E-Healtcare in Asia and the Pacific Challenges and Opp or Unities

8/8/2019 E-Healtcare in Asia and the Pacific Challenges and Opp or Unities

http://slidepdf.com/reader/full/e-healtcare-in-asia-and-the-pacific-challenges-and-opp-or-unities 1/36

Economic and Social Commission for Asia and the Pacific

e-HEALTH

IN ASIA AND THE PACIFIC

CHALLENGES AND

OPPORTUNITIES



e-HEALTH IN ASIA AND THE PACIFICCHALLENGES AND OPPORTUNITIES

This report has been produced without formal editing.



The designations employed and the presentation of the material in this report do not implythe expression of any opinion whatsoever on the part of the Secretariat of the United Nations

concerning the legal status of any country, territory, city, or area or of its authorities, orconcerning the delimitation of its frontiers and boundaries.

The views expressed in this report are those of the contributors alone, and in no wayreflect the views of the United Nations. The mention of any products or organization in noway implies an endorsement of them by the United Nations in any way whatsoever.

For further information on the materials contained in this publication, please contact:

Mr Guennady FedorovChiefHealth and Development SectionEmerging Social Issues DivisionUnited Nations Economic and Social Commission for Asia and the PacificUnited Nations BuildingRajadamnern Nok AvenueBangkok 10200, ThailandEmail: [email protected]



Acknowledgements

This report is based on the background paper developed for the EGM by Orasa Kovindha,

consultant for UNESCAP and the working paper prepared by the InformationCommunication and Space Technology Division of UNESCAP.

This report has been revised based upon the comments received from experts during theEGM. Srinivas Tata, Marco Roncarati, and Yu Kanosue from the Health and DevelopmentSection (HDS) of UNESCAP, have contributed to its reformulation and revision. GehendraDhakal and Ployparn Khunmuang, Likewise from HDS, have also contributed to theproduction of the document. The document has been prepared under the overall guidanceand supervision of Guennadi Fedorov, Chief of HDS.



Preface

This report is based upon a background paper prepared for an expert group meeting (EGM)

on “regional trends in trade in health services in the Asian and Pacific region” held inBangkok from 9 to 11 October, 2007. It has also relied on the working paper “e-Health for aLeapfrogging Asia and Pacific: Challenges and Opportunities” prepared by the InformationCommunication and Space Technology Division, UNESCAP. This report has been revisedbased on information contained in the presentations made by experts attending the meetingand their suggestions. The experts were drawn from a wide range of sectors includingacademia, tourism, public health, as well as regional organizations and international agencies.The recommendations contained at the end of the report were adopted by the experts at theEGM, and reflect key priorities for action at national and regional levels.

e-Health, commonly referred to as the application of information and communicationtechnology (ICT) in the health sector, has rapidly developed around the world in the last fewyears. Globalization is one of the factors driving such development, regardless of theintentions of stakeholders. Therefore, it is critical to be aware of factors driving e-Healthdevelopment, in order to manage and promote it as a public good. The objective of e-Healthapplications, as commonly understood, includes the promotion of the greater use of ICT inhealth-care systems in order to improve efficiency, access and accountability of health-careservices.

This report explores the experiences of countries in the region, both in e-Health initiativesand policy actions. It also looks at the initiatives and polices at the trans-boundary level. Theanalysis both at national and regional levels sheds some light on the great potentials of e-Health in improvising the delivery of health care in the region, as well as the remainingchallenges to fulfill such potentials. It is hoped that this would provide the basis for furtherresearch and analysis in specific areas, which would serve as a reliable guide for policyformulation and for regional cooperation.



Table of Contents

1. The current status of e-Health within health-care systems ........................................... 1

1.1 e-Health definition................................................................................................................. 11.2 Use of e-Health in national health-care systems ............................................................... 2

1.2.1 India ................................................................................................................................. 21.2.2 Malaysia .......................................................................................................................... 41.2.3 Russian Federation ........................................................................................................ 61.2.4 Singapore......................................................................................................................... 71.2.5 Thailand........................................................................................................................... 8

1.3 Use of e-Health in cross-border health-care services........................................................... 111.3.1 Hospital referral ........................................................................................................... 111.3.2 Health personnel education ....................................................................................... 11

1.3.3 Surveillance................................................................................................................... 121.3.4 Medical transcription and medical records.............................................................. 131.3.5 Medical travel/tourism............................................................................................... 14

2. Potential of e-Health as a means to overcome health-care challenges....................... 152.1 Efficiency............................................................................................................................... 152.2 Distance/isolation................................................................................................................ 162.3 Health outcomes .................................................................................................................. 16

3. e-Health policies .............................................................................................................................. 163.1 e-Health policy at the national level.......................................................................... 16

3.1.1 Russian Federation ...................................................................................................... 183.1.2 Japan .............................................................................................................................. 203.1.3 India ............................................................................................................................... 21

3.2 International policies pertinent to e-Health ........................................................................... 213.2.1 e-Health in trade policies............................................................................................ 213.2.2 e-Health in ICT policies............................................................................................... 22

4. Factors regarding further expansion of e-Health....................................................................... 23

4.1 Clearer direction on the role of e-Health............................................................................... 234.1.1 Policy framework......................................................................................................... 234.1.2 Legal framework.......................................................................................................... 23

4.2 Human resources ................................................................................................................. 244.3 Financial and technical support......................................................................................... 26

5. Conclusions and recommendations ............................................................................................. 265.1 Positive impacts of e-Health on health systems.............................................................. 265.2 Negative impacts of e-Health............................................................................................. 265.3 Barriers in the further expansion of e-Health .................................................................. 275.4 Recommendations at the regional level............................................................................ 27

5.4.1 Regional vision ............................................................................................................. 275.4.2 Needs and preparedness at the regional level......................................................... 275.4.3 Role of regional/international cooperation ............................................................. 27

5.5 Recommendations at the national level............................................................................ 28



Tables, Box and Figures

Table 1. Examples of e-Health............................................................................................................. 1Table 2. e-Health objectives and approaches – A diversity .......................................................... 17

BOX 1 – Experimentations in Malaysia – eFarmaci and tele-pregnancy support ........................ 5

Figure 1. Modernize Thailand............................................................................................................. 9Figure 2. e-Health in Thailand .......................................................................................................... 10Figure 3. Teleconsulation topology in Pacific Islands ................................................................... 11



1

1. The current status of e-Health within health-care systems

1.1 e-Health definition

e-Health is a relatively new term that came into common use only in the last decade.Because of its dynamic and ever changing nature, it is almost impossible to provide asimple definition of the term. However, the term is commonly used to describe theutilization of information and communication technology (ICT) in the health sector.1 Itencompasses the use, in the health sector, of digital data - transmitted, stored andretrieved electronically – for clinical, educational and administrative purposes, both at thelocal site and at a distance. e-Health is used as an all-inclusive term, capturing the use ofinternet technologies and the rise of the information economy, including informationtechnology, telecommunication technology and data transmission protocols andtechniques. It is also all-inclusive in a way to capture all types of health care and health-

care professionals: it is not limited to medicine and not limited to doctors. The table belowsummarizes some of the examples of e-Health.

