Please note: This archive was last updated in 2005.

RHO archives : Topics : Information and Communication Tech.

Key Issues

This section provides summaries of issues related to the use of information and communication technologies in reproductive health programs in low-resource settings. Click article references to read article abstracts from the Annotated Bibliography. Also see the Program Examples and Links sections for more information.

 

General and best practices

In the early 1990s, government agencies, donor agencies, and private companies began investing in infrastructure, hardware, and software along with training programs for ICT initiatives in many sectors in developing countries. Reproductive health organizations were soon exploring the potential benefits of computer-based technologies and the Internet, as well as continuing to develop innovative programs with telephones, radio, and television. Pioneers and champions at many organizations developed email discussion groups and published newsletters, training materials, and research results on websites and CD-ROMs. With developing-country partners, they created telecenters, virtual libraries, interactive databases, and hotlines. There have been many efforts to translate and adapt reproductive health materials that are published electronically to ensure languages are relevant to developing-country users.

Experiences with ICTs have been shared in conferences, workshops, and publications, and a body of evidence for best practices is beginning to emerge. The guidelines and handbooks published recently by reproductive health organizations detailing ICT experience emphasize the fundamentals of program planninginformation needs assessments, human and technical capacity assessments, training needs, and sustainability issues. In addition, depending on the context and the technology, other considerations are discussed. For example, a dedicated information coordinator is essential to provide leadership for learning centers (AIHA 2003); ICTs should complement other communication work and be integrated into broader programs (Chetley 2001); and gender considerations should be incorporated into project analysis and design from the beginning (Hafkin and Jorge 2002). Donor relations, community ownership, and space planning are also discussed (Stratten and Ainslie 2003; Mchombu 2003), as are the advantages of electronic publishing: international reach, speed, additional capabilities, and lower cost (Morris 2002).

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Benefits for reproductive health programs

Research

Reproductive health researchers are using the Internet across the research process, which includes identifying research issues, using databases for literature searches, using the web for surveys and clinical trials, and publishing research results (Eysenbach and Wyatt 2002; Morris 2002). Researchers use email to share information and consult or collaborate with other professionals. The increased availability of online publications and databases for literature searches improves research quality. ICTs used for interviewing show promise for sensitive subject matter (Rhodes 2003), and a variety of data-analysis software such as Epi Info has been produced.

Networking and Advocacy

The expansion of communication networks and email has markedly enhanced the development of professional networks and online communities of practice by making it possible to reach across geographical boundaries and communicate with one or many quickly and easily. The SATELLIFEdiscussion groups, for example, are reported to reach more than 10,000 health professionals in developing countries. Membership in electronic discussion groups is self-selected and may be active or passive, allowing anyone with a genuine interest to participate at the level of activity they choose (Vyas 2002; Kanyengo). Members may stay up-to-date, discuss issues, learn of conferences and training, disseminate findings or materials, and organize advocacy campaigns. Online discussion groups in conjunction with face-to-face interaction at conferences or trainings enrich professional relationships and reinforce new learning. A list of electronic listserves, discussion groups, and other information and networking resources are provided in Table 1. Perhaps the most tangible benefit of connectivity has been in enhancing regional and international links that reduce isolation and increase knowledge-sharing (PIWH 2002). Advocacy groups use email networks to build alliances, discuss strategies, and share experiences in efforts to build support for their issues (World Bank and Development Gateway 2003).

Training

ICTs present important new opportunities to enhance training, especially for rural health workers. Curricula on CD-ROMs, tapes, and websites reduce barriers associated with distanceallowing health workers to learn in their own workplace and in their own time. Email provides learners with opportunities for interactive communication with trainers and other learners. ICTs also offer opportunities to generate and disseminate health information at the periphery and to inform practice and policy at the center (Ntiro and Mrema 2003). They assure quality learning, empower learners, and offer potential cost-effectiveness (Long and Kiplinger 1999). A computer provides a safe learning environment where users can practice skills free of judgment. When electronic tools are carefully integrated with face-to-face learning, they can enhance development opportunities for health care professionals (MSH 2003).

Reaching Youth

Reproductive health programs for youth have found that ICTs are exciting, attractive, and effective for youth projects (IPPF/WHR 2001; EnCompass 2002). Information for youth has been successfully presented through global programs that reach youth using multimedia with HIV-prevention messages in local languages or through websites and CD-ROMs with sexuality information. Information on computers can also provide confidential and anonymous access to explicit information. This last benefit is particularly important to adolescent sex education projects. According to an APROFA psychologist, It is a perfect tool for youth, because it does not impose a sequence or an order. The issues are laid out on the page, and its up to the users to follow their own interests, at their own rhythm. (IPPF/WHR 2001). Hotlines and radio call-in programs are also an effective way to reach large numbers of youth at relatively low cost. They provide youth with convenient, confidential, interactive, and compassionate access to information, counseling, and referrals, and hot lines can help parents and community members understand the unique sexual and reproductive health needs of young people (Moch and Stevens 1999). For more information on effectively using ICTs in reproductive health projects for youth, see the global Program Examples from Staying Alive and Sexwise.

