) published in 2012, aims to eliminate poverty and reduce inequality by 2030. It recognises that the public health system cannot meet demand or sustain quality without strengthening primary care services and broadening district based health programmes. The NDP aligns with the United Nations Sustainable Development Goals for 2030 (UN, 2015). All of the relevant policies discussed thus far are embedded within this plan. One of the NDOH aims of the NDP is to develop an efficient health management information system for improved decision-making (Day & Gray, 2015).

Overview of the policies presented

The relationship of these policies is illustrated in Figure 8.

Figure 8. The relationship of South African policies related to eHealth and mHealth used to inform the Vutivi study

The baseline of the triangle in Figure 8, consists of the central eHealth and mHealth Strategies as the foundation or building blocks for the other policies. The Normative Standards, POPI Act, ICT and Broadband polices are interwoven into the core of the eHealth and mHealth documents. The tip of the triangle is the country’s national health insurance, development plans and act that build on the implementation of all the other policies, in particular the success of the eHealth and mHealth strategies. This diagram has been created to inform the Vutivi study’s findings.