Table 1. Examples of e-Health

Technology Devices and software Applications

Remote MonitoringSensorsInstrumentsUltrasound

Telehomecare

Diagnostics

StethoscopeElectrocardiogram (EKG)X-ray/CatScan & medical imageanalysis software

ConsultationsTelehomecare

Videoconferencing

Cameras (e.g. videocams, webcams)Computer-based desktopsPortable communications & datasystems

ConsultationsTeledermatologyTelementalhealth

Digital imaging

InstrumentsMedia (e.g. film, magnetic tape)

Scanners/ViewersDigital camerasVideocams with scopes

TelepathologyTeleradiology

TeledentistryTeledermatology

1 The following definitions of e-Health provide a glimpse at a broader conceptualization.“e-Health is defined as the use of emerging interactive technologies (e.g., Internet, CD-ROMs, personaldigital assistants, interactive television and voice response systems, computer kiosks, and mobilecomputing) to enable health improvement and health care services”, David K. Ahern, Jennifer M. Kreslakeand Judith M. Phalen, “What Is eHealth (6): Perspective on the Evolution of eHealth Research”, Journal of Medical sInternet Research, vol. 8, No. 1 (2006) [electronic version], http://www.jmir.org/2006/1/e4/

accessed on 5 August 2007; “e-Health refers to the use of modern information and communicationtechnologies to meet needs of citizens, patients, healthcare professionals, healthcare providers, as well aspolicy makers.” The Telemedicine Alliance, Towards Interoperable eHealth for Europe: Telemedicine Alliancestrategy (Noordwijk, European Space Agency, 2005), p. 30.



2

Information

Technologies

Data storage systemsServersSoftware/Informatics –Data Base Management Systems/Geographical Information Systems

Middleware

Electronic medical (e.g.Patient Information System,Hospital Information System,General Practitioner Information System).

recordsData miningWeb portalsDecision-support systemsAdministration (e.g. hospitalautomation)

Store-and-Forward

Data/image/video/audio cardcapture/scannersComputer/camera/microphone &image management software

Electronic medical/healthrecordReport generator

Simulation &Training

Multi-media graphics SoftwareAudio-visual

e-LearningCurriculumConferencing

Source: Adopted and modified from “Table 2.a Telehealth Technologies” in David Brantley, Karen Laney-Cummings and Richard Spivack, Innovation, Demand and Investment in Tele-health, February 2004,<http://www.technology.gov/reports/TechPolicy/Telehealth/2004Report.pdf> accessed on 10 December2007.

1.2 Use of e-Health in national health-care systems

Recognizing the potential of e-Health in filing gaps and disparities in health-care delivery,certain countries in the Asian and Pacific region have made considerable progress in e-Health within the context of national health-care systems. This section summarizes theexperiences of a few countries in the region.

1.2.1 India

India is a vast country with a population of more than one billion in an area of threemillion square kilometres. The country has 29 states and six union territories governed bythe federal system. The national government does not have a national health insurance

policy. Each state has the primary responsibility for public health-care delivery commonlyorganized in a three-tire system. There exists a significant disparity in quality and accessto health-care services between urban and rural regions. At the same time, with regard toICT, India now is self-sufficient in meeting the needs of hardware, software, connectivityand services. Thus, e-Health has the potential to bridge this gap, if the tool is integratedinto existing health-care delivery systems. Both public and private sectors have activelypursued the development of e-Health in India.

The major fields of e-Health more rapidly developing in India include electronic medicalrecords, hospital automation and e-Learning. The majority of private and a few of public

sector hospitals have adopted electronic medical records and hospital automation. Healthsystem development projects by state governments, aided by the World Bank, arepromoting rural electronic health records. In 1998, the Centre for Development of



3

Advanced Computing, an autonomous public scientific organization, deployed the totalHospital Information System software, developed for the first time in India, incollaboration with the Sanjay Gandhi Post Graduate Institute of Medical Sciences(SGPGIMS), Lucknow.2

e-Learning has also been growing in the health sector, including online open accessbibliographies. Two government agencies, the National Informatics Centre and the IndianCouncil of Medical Research, have established the Indian Medical Literature Analysis andRetrieval System Centre to cater to the information needs of the medical community in thecountry. This centre has developed various web based modules, including the unioncatalogue of journal holdings of medical libraries of India (http://uncat.nic.in), thebibliographic database of Indian biomedical journals (http://indmed.nic.in) and the fulltexts of Indian biomedical journals (http://medind.nic.in).3 Premier academic medicalinstitutions are also actively involved in sharing their academic activities over thetelemedicine network.4

Those who have played the most significant roles in the development of e-Health in Indiainclude the Ministries of Health, of Family Welfare, of Communication and InformationTechnology, as well as state governments and the Indian Space Research Organization(ISRO). The Ministry of Health and the Ministry of Family Welfare are currentlyimplementing a network called the “Integrated Diseases Surveillance Programme.” Thenetwork connects all district hospitals with medical college hospitals of a state to facilitatetele-consultation, tele-education, training of health professionals and monitoring diseasetrends. Similarly, the “national cancer network” has been implemented to connect 25regional cancer centres with peripheral hospitals to facilitate the national cancer control

programme. These ministries are also initiating the networking of all public medicalcolleges with high bandwidth fibre to facilitate e-Learning. In addition, the Ministry ofCommunication and Information Technology has established more than 75 nodes all overIndia in collaboration with the sate governments, such as the telemedicine network inWest Bengal for diagnosis and monitoring of tropical diseases.

State governments, often in collaboration with ISRO, have taken various initiatives. Thegovernments of Orissa and Uttarakhand have supported networking of secondary levelhospitals to strengthen health-care facilities and further with SGPGIMS for specialtyconsultations. 5 The Chattisgarh State Government, with the support of ISRO, has

established a state-wide network, linking state public medical colleges to each other andalso further to premier hospitals across the country.6 The Rajasthan State Government,also in collaboration with ISRO, has established a telemedicine network. The Rajasthannetwork not only connects medical colleges and district hospitals, but also six Mobile Vans

2 Sanjay Gandhi Postgraduate Institute of Medical Sciences, “Home”, <www.sgpgi.ac.in> accessed on 12December 2007.3 Indian Medlars centre, “medIND”, <www.indmed.nic.in> accessed on 12 December 2007.4 A.K. Mahapatra and S.K. Mishra, “Bringing the Knowledge and Skill Gap in Healthcare: SGPGIMS,

Lucknow, India Initiatives”, Journal of eHealth Technology and Application (2007), Vol. 5, No. 2, pp. 67-69.5 L. Kapoor, S.K. Mishra and K. Singh, “Telemedicine: experience at SGPGIMS, Lucknow”, Journal of Postgrad Medicine (2005), Vol. 51, No. 4, pp. 312-5.6 Indian Central Bureau of Health Intelligence (CBHI), “Policy Reform Options Database”, <www.cbhi-hsprod.nic.in/searnum.asp?Num=210> accessed on 12 December 2007.



4

- automobiles with e-Health equipment. 7 The Karnataka State Telemedicine NetworkProject, run by an autonomous trust formed by the State Government, has set up thirtynodes.

In addition to ministries and state governments, and often with their support, some

tertiary level hospitals with specialties have also taken initiatives in e-Health. For example,SGPGIMS, a premier institution in the public sector, started its telemedicine activities in1999 in a project mode.8 It has networked with 14 national and international partnernodes and has been carrying out tele-education and tele-health-care activities. It hasdeveloped various modules for these activities, in addition to various research anddevelopment activities. SGPGIMS has also established the School of Telemedicine andBiomedical Informatics to develop human resources. This school has been recognized asthe National Resource Centre in Telemedicine by the Ministry of Communication andInformation Technology. Various private hospitals are also active in e-Health. Forexample, recently, the Sir Ganga Ram Hospital in New Deli launched its telemedicine

centres in Haryana and Rajasthan states. Under the National Blindness ControlProgramme, Shanker Nethralaya in Chennai, Meenakshi Eye Mission in Madurai and fourother private hospitals have launched the Mobile Tele-ophthalmonology service for earlydiagnosis and treatment of ophthalmic diseases with the support of ISRO.9 Sir GangaRam Hospital has also launched a mobile tele-hospital for rural access of specialty health-care services with the Amrita Institute Medical of Sciences.