Improving Health Systems

Providing connectivity to fragmented or decentralized health systems is cost-effective and may significantly improve health outcomes (Wideray and Satellife 2003). The ability to communicate quickly and directly by cell phone, email, or walkie-talkie has improved supply and referral systems, improved epidemiological monitoring systems, and reduced isolation. Automating systems may provide additional efficiencies, with the reduction of duplicate paperwork, saving time for both staff and patients (Rotich 2003; PAHO 2001). The World Summit on the Information Society (WSIS) Plan of Action includes connectivity for hospitals and health centers as a priority for the future. See the Program Examples from Peru and Uganda for more information on using ICTs to connect health care providers.

Additional examples of programs benefiting from the use of ICTs can be found in Table 1.

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Future trends

Convergence of Old and New Technologies

One of the most potentially important trends in technological innovation is the convergence of the newer ICTs with radio and television (Dagron 2003). Case studies of interactive radio instruction (IRI) in the Dominican Republic, Zambia, and Guinea show that this use of a previously one-way technology can effectively reach hard-to-reach populations and result in high learning gains and decreased inequality (Bosch 2002). Some programs have combined newer technologies with older technologiessuch as radio broadcasts based on information from websites or face-to-face training combined with e-learning. Building ICT programs with existing older technologies as a foundation may enable the information poor and ICT-excluded to be included (Chetley 2001; Girard 2003; DOT Force 2002; UN Department of Economic and Social Affairs 2002).

Technology Innovation

Rapid technology innovation continues. The advent of wireless Internet access potentially allows the use handheld communication devices, web-enabled telephones, interactive television, web and email terminals, and Internet gaming consuls (Eng 2001; Primo Braga 2003; Wideray and Satellife 2003). The novelty and improved efficiency of new technologies may have the biggest effect on the acceptance of second-generation technologies in youth programs (IPPF/WHR 2001). There is a need to identify or develop methodologies for passing content from one medium to another, for example, from the Internet to community radio. Several organizations are modifying computer technology to make it more appropriate for rural areas; for example, the Simputer is being developed in India for rural low-literate populations (Harvy 2002).

International policy initiatives

International conferences on ICTs for development are emerging with greater frequency and illustrate the increasing efforts to harness communication technologies for the plight of the underprivileged and to create solid, effective ICT policy. Much of this discourse focuses on Millennium Development Goals. The World Summit on the Information Society (WSIS) (www.itu.int/wsis/index.html) was endorsed by the UN General Assembly in 2001 and is run by the UN agency the International Telecommunication Union (ITU). It involves two international conferences in 2003 and 2005, each of which “marks the culmination of many months of consultations and negotiations among Member States, UN experts, the private sector, and nongovernmental representatives, who review vast amounts of information and share a broad spectrum of experiences in issues related to the Information Society.”

As a follow-on to the World Summit on the Information Society’s 2003 summit, the United Nations Information and Communication Technologies Task Force (www.unicttaskforce.org/) held a conference in March 2004 on Internet Governance where “there was broad consensus on some baseline principles that should guide the evaluation of governance mechanisms and their future evolution and development” (UN ICT, 2004). Other global initiatives include the World Bank’s Global Technology Conference 2004 on Emerging Technologies in Emerging Markets (http://wbln0018.worldbank.org/ict/projects.nsf/WebPages/E1D93943732CA27C85256E3D00515D03?OpenDocument).

How these global initiatives focusing heavily on the ICT industry impact relevant development efforts is largely yet to be seen. Conferences and major reports on ICTs focused on specific development issues such as health may lead the way in this international dialogue. For example, the International Health Information Congress (www.aspefam.org.pe/CIIS.htm) held in Peru in May 2004 and INASP's global review on health professionals’ access to health information in developing countries (www.inasp.info/health/globalreview/), launching in July 2004, are promising strides forward. An important new report is the United Nations Development Program’s Promoting ICT for Human Development in Asia 2004: Realising the Millennium Development Goals (UNDP 2004). This report summarizes research from nine Asian countries, exploring the potential of ICT applications toward the achievement of the UN’s Millennium Development Goals. The UNDP, with the UNIFEM Central and Eastern Europe Office, has also recently published Bridging the Gender Digital Divide: A Regional Report on Gender and ICT in Central & Eastern Europe & the CIS (UNDP and UNIFEM 2004).