1.2.2 Malaysia

The scale and scope of e-Health in Malaysia indicates significant potential in internet-

based health services. e-Health in Malaysia covers all forms of electronic health caredelivered over the internet, from informational, educational and commercial “products” todirect services offered by professionals, non-professionals, businesses or consumersthemselves. It also includes a wide variety of clinical activities that have traditionally beencharacterized as “telehealth”, but delivered through the internet.

Malaysia implemented its national plan for the development of ICT in health in 1995. Twoyears later, the Malaysian Government made one of the most clearly defined public policystatements on e-Health with its strategy and vision to 2020 of the Multi-Media SuperCorridor initiative and the Telemedicine Act 1997.10 The Multi-Media Super Corridor

project was aimed to establish a health-care system which could leverage advancedinformation and multimedia technologies to deliver previously unattainable health-careservices at the individual, family and community levels, with telemedicine and medicalinformatics as the crucial components. In 2000, when the wider utilization of e-Health had

just started, WorldCare, a global player in e-consultation, set up the world’s first

7 Government of Rajasthan, “e-Governance Initiatives in Rajasthan”<http://www.rajasthanfoundation.org/todays_rajasthan/it_com.htm> accessed on 12 December 2007. 8 SGPGI Telemedicine Centre, “SGPGI Telemedicine”, <www.sgpgi-telemedicine.org> accessed on 12December 2007.9

Sankara Nethralaya, “The Temple of the Eye,” <http://www.sankaranethralaya.org/> accessed on 12December 2007; Meenakshi Mission Hospital & Research Centre, <http://www.meenakshimission.org/>accessed on 12 December 2007.10 WHO, Building Foundations for eHealth: Progress of Member States (Geneva, WHO, 2006) (hereinafter“Foundations for eHealth”), pp. 312-313.



5

comprehensive tele-consultation network in Malaysia, connecting forty-one centres of itsMinistry of Health across the country. The Government has also allocated funds to expandtelehealth and tele-consultation services, to share health records and plans, to set up theNational Health Informatics Centres and to implement hospital information systems inselected hospitals and clinics. Further, the introduction of the Health Management

Information System has contributed to the increase in the use of ICT in the health sector.

The challenges that Malaysia faces in expanding e-Health include high costs, inadequatehuman resources, computer illiteracy and inadequacy in extension of infrastructurethroughout the country. To overcome such challenges, intersectoral andnongovernmental cooperation was introduced to make infrastructure more affordable, toreduce the digital gap between urban and rural areas, and to improve the provision ofinternet access to rural clinics. Another initiative is Health Online which provideselectronic multicultural health information.11

BOX 1 – Experimentations in Malaysia – eFarmaci and tele-pregnancy support

e-Farmasi is a project that links communities to their neighbourhood pharmacies andprovides an impartial database on illnesses and medicines. It aims to enable thecommunity to access a website with a database of unbiased information on medicines,including their use, side effects, and directions in taking them. The database createdunder the project allows the community members to direct questions to a pharmacist, andalso to complete a pharmaceutical transaction over the internet when appropriate. Thedatabase contains information on over 27,000 products that are nationally registered in

both English and the Malay language. Medicines can be searched by either ingredient orbrand name. Assistance is also provided to guide patients towards the right product fornon-serious ailments. The site contains information on a variety of ailments, includingdiagnostic guides and self-care strategies. In addition, it contains extensive listings ofparticipating and independent pharmacies as well as some non-registered outlets such asapothecaries. The project also involves the provision of a pharmacy managementprogramme to pharmacists to help them manage their pharmacies, to keep patientmedication records and to provide pharmaceutical care.12 Another project in Malaysia introduced the “prototype mobile phone-based pregnancysupport” to a local private hospital and a few maternity clinics. The project aims to adopt

a breakthrough approach in educating women on pregnancy, monitoring the growth offoetuses and providing follow up with medical checkups, critical updates and post-natalsupport through mobile phones, especially targeting women in rural areas. The projectdeveloped the mobile application to interact with mobile internet platforms, in sendingand receiving short messages and alerts. A web portal was also developed to support thesystem with updates and to provide more content-rich information.13

11 Ibid. at pp. 312-313.12International Telecommunication Union, “e-Farmasi Malaysia”, ICT Success Stories, World Summit on the

Information Society, Geneva 2003- Tunis 2005, <http://www.itu.int/osg/spu/wsis-themes/ict_stories/themes/e-health.html> accessed on 1 September 2007.13 Jayanthy Maniam, Kanaga Chenapiah and Chin Chee Ken, “Mobile phone based pregnancy support,”eHealth, February 2007, <http://www.ehealthonline.org/articles/article-details.asp?articleid=1022&typ=Case%20Study> accessed on 27 September 2007.



6

1.2.3 Russian Federation

e-Health in the Russian Federation developed closely linked with space medicine.14 Thefirst such application in space flight was monitoring the physiological parameters of dogLaika flown on Sputnik-2 in November 1957. Since then, ground medical personnel hasconducted real-time monitoring of astronauts’ health status, medical predication and

management, and evaluation of effectiveness of health maintenance procedures throughthe analysis of data received via telemetric facilities. The significance of the application ofthese technologies in health care was first recognized during a series of telemedicine“bridges” projects across the ocean under the auspices of the USSR-US Working Group onspace biology and medicine. 15 The large-scale telemedicine project was the firstexperience in international telemedicine application at the sites of emergencies. Theparticipants found the particular value in records of telemedicine practicalities at the sitesof the earthquake in Armenia in 1988 and the gas pipeline explosion in Ufa in 1989.Following this project, to facilitate ground applications of telemedicine, the SpaceBiomedical Centre for Training and Research conducted a demonstration of advantages of

reliable and low-cost technologies, including the internet, for health-care services.16 TheCentre also set up a basis to provide fundamental training in telemedicine to medicalstudents.17

The Russian academic community contributed to the assimilation of technologiesdeveloped by space physicians into the ream of national health-care policy. The RussianAcademy of Medical Science (RAMS) launched the programme of building a corporativenetwork of the federal medical centres, in collaboration with the Government of Moscow.Further, to extend the field of telemedicine to rural areas, Bakulev’s Research Centre ofCardiovascular Surgery and the Research Institute of Paediatrics and Children’s Surgery,

under the Ministry of Health, commenced a co-operative project known as “Moscow tothe regions of Russia.” 18 In 1997, to build the telemedicine system in the RussianFederation, the Telemedicine Foundation (the Foundation) was established. TheFoundation then included Ministries of Health, of Science, and of Catastrophes, theRussian Space Agency, RAMS and the Russian Academy of Science. Subsequently, theMoscow sector of the Foundation actively conducted the field testing of telematicstechnologies with the best clinics and regional telemedicine centres.

Currently, one of the major e-Health technology applications in the Russian Federation istelemedicine consultations. In recent years, more and more clinical and educational

centres have been deploying telemedicine capabilities to provide health-care services

14 Газенко О.Г., Какурин Л.И., Кузнецов А.Г. Космические полеты на кораблях “Союз”:Биомедицинские исследования. М.: Наука, 1976. 272 с; Григорьев А.М., Баевский Р.М. Концепция здоровья и проблема нормы в космической медицине.М.: Фирма “Слово”, 2001 . 96 с.15 Григорьев А.И., Саркисян А.Э. Шаги к медицине будущего. Российский опыт в области телемедицины // Компьютерные технологии в медицине. 1996. № 2. С. 56-64.16 P.B. Angood, C.R. Doarn, L. Holoday, A.E. Nicogossian and R.C. Merrell, “The spacebridge to Russiaproject: Internet-based telemedicine”, Journal of Telemedicine (1984), Vol. 4, No. 4, pp. 305-311.17 Григорьев А.И., Логинов В.А., Буравков С.В. и др. Использование информационых подходов

космической медицины в преподавании телемедицины// Рос.гастроэнтерол.журн. - 1998.- №2.-С.3-4.18 Бокерия Л.А., Бузиашвили Ю.М., Столяр В.Л. Опыт и перспективы использования медицинских видеоконференций в кардиохирургии // Анналы хирургии. 1998. № 1. С. 30-34; Кобринский Б.А.Телемедицина в системе практического здравоохранения. М.: МЦФЭР, 2002. 176 с. (Приложение к журналу “Здравоохранение”. 2002. № 2).