Challenges and concerns

Significant financial, political, cultural, and technological obstacles affect the establishment of sustainable programs, especially for computer-based ICTs. These obstacles have been identified as lack of affordability, lack of human capacity, lack of awareness of the benefits of ICT, lack of ability to use ICT proficiently, and lack of contents suitable for local residents (Cheung-Moon 2002). ICTs that rely on access to the Internet need good-quality access to be truly useful (Skinner 2003).

Cost and Affordability

The allocation of scarce financial resources is the most fundamental and pervasive concern about introducing and sustaining ICTs in low-resource settings (Geyoushi 2003). Governments in low-income countries and many in middle-income countries are faced with choices between ICT-related objectives and responding to urgent basic needs including food, education, and health priorities (Curtain 2003). Cost is an issue for every activity related to the introduction of computer-based programs, including investing in adequate infrastructure, buying and upgrading computers, paying for connectivity, investing in adequate training, and translation of content.

The challenges posted by the costs and affordability of ICT-based programs has been addressed on multiple levels. The World Summit on the Information Society Plan of Action states, International and regional institutions, including international financial institutions, have a key role in integrating the use of ICTs in the development process and making available necessary resources for building the Information Society and for the evaluation of the progress made. Private companies, donor agencies, NGOs, and others involved in international development also play key roles in addressing the challenges related to costs and affordability. Technical innovations, economies of scale, improved ICT literacy over time, and innovative partnerships among development sectors can potentially reduce costs in the future (Primo Braga 2003; UNDP Evaluation Office 2001).

Some projects using ICTs in the health sector have demonstrated cost savings, which offset the original investments. Projects that significantly improve connectivity for health systems have shown savings in travel expenses, more efficient patient referrals, and reduced fax and telephone charges (see the Program Example from Peru). Distance education projects also have demonstrated cost savings with reductions in travel expenses and learners time away from work (Long and Kiplinger 1999). Online publishers report lower costs for publishing online, although there are no data on the costs to users in low-resource settings of accessing and using online publications (Morris 2002). Research from other sectors suggests that radio and telephones may be the most cost-effective ICTs for effecting significant changes in the lives of the poor (UNDP 2001).

Technology Maintenance and Support

Issues related to the maintenance of ICTs, particularly of computers, are among the major challenges facing users of ICT programs (DOT Force 2002; PIWH 2002). The lifespan of computer equipment is rarely more than five years, and local capacity to troubleshoot problems and repair equipment is often limited. The lack of reliable electricity, readily available spare parts, and reliable service providers further limits effective use of many technologies. Chronic problems such as viruses, lack of proper data backup, and use of unlicensed software contribute to difficulties faced by computer users in low-resource settings (Plaisance 2003).

To partially address these challenges, organizations such as the Advocacy Project have developed programs using eRiders or circuit riders that are part trainer, part management consultant, part computer expert. Ninth Bridge eRiders provide consulting and assistance with technology strategy development, make multiple visits to the organizations they serve, and provide advice and information by telephone and email.

Relevant Content: Gender, Language, and Culture

Gender, language, and cultural inappropriateness are frequently identified as major barriers limiting the success of projects using ICTs (Hafkin and Taggart 2001; Pakenham-Walsh 2002; DOT Force 2002). All three factors must be addressed in developing content that is relevant to users.

Gender

A significant gender gap exists between women's and men's participation in every aspect of ICT, including access to and use of ICTs, as well as in the fields of education and employment within the ICT sector (Hafkin and Taggart 2001). A gender perspective needs to be designed into projects, including recognition that women and girls may learn about and use ICTs differently than men and have different information needs. Gender relationships and traditional womens roles may hamper access within the workplace and in the community. Women often have low levels of literacy and lower levels of education in the languages most often used in Internet-based technologies.

The inclusion of a gender perspective in the design, implementation, and evaluation of ICT projects can contribute to womens health and economic well-being over the long term (Hafkin and Jorge 2002). Successful applications have included email, which is one of the technologies most commonly and effectively used by women and womens groups. It is considered a more "horizontal than hierarchical communication format (Vyas 2002; Kibaalya 2002; Huyer and Sikoska 2003). Older ICTs may have several advantages over the more recently developed ICTs because they are more accessible, less expensive, easy to use, appropriate for multi-tasking situations, familiar and less intimidating, and an inexpensive means of information storage. Many projects use older ICTs because literacy is not a prerequisite to participation. Older ICTs can also serve an important role, when necessary, as a bridging point of access to the newer ICTs. WSIS encourages the exchange of best practices on the integration of gender perspectives in ICT education and developing gender-specific indicators on information needs and ICT use (WSIS 2003; APC WNSP 2004).

Language and Culture

Fifty percent of the content on the web is in English, and many local languages and cultures are underrepresented or missing (Dagron 2003). Local ownership is essential to ensure the cultural relevance of health information. Materials that are literally translated from source material rather than locally adapted can result in inaccurate or culturally inappropriate messages.