7

distantly. On the internet, accessible in the Russian language alone, nearly fortyinstitutions announce availability of tele-consultation services. Telemedicine centresfunction in more than sixty out of eighty federal parts of the Russian Federation. Amedical imaging technology facilitates distant consultation and a network to link togetherthe federal consultation centres with authoritative specialities. Regional centres and some

clinical hospitals receive consultative services of almost twenty medical centres in theRussian Federation as well as other countries. Many clinics are also equipped to deploytheir own telemedicine.19

Another significant application of e-Health is the distant training of medical professionalsand patients through the internet. e-Health has also contributed to the distant supervisionof patients. The recently developed infrared telemetric troll has been used not only inhospitals, but also in homes to supervise patients distantly. It contributes to monitoringthe health of employees at potentially dangerous industries. Mobile e-Health complexes,automobiles equipped with information technologies, have also extended services to rural

areas through tele-consultations and distance education. These automobiles are usuallyconnected to the larger telemedicine system, rather than local hospitals, contributing toimproved cost efficiency.

Still some challenges remain in the further application of e-Health for the improvement ofthe Russian health-care system. One of the major problems is the inconsistency between e-Health projects. Telemedicine services in the Russian Federation have been developed byvarious actors, such as state and regional agencies and private companies. These systemsare developed through different projects, adopting the most effective ICT project at theirdifferent regions and different sites, thus contributing to the great inconsistencies between

them. Further, these ad hoc developments often have led to short term projects, makingsustainability a major challenge.

Education of medical students and policy makes still poses another challenge.Telemedicine is not incorporated as a part of the medical discipline, thus there is nostandard class time set aside for the subject. From the psychological perspective, the issueof how physicians and managers are ready to implement telemedicine has never beenthoroughly researched. However, the Foundation has been making special efforts to trainusers of telemedicine technologies. A course in telemedicine was delivered in theFoundation’s quarters for medical students, general practitioners and technical and

information personnel from clinics and hospitals. The first Russian text book on clinicaltelemedicine has also been published.20

1.2.4 Singapore

Singapore has one of the most advanced economies in the Asian and Pacific region, and e-Health is uniquely positioned to take full advantage of the country’s high level of medicaland information communication technologies. With the second highest GDP per capita in

19

Николаев М.Х. Научно-организационные аспекты внедрения телемедицины в управление системой здравоохранения Республики Саха (Якутия): Канд. Дис. 2003.20 Клиническая телемедицина / А.И.Григорьев, О.И.Орлов, В.А.Логинов, Д.В. Дроздов, А.В.Исаев,Ю.Г.Ревякин, А.А.Суханов. М.: Фирма “Слово”, 2001. 144 с.: Практическая телемедицина. Серия под общей редакцией А.И.Григорьева. Вып.1-4. М.: Фирма “Слово”, 2001-2002.



8

the Association of Southeast Asian Nations (“ASEAN”) and the fourth highest projectedGDP growth rate in the world, the country has a well established health-care system. Thecountry has both doctors and hospital beds per thousand population well above globalaverages. Further, the country has well established investment in ICT infrastructure.Computers, along with web TV, are readily available in the public domain, including at

schools and libraries. High technology characterizes Singapore’s health-care industry.

Against this background, e-Health in Singapore has also been recognized as a means tomeet the challenges in accommodating one of the fastest ageing populations in Asia. It isforecasted that by 2030, 19 per cent of Singapore’s population will be over the age of 65,compared to the current level of seven per cent. The ageing population, along with rapidadvancement in medical knowledge and technology, has continuously raised the demandfor and the cost of health care. The current major challenge for the country is to ensurethat Singaporeans continue to have access to good and affordable health care.

The Singaporean Government took the initiative to build an enabling environment for theuse of ICT in e-Health, by including e-Health within the e-Government plan.21In 2001, theGovernment launched Singapore One Infrastructure which aimed to engage the entirepopulation in its nationwide electronic Citizen (eCitizen) programme. The Singapore Oneproject aimed at delivering a new level of interactive, multimedia applications andservices to homes, business and schools throughout the country by high capacity networksand switches. It integrates information and services from various government agencies tohelp users handle common events in life, with one of the modules focusing on health.22 Most health-care providers set up their own websites. The Ministry of Health websiteenables online searches for general practitioners nearest to the homes of the patients. The

nature of services available in this track is mainly administrative, including reschedulingappointments and providing admissions information and informing hospitals of a changein address. However, it also emphasizes health education, especially health promotion.

e-Health in Singapore has also supported health-care providers to gain access to medical,pharmaceutical and clinical trial information and electronic journal articles and tocontinue medical education. Another initiative is online support groups for health-careproviders, payers, or patients and their families.23 Electronic medical records have linkedfacilities together and enabled health-care providers to communicate with each other andshare information swiftly, including that of patients’ medical conditions and test results.

1.2.5 Thailand

Thailand has seen e-Health as one of the initiatives for a new model of development toreap the benefits of globalization and to meet the negative consequences of globalization.Initially, the Thai Government prepared a mega-development projects package to be

21 Foundations for eHealth, supra at note 10, pp. 320-2122

IDA Singapore, “Singapore One : Universal Access to Broadband Singapore”, 21 September 2003,<http://www.etw.org/2003/case_studies/reg_dev_singapore-one.htm> accessed on 5 August 2007.23 Joanne Tay-Yap and Suliman Hawamdeh, “The Impact of the Internet on Healthcare in Singapore,” Journalof Computer-Mediated Communication (2001) [electronic version] , Vol. 6, Issue 4, < http://www.blackwell-synergy.com/doi/abs/10.1111/j.1083-6101.2001.tb00131.x> accessed on 27 September 2007.



9

implemented over 2005-2009.24 The project package included basic infrastructure, such asmass transit, power plants and highways, as well as intermediate infrastructure, such aseducation and public health services. Further, in early 2006, the Thai Governmentlaunched the programme “Modernization of Thailand” to transform the country into amodern, competitive and knowledge-based economy. This project aims at utilizing the

application of evolving knowledge, technology and management to achieve the nationaleconomic, social and political development goals. Figure 1, below, shows health care asone of the priority sectors in the “Modernization of Thailand” project.

Currently, the Thai health sector consists of various agencies, both public and private.Primary health-care providers are generally located in rural areas, while hospitals are inurban areas and act as the referral system. Three main health insurance schemes act as themain health-care purchasers: the universal health-care coverage policy scheme, the socialsecurity scheme and the civil servant benefit scheme. At this stage, manual medicalrecords consist of the basic information of the patients of these three schemes and do not

link the services delivery units to the payment system.

Figure 1. Modernize Thailand

Source: Thai Ministry of Public Health, “Health Industry and Modernizing Health Care Systems in Thailand”,Health Policy in Thailand (2006), p. 56 [electronic version],<http://203.157.19.191/HealthPolicy6.pdf>[hereinafter “Health Policy in Thailand, 2006”] accessed on 27September 2007.

Figure 2 shows the framework on e-Health of the Thai Ministry of Public Health. TheMinistry plans to develop an electronic health information system to link the three

24

Thai Ministry of Public Health, “Health Industry and Modernizing Health Care Systems in Thailand”,Health Policy in Thailand (2006), pp. 55-61 [electronic version],<http://203.157.19.191/HealthPolicy6.pdf>[hereinafter “Health Policy in Thailand, 2006”] accessed on 27September 2007.



10

systems in order to improve their quality and to increase the efficiency of use of resources,and also to have enough information to support the Management Information System forpublic health. This information system is planned to finally connect the records ofindividuals through thirteen digit numbers and a smart card system. Through this systemessential information for efficient management of the health-care system is collected,

analyzed and communicated within and between all public health facilities in the Ministryof Public Health.

Other areas of e-Health are also developing in Thailand. Tele-consultation andappointment are providing patients twenty-four hour live and interactive consultationswith physicians, directly via the internet/telephone from anywhere in the country.Telemedicine is allowing health personnel from 10,000 health centres and 750 districthospitals to have live consultations with physicians or specialists. Essential informationcan be communicated through the internet. Tele-conference and Tele-education are alsoallowing students in more than 40 nursing schools and public health colleges to

participate in live and interactive technical conferences, lectures or other educationalactivities.In short, Thailand has developed an e-Government policy with e-Health as a significantcomponent. Though there have been changes in the Government and delays ininvestments in ICT infrastructure to undertake initiatives, the Government still sees e-Health initiatives, including medical e-Consultation and e-Learning, as priority pilotprojects.

Figure 2. e-Health in Thailand

E - HealthE - Health

HEALTH INFORMATION CENTERHEALTH INFORMATION CENTERHEALTH INFORMATION CENTER

Tele - consultation,

appointment

Tele - consultation,appointment

Tele - conference,Tele - education

Tele - conference,Tele - education

Tele - medicine

GENERAL HOSP.

PCUCOMMUNITY

HOSP

UNIVERSITY HOSP.INSTITUTE

NURSING COLLEGE

RRCEXCELLENT CENTER

MISMIS

Tele - medicine

Tele - medicine

Data & Information

Source: Thai Ministry of Public Health, “Briefing of Modernizing Health Care Systems in Thailand” (26

January 2006).



11

1.3 Use of e-Health in cross-border health-care services

As a result of the transboundary nature of ICT today, e-Health is also facilitating thedelivery of health-care services beyond national borders. This section briefly summarizessome of the trans-boundary e-Health initiatives in the Asia-Pacific region.

1.3.1 Hospital referral

e-Health has facilitated the use of specialized medical technologies andskills otherwise unavailable in certain countries. It allows consultations and diagnosticsby foreign specialists. For example, ICT networks have connected islands in the Pacificregion, so that patients who need special care are referred to countries with necessarytechnology (See Figure 3, below). In Indonesia, telepathology was used to enhance theexamination of pap-smear using a technology only available in Australia, with specimensbeing sent to an Australian laboratory for examination.

Figure 3. Teleconsulation topology in Pacific Islands

Source: Isao Nakajima, “Issues concerning e-Health applications in developing countries, especially n thePacific”, presentation at the ESCAP Exert Group Meeting “Regional trends in trade in health services, andtheir impacts on health system performance in the Asian and Pacific region”, Bangkok, 9-11 October 2007.

1.3.2 Health personnel education

The Pacific Open Learning Health Network (POLHN) provides an example of the cross-

boundary use of e-Health in human resource development. The network aims to enhancecontinuing education and professional development to improve the quality and standardsof practices of health professionals in Pacific island countries and areas by using e-



12

Learning. It also aims to develop ICT in health-care facilities in rural areas and depressedurban areas for the training of health professionals and improvement of medicalinformation and health management systems. This tele-health open learning project wasstarted in 1999 with funding support from the Government of Japan, covering tencountries in the region; Cook Islands, Fiji, Kiribati, Marshals Islands, Federated States of

Micronesia, Palau, Samoa, Solomon Islands, Tonga and Vanatu. These participatingcountries have expressed a strong interest to contribute to the long term-sustainability ofPOLHN, integrating it as a component of national human resources for healthprogrammes of the ministries of health. The countries have also expressed a desire toexpand the network’s coverage to include other countries and to make it a Pacific regionallearning network.25

The activities of POLHN have taken place in two phases. In the first phase, ten POLHNlearning centres were established. These centres are computer laboratories and functionas resource centres for the health professionals on these countries. They are equipped

with computers, servers, networked printers, data projectors, web cameras, internetconnectivity and various learning and reference materials. Such reference materials alsoincluded the Blue Trunk Library Kit, a set of more than one hundred books on medicineand public health, developed by WHO as a means to compensate for the lack of up-to-datemedical and health information.26

In the second phase, educational courses are offered through learning centres which havenow expanded to fifteen.27POLHN provides distance learning opportunities, includingonline and hybrid courses, course materials and health information to health personnel inthe Pacific island countries through its websites. It also distributes digital and print

materials to learning centres in hospitals, community health centres, and nursing schoolsthroughout the subregion.28

1.3.3 Surveillance

e-Health has made a significant contribution to the cross-border surveillance of diseaseswith the potential to result in epidemics. Since the outbreaks of Severe Acute RespiratorySyndrome (SARS) and Avian Influenza, both Governments and international agencies,including WHO and FAO, have recognized geo-informatics as powerful tools supportingeffective preparation and planning for control of pandemics. WHO, for instance, uses its

website to connect the Global Outbreak Alert and Response Network29 which monitorsoutbreaks of Avian Influenza and other infectious diseases.

25 Nakajima, et al., “eHealth trends in Pacific Island 2006”[electronic version]<http://www.apami.org/apami2006/papers/eHealth%20trends%20in%20Pacific%20Isalnds%202006.pdf>accessed on 4 December 2007.26 WHO, “Blue Trunk Libraries: Summary”[electronic version],<http://www.who.int/ghl/mobile_libraries/bluetrunk/en/index.html> accessed on 6 December 2007.27 POLHN, “POLHN Learning Centres”[electronic version], < http://polhn.org/centres> accessed on 7

December 2007.28 POLHN, “About POLHN”[electronic version], <http://polhn.org/node/48> accessed on 4 December2007.29 WHO, “Global Outbreak Alert and Response Network”[electronic version],<http://www.who.int/csr/outbreaknetwork/en/> accessed on 12 December 2007.



13

The Pacific subregion offers another example. The Pacific Public Health SurveillanceNetwork (PPHSN) is a voluntary network of countries/territories and organizations,dedicated to the promotion of public health surveillance and response. The PPHSN wascreated in 1996 under the joint auspices of the Secretariat of Pacific Community (SPC) andWHO.30 Before the creation of PPHSN, all countries and territories in the Pacific island

subregion conducted public health surveillance activities and submitted the data tovarious regional and international agencies, including WHO, UNICEF, SPC, UNFPA andthe Untied States Centre for Disease Control. Each country or territory had its own systemof data collection, processing and reporting. This situation resulted in several problems,including the selection and determination of the indicators included in the surveillance bydifferent international agencies; a lack of integration of activities to provide acomprehensive perspective of subregional needs and priorities; a lack of coordination oftraining for data collection, analysis and interpretation at the national level to providesubregional perspective; and a lack of uniformity in the format of indicators.