Local producers and end users should be involved from the earliest stages in dialogue, priority setting, problem solving, creative thinking, and the creation and adaptation of materials. They require access to the full range of existing source materials, both internationally and nationally. This is a resource-intensive activity and requires a full range of skills, including medical knowledge, knowledge of end-user needs, and writing and editorial skills (Pakenham-Walsh 2002).

Content that is culturally and linguistically relevant for both men and women is based on assessments, often on an ongoing basis, of the information needs of a clearly identified group. Needs assessment is a step that must be taken before project planning and implementation begins, and will identify performance indicators, which will be used to evaluate the success or failure of the project. Conducting an ICT needs assessment involves identifying stakeholders, mapping communication flow, and identifying the outputs people wish to see at the end of the project (DOT Force 2002; Stratten and Ainslie 2003).

Adequate Capacity

The capacity of a country to develop equitable access to ICTs is critical for its citizens to benefit fully from ICTs. Equally important are users ICT literacy, the level of interest in adopting ICT technology, and the social networks of co-workers, friends, or relatives in which people access digital information to achieve social, economic, political, or social goals (Warschauer 2003). The lack of appreciation of the benefits and the lack of ICT literacy have been identified as major barriers to computer use (Braa 2001; PIWH 2002; Ogunyade and Oyibo 2003; Gladwin 2002).

ICT Literacy

Currently, developing-country health workers who are routinely able to use the Internet are most often urban-educated professionals working in organizations with adequate connections, electricity, and training. They use information technology at work, to produce or communicate information (Hafkin and Jorge 2002). The reproductive health workers who use these technologies work in government ministries, NGOs, research institutes, academic medical libraries, hospitals, and clinics. The International Planned Parenthood Federation reports that the youth reached through their computer-based projects are educated, middle-income, in-school, urban youth (IPPF/WHR 2001).

Pilot projects and guidelines have been designed for other users: rural communities (Mchombu 2003) and African womens NGOs (PIWH 2002). For rural areas with poor access to computer-based information, work blending radio with the Internet is promising because radio is pervasive, local, an oral medium, and it can involve communities and individuals interactively (Girard 2003).

Country Readiness

An economic analysis of countries readiness to use ICT suggests that countries with low per capita income levels have limited capacity to adopt advanced forms of ICT. Low per capita income also tends to be associated with other social, economic, and cultural barriers to using ICT (Curtain 2003). Canadian research with youth indicates that the quality of Internet access affected Internet use more than simply having access. Quality access depends on the number of available computers at school and in libraries, the amount of time allowed to use them, and the difficulty and cost of downloading information (Skinner 2003).

Reproductive health program planners can anticipate challenges by conducting a preliminary assessment of ICT readiness to look at their countrys policy structure, basic infrastructure, number of telephones, and Internet service providers. This initial review can be done using guides that provide statistics on country readiness and capacity to use ICT (Strehier 2002; Kirkman 2002; Bridges 2001; World Bank). An on-the-ground technical assessment will provide additional valuable information about the quality of access (Skinner 2003).

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Measuring results

Current evaluation of ICT programs varies considerably, from anecdotal reports to published program descriptions to complex research studies. Most common are reviews and formative evaluations of projects and indicator frameworks that are in the process of being developed and tested (Mechael 2002; McConnell; APC WNSP 2004). Efforts to measure the impact of information on development are not new and unique only to the 21st century or even to the Information Age—older frameworks also offer insight (Menou 1993). ICT applications have been shown to save costs over telephone and fax (PIWH 2002), increase adolescent knowledge and change attitudes (IPPF/WHR 2001), reduce maternal mortality, and improve distance learning. However, many assessments have been limited to small groups, have had limited follow-up, or have not yet been published. (See the Program Example from Peru for more information on the cost savings of ICT, and the Program Example from Uganda for more information on using ICT to reduce maternal mortality.)

The Robert Wood Johnson Foundation has begun the new Health e-Technologies Initiative supporting U.S. research, which evaluates the effectiveness of interactive eHealth applications for health behavior change and chronic disease management. They will evaluate the use of the Internet, interactive TV and voice response systems, kiosks, personal digital assistants, CD-ROMs, and DVDs. The initiatives projects, which focus on U.S. applications, may inform global efforts (Robert Wood Johnson 2003).

Development organizations need to take on the complex and necessary evaluation of ICT programs, acknowledging that it is a complicated and long-term task. Evaluation can be approached as an adaptable and iterative learning process that is used to understand the changes that ICT use brings, to improve on past experiences, and to influence future decision-making and policy formation (UNDP Evaluation Office 2001; Vincent 2001). In particular, indicators need to be developed for ICT accessibility and regional and local connectivity. Gender-specific indicators should be identified to assess the impact of funded projects on the lives of women and girls.

As more ICT initiatives and projects are implemented, there is a greater need to develop evaluation frameworks that can effectively measure the impacts of these technologies.

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