Thus, the PPHSN was established with the goal to improve public health surveillance andresponse in the Pacific Islands in a sustainable way. Its five main strategies are; 1)harmonization of health data needs and development of adequate surveillance systems,including operational research, 2) development of relevant computer applications, 3)adaptation of field epidemiology and public health surveillance training programmes tolocal and regional needs, 4) promotion of e-mail use, opening the network to new partnersand new services and other networks, and 5) publication. The current focus and firstpriorities of PPHSN are outbreak-prone communicable diseases. These target diseasesinclude dengue fever, measles, rubella, influenza, leptospirosis, typhoid fever, cholera,SARS, HIV/AIDS and other sexually transmitted diseases.

1.3.4 Medical transcription and medical records

Other aspects of cross-border e-Health are medical transcription and medical recordoutsourcing. Medical transcription is the process whereby the medical transcriptionisttranscribes medical records dictated by physicians and other health-care providers. Theinformation transcribed ranges from physical history and reports; clinic, office andconsultation notes; operative, laboratory, x-ray and pathology reports; dischargesummaries; and psychiatric evaluations. Customarily, the information dictated by doctorsis recorded either into tape or onto digital voice processing systems. Medical transcription

transfers this information, using word processing. Transcription services range fromsmall, one-person, home-based businesses to sophisticated, high-tech corporations. Somemedical transcription services now employ both “on-site” and home-based medicaltranscriptionists.

Today, most medical transcription service providers serve client hospitals both nationallyand internationally. At the same time, the demand for off-shore transcription service is onthe rise. Medical transcribers are in high demand in Western countries, especially in theUntied States where the health-care industry heavily relies on insurance which requiresdetailed medical records. Facing an acute shortage of medical transcriptionists, many

hospitals in developed countries have decided to outsource transcription services.

30 PPHSN-ROSSAP, “Background” [electronic version], <www.spc.int/phs/pphsn/index.htm> accessed on4 December 2007.



14

Instructions and letters are dictated into digital voice records. The files are forwarded to amedical transcript company, which then sends the recordings to a team of transcribers indeveloping countries.

India, with a large educated and English-speaking population and comparatively low cost,

has proved to be an ideal location to supply medical transcribers. In fact, the countryexperienced a boom in the early 2000s, with numerous companies and training institutionsentering the field. Services handled by Indian companies include, operative, progress andphysical notes, and discharge summaries. By improving work standards and quality ofservice, India attempts to capture a large clientele in the United States, at the same time asproviding employment opportunities to its large population of English-speaking andcomputer literate people. Similar successes can be seen in other countries with largeEnglish-speaking populations, such as the Philippines.

Medical record outsourcing is another key area within cross-border e-Health. The

advance of electronic communications makes it easier to send records abroad to betranslated. At this point, two major issues, concerning both medical transcriptions andmedical records, are confidentiality and accuracy. The lack of a regulatory framework forprocessing personal data raises concerns regarding the processing of data off-shore.

1.3.5 Medical travel/tourism

One aspect of today’s globalized health care is medical travel/tourism in which a patienttravels to another country to receive medical treatment or health-care services. India,Singapore and Thailand are the most popular medical travel destinations in the Asian and

Pacific region. Each year, millions of foreign patients seek care in hospitals in thesecountries.31 A combination of many factors has led to the recent increase in popularity ofmedical travel, but e-Health has played a critical role in the growth of the industry beyondnational borders. e-Health has facilitated this emerging industry, as a required part of theprocess of delivering high quality health-care and ensuring the exchange of critical pre-and post- treatments data between sending and receiving providers.

Most providers in the medical travel industry utilize e-Health as a major channel to linkand attract global consumers. ICT provides the support for timely health-serviceadministration. Access to knowledge that the same care is available elsewhere at a much

lower cost encourages consumers to be more price-sensitive about certain medicalprocedures. At the same time, e-Health has made the easy and continued sharing of theinformation between patients, service providers and institutions possible. Like financialinformation, transactions can be accessed wherever a person is located; important healthinformation too can be used with the same technologies and methods regardless ofphysical locations.

31Oxford Analytica, “'Medical Tourism' Industry Grows Rapidly”, Forbs.com (26 October 2006),<http://www.forbes.com/business/2006/10/25/health-medical-tourism-biz-cx_1026oxford.html> accessedon 27 September 2007.



15

2. Potential of e-Health as a means to overcome health-care challenges

e-Health has increasingly been seen as a solution to address challenges of limitedresources, while meeting expectations for improved quality of health-care services.32 Infact, WHO has described telemedicine services as more of a necessity, especially in

developing countries. A WHO survey finding presents some compelling cases of the needfor telecommunications for health care in view of the following:

• A severe shortage of health-care professionals;

• A lack (or absence) of health care for the population living in rural areas;

• High maternal and prenatal mortality rates (as high as 30 per cent in some cases),which are partly triggered by a lack of appropriate natal care and reproductivehealth services;

• A lack of access to medical journals after graduation by physicians, particularlythose in rural and remote areas. 33

2.1 Efficiency

One of the great potentials of e-Health is efficiency. e-Health can contribute to eliminateduplications or errors. It can also save time and cost of travelling, as well as allow moreefficient allocation of human and other resources. For example, a report published by theAustralian Centre for Health Research estimates that improved knowledge sharing, alongwith care plan management, would save more than AUD 1.5 billion (USD 1.3 billion34) perannum and increased workforce participation and productivity could add another AUD 4billion (USD 3.5 billion) to the economy per year.35

This potential of e-Health to greatly increase the efficiency of health-care systems hassignificant implications in societies with increasing strains on health care, especially wherethe percentage of people over 65 years old is rapidly growing. For example, as in the casein Singapore discussed above, in Japan, the increasing number of the older people was thecrucial factor in shifting the policy to recognize the role of e-Health in its health-caresystem. The country has started taking various initiatives to improve the efficiency ofhealth care through e-Health. The example of Katsurao Village is one such initiativesinvolving direct patient care through telemedicine and delivery of medications. In thevillage, the clients and physicians are connected by an interactive video conferencingsystem which allows direct patient care as well as the monitoring of chronic diseases. The

physicians send prescriptions by fax to pharmacists who receive payments by mail. Thepharmacists mail the medications to the clients. Patients and pharmacists are alsoconnected through a web process which allows access to medicines through such aprocess.

32 Salah H. Mandil, “Tele-health: what is it? Will it propel cross border trade in health services?”,International trade in health services: a development perspective (Geneva, UNCTAD and WHO, 1998), pp.79-104.33

Foundations for eHealth, supra note 10, pp 27-29.34 USD 1 = AUD .1.13 as of 18 July 200735 Michael Georgeff, “E-health and the Transformation of Healthcare” (April 2007)[electronic version],<http://www.achr.com.au/pdfs/e-health%20and%20the%20transofrmation%20of%20healthcare.pdf>accessed on 12 December 2007.



16

2.2 Distance/isolation

e-Health offers prospects for extending coverage of services to many remote or ruralvillages that lack easy access to hospitals and medical facilities. Many countries in theAsian and Pacific region face the burdens of diseases related to poverty and a lack ofinfrastructure and investment. At the same time, rural and poor areas in developing

countries are often prevented from benefiting fully from the development of ICT. In manycases, multi-purpose telecentres36, which often play a crucial role in overall e-Governanceinitiatives, have been seen as a solution to provide necessary infrastructure and services toremote areas. Once all the requirements are met, telecentres could be used for diagnosticmedical services through telemedicine and providing public health information. Suchinformation and services are also vital during epidemic outbreaks and disasters.Telemedicine facilities can assist relief workers by providing them with instant supportfrom remotely located health-care professionals. Furthermore, telecentres could be usedfor medical practitioners to update their knowledge and skills which are critical inproviding quality care in rural and remote areas.

Electronic health records now being utilized in many countries also enable easy access topatient data by concerned health-care professionals, from general practitioners, specialists,and care teams to pharmacists, regardless of their physical locations. Electronic healthrecords allow the timely transferral of health information, instantly and to anywhere.This enables those who are in remote areas to receive the diagnostics or consultation bythe specialist in another location.

2.3 Health outcomes

Some studies have identified areas where e-Health has contributed to health outcomes.For example, telephone and mobile technologies can improve health-care delivery, such asadherence to medication, more targeted consultations and patient monitoring. 37 InPakistan, one study evaluated the role of telemedicine in a follow-up treatment of traumapatients of the earthquake of 2005 and concluded that significant reductions inreadmissions to tertiary care hospitals and reduced workloads at main trauma care centreswere observed.38

3. e-Health policies

3.1 e-Health policy at the national level

e-Health and telemedicine are largely technology-intensive initiatives. To ensure optimaland sustainable investment in the area, health should be positioned as one of the key

36 A multi-purpose telecentre is a shared information and communication facility for people in un-served orunder-served areas to facilitate access to email, web browsing, file transfer, electronic libraries, databases,government and community information services.37 W. Kaplan, “Can the ubiquitous power of mobile phones be used to improve health outcomes in

developing countries?”, BioMed Central (2006).38 M. Faisal Murad, Riaz Ahmad, Salman Naeem, Qasim Ali, Aisha Ehsan, Tariq Sohail, Asif Zafar Malik,“Follow-Up of Earthquake Victims in a Remote Hospital Using Telemedicine” paper presented at the APTRegional Workshop on Telemedicine, February 2007.



17

social sectors in national ICT policies and ICT in national heath policies. The InformationCommunication and Space Technology (ICST) Division of the ESCAP Secretariat hasconducted a study of 25 ICST policies and strategies, both drafts and approved versions,as well as six ICST related policies and programmes in 24 member states in the region toassess the level of synergies between ICST and health.39 The study found that ten out of

thirty-one of the ICST policies have no mention to health, with the rest having somecomponents related to e-Health or telemedicine. However, it is not only ICST policies andstrategies that address and promote e-Health: some Governments have articulated visions,objectives and activities of how to use ICST in the health sector in other forms, such asnational five year plans (China)40 and science and technology master plans (Maldives).41 Interms of how health is addressed in the above-mentioned ICST policies and strategies, theobjectives and approaches vary from country to country, with selected examples in Table 2,below.

Table 2. e-Health objectives and approaches – A diversity

MainFocus

Country Activities

Basichealth

Thailand42 Develop IT systems in order to ensure quality, equaland thorough coverage, providing information onbasic public health and ensuring the health and well-being of the people

R&D Philippines43 Aim greater interaction within the country’s scienceand technology community including the Health R&D

Information Network (HERDIN)Afghanistan44 Provide health services virtually by specialists at a

distance using e-medicine techniquesEnhancedservicedelivery Indonesia45 Develop online public services including telemedicine

and health data centres

39Afghanistan, Armenia, Azerbaijan, Bangladesh, Bhutan, Cambodia, China, India, Indonesia, Iran,Kyrgyzstan, Malaysia, Maldives, Mongolia, Nepal, Pakistan, Philippines, Republic of Korea, Samoa,Singapore, Sri Lanka, Thailand , Uzbekistan and Viet Nam; ESCAP, “Working Paper: e-Health for aLeapfrogging Asia and Pacific: Challenges and Opportunities,” October 2007, available athttp://www.unescap.org/esid/hds/lastestadd/eHealthICTpaper041007.pdf.40Telecommunications Research Project“, China: Summary of the 10th Five Year Plan, 2001-2005”[electronicversion], <http://www.trp.hku.hk/infofile/china/2002/10-5-yr-plan.pdf> accessed on 12 December 2007.41 Ministry of Communication, Science and Technology, “Maldives Science and Technology MasterPlan”[electronic version], <http://www.mcst.gov.mv/Documents/mplan.htm> accessed on 12 December2007.42National Information Technology Committee Secretariat, IT Policy Framework 2001-2010: Thailand VisionTowards a Knowledge-Based Economy (Bangkok, National Information Technology Committee Secretariat,2003).43National Information Technology Council, Philippines, “IT 21: Philippines Asia’s Knowledge Hub”, 1997,<http://www.neda.gov.ph/Subweb/IT21/it21.pdf> accessed on 12 December 2007.44 Ministry of Communications, Afghanistan, “Draft Information Communication Technologies Policy

Paper”, <http://www.export.gov/afghanistan/pdf/ict_policypaper.pdf> accessed on 12 December 2007.45Indonesian Telematics Coordinating Team (TKTI), “Five Year Action Plan for the Development andImplementation of ICT in Indonesia”, 2001,<http://unpan1.un.org/intradoc/groups/public/documents/apcity/unpan002101.pdf> accessed on 12December 2007.



18

Philippines Develop and implement information systems forgovernment front-line services, such as health

Bangladesh46 Deliver new capabilities for hospitals and health-careproviders through electronic medical records,telemedicine, medical and health education as well as

development of Bangladesh Health Portal andnetworked medical centre of excellence

Bhutan47 Harness ICT to enhance the quality and accessibilityof health services through the establishment of linkswith neighbouring countries and internationalagencies to track emerging health threats, real timetelemedicine and integrated health managementsystems

Malaysia48 Transform the Malaysian health-care system to bemore integrated, distributed and virtual through

lifetime health records, MyHEALTH portal,continuing professional development and tele-consultation

Integratedhealthsystem

Mongolia49 Harmonize health sector and transport to otherpatient-centred, inexpensive, reliable and worry-freeservices anywhere and anytime with theestablishment of the integrated electronic databasesystem of medical records, applying ICT as a tool toimprove public health education and utilization ofdistance treatment, diagnosis and monitoring as new

tools for providing access in rural areasSource: ESCAP, “Working Paper: e-Health for a Leapfrogging Asia and Pacific: Challenges andOpportunities,” October 2007, available athttp://www.unescap.org/esid/hds/lastestadd/eHealthICTpaper041007.pdf.

This section summarizes policy approaches in some countries in the Asian and Pacificregion.

3.1.1 Russian Federation

In the Russian Federation, the telemedicine system has developed through a matrixmanagerial structure which involves state agencies, regional level telemedicine initiativesand private companies. This has required coordination to create homogeneity intechnologies and structures, to better integrate telemedicine into the health-care systems to

46 Bangladesh Development Gateway Foundation, “Bangladesh National Policy on ICT”, (2002)[electronicversion], <http://www.bangladeshgateway.org/npict.php> accessed on 12 December 2007.47 Royal Government of Bhutan, “Bhutan Information Communication Technology Policy and Strategy(BIPS)”(2004)[electronic version],

<http://www.dit.gov.bt/guidelines/BIPS%20Final%20Report%20-%20v5.1.pdf> accessed on 12 December2007.48Multimedia Development Corporation, “Malaysia Multimedia SuperCorridor: tele-health” athttp://www.msc.com.my/msc/tele-health.asp.49Information and Communication Technology Agency, Mongolia, “E-Mongolia National Program” (2006).



19

serve the most indigent or insufficiently served population, and for emergencies andcatastrophes.

Inter-agencies coordinationMultiple attempts have been made to set up an inter-institutional coordination of the

activities to introduce telemedicine into health services. Since 1997, the TelemedicineFoundation (the Foundation), under the auspices of seven federal agencies, has beenbearing the responsibility of coordination. In 2000, the Ministry of Health appointed theTelemedicine Coordinative Board. In the subsequent year, the Foundation proposed theState Duma to provide a legislative basis to telemedicine and informatics within theRussian health-care system. The Telemedicine Coordinative Board adopted the proposaland used it to outline the concept of telemedicine services in the Russian Federation. In2002, the State Duma adopted the conceptual document and recommended it to theRussian Government as a basis to develop a federal programme. Following theserecommendations, the Ministry of Communication and Informatics took a decision to

support the telemedicine section of the programme “Electronic Russia.”

The current main areas of the inter-agency coordination include reviewing andsummarizing up-to-day practices and comparatively analyzing domestic and internationalexperiences. The inter-agency coordination has also developed recommendations onupdating the governmental policy with respect to principles, standards and budgeting ofthe telemedicine service system. Guidelines regarding prioritized telemedicine-relatedinvestigations were similarly developed. Finally, the inter-agency coordination has alsocontributed to scientific and public evaluation of proposed resolution and programmes inthe field of telemedicine and performance evaluation.

The “Telemedicine in Russia” programme is the major federal programme to deploy thenational telemedicine system. Primary goals of the project include; increased affordabilityand quality of medical care; governmental assurance of free medical care; extension of thelist of back-up medical services; establishment of a single medical care standard;technological and managerial unification of the telemedicine system as required foraddressing the national needs; improvement and continuity of medical training;promotion of economic (including market) conditions for telemedicine advancement;consolidation of the functional structure of health services in the Russian Federation andacceleration of integration with other states. The project aims to achieve these goals

through multiple structures, including telemedicine information infrastructure and aunified system of telemedicine consultations.

Legislative regulationSetting up a legal framework for e-Health is currently another major task in the RussianFederation. Today, “telemedicine services” are interpreted as provision of medicalinformation and health services through the use of telematics and associated structures.However, depending on the character of contacts between users, telemedicine services canbe classified as tele-consultations and remote diagnostics, monitoring of patients,telemedicine training and internet-medicine. These uncertainties raise a broad range of

legislative, regulatory and ethical issues. Related issues include; policy formulation andauthority regulation for services organization and development; elaboration oforganizational and economic mechanisms for telemedicine systems; definition of rights



20

and responsibilities of subjects in the telemedicine sphere; provision of high-qualitytelemedicine services and assurances of patients’ rights. Development and improvementof a legal base for telemedicine at the federal, regional and institutional levels are stillongoing, in addition to their harmonization with international legal acts.

3.1.2 Japan

Telemedicine policies of Japan started in 1997, when the country’s reliable communicationcircuit was set in place. At the background of this initiation was a rapidly ageingpopulation. The percentage of the persons over 65 years old is expected to reach 22 percent by 2010. The lack of availability of hospital beds to care for the growing number ofolder people has meant increased needs to care for them at home. The Governmentintroduced new policies to make it possible to treat patients with chronic conditions athome through telemedicine, as well as the reimbursement of payment for such care.

As the first step of this policy development, in December 1997, the Ministry of Health andWelfare issued the official notice, HPB #1075. The notice was directed to all prefecturalgovernors across the country. The notice set the Ministry’s position that telemedicineutilizing telecommunication and information technologies devices do not infringe onArticle 20 of the Medical Practitioners’ Law regarding the “face-to-face examination”principle. Such telemedicine was to complement “face-to-face examinations,” and to beadministered to patients with chronic diseases and in stable conditions. The notice alsopermitted the administration of telemedicine for patients who were otherwise unable tohave a “face-to-face examination” with a physician, such as those in isolated areas andbedridden older patients.

One year later, the Ministry of Health and Welfare issued the official notice number 90concerning tele-pharmacies. The notice pertained to the matter of “Receiving ofprescriptions by fax and the home delivery of prescriptions to patients”. This noticerendered it legal to receive prescriptions through telecommunication lines and to sendprepared prescriptions by mail, provided that the service satisfied certain requirements.The requirements included 1) the agreement by patients to receive deliveries made bypersons other than a pharmacist; 2) verification of the delivered prescriptions as beingidentical to the prescription order transmitted by fax; and 3) the record keeping bypharmacies of the drugs dispensed to patients. It should be noted that in addition to these

requirements, Article Nine of the Japanese “Law on Postal Service” stipulates that apatient’s privacy must be strictly guarded and that delivery personnel are responsible fordoing so.

In 2000, the Japanese Social Insurance Medical Fee Payment Fund approved the actualfunding for telemedicine. More specifically, the Fund approved that “tele-diagnosis usingpathological images during surgery” could add points in the table of points for fees.However, the Fund also set conditions, including 1) facilities standards are subject to priornotification and approval, in reality requiring medical treatment centres to be highly



21

advanced, and 2) medical institutions to have a clinical engineer on its staff with morethan five years of experience in the field of pathology.50

3.1.3 India

In India, the Department of Information Technology, Ministry of Communication andInformation Technology has prepared a guideline “Recommended Guidelines &Standards for Practice of Telemedicine in India” to standardize services of differenttelemedicine centres. The guideline aims at enhancing interoperability among the varioustelemedicine systems being set up in the country. These standards are to assist theMinistry, state governments and health providers in planning and implementingoperational telemedicine networks. The Ministry also took an initiative, in a project, fordefining “The framework for Information Technology Infrastructure for Health” toefficiently address information needs of different stakeholders in the health-care sector.At the same time, the Ministry of Health and Family Welfare has set up a National Task

Force on Telemedicine in the year 2005 to address issues in telemedicine in the nationalcontext. A number of sub-committees are working on these issues to develop a nationalpolicy document.

It should be noted that e-Health is an important part of the overall e-Governance networkstate wide in India. The Ministry of Communication and Information Technology, haslaunched the National e-Governance Action Plan to facilitate the development of e-Governance within the country. One of the proposals formulated by the Ministry aims toestablish 100,000 Common Service Centres in rural areas, not only to serve as the front endfor most of the government services, but also to connect those in the rural area to the

internet. The reach of electronic services, both by public and private sectors, would extendto the village level through these centres. At the same time, Indian Space ResearchOrganization has developed the concept of Village Resource Centre to provide a variety ofservices including e-Governance services, tele-education, interactive farmers’ advisoryservices, tele-fishery, weather services, water management and telemedicine. Thesecentres will provide connectivity to specialty hospitals, thus bringing the services of expertdoctors closer to the village.

3.2 International policies pertinent to e-Health

3.2.1 e-Health in trade policies

The development of e-Health beyond borders in the last decade has had the effect ofmutual reinforcement, with an increase in global and regional transboundary trade. Inrecent years, national markets and economies have become increasingly integrated. At theglobal level, successive rounds of the World Trade Organization (WTO) trade negotiationshave encouraged increased trade in both traditional sectors, such as agriculture, and alsonew sectors, including services. At the regional level, various regional and free tradeagreements (RTAs and FTAs) have also been established. With the slowing down of WTO

50 Isao Nakajima, “Inclined trends in the telemedicine polices of Japan,” Telecommunication DevelopmentBureau, ITU-D Study Groups, Raporteurs Meeting Q14 1/2 Japan, 25-27 June 2005 [electronic form],<http://www.ets8.jp/iturapp2004/Japan_Rapp_005.doc> accessed on 10 December 2007.



22

multilateral trade negotiations in the late 1990s, the numbers of RTAs and FTAs haveincreased considerably.

With regard to e-Health, the members of ASEAN have taken significant steps. They arecurrently engaging in negotiations to establish the ASEAN Free Trade Area (AFTA) and

the ASEAN Economic Community (AEC).51 AEC aims, by the year 2015, at turningASEAN into a single market and production base, with over 500 million consumers toencourage the free flow of goods, capital, services and skilled labour with transport andcommunication linkages. Under the AEC initiative, 12 priority sectors, such asautomotives, agro-based products, air travel and tourism, have been identified. e-ASEANand health care are also among the 12 priorities. In fact, health care and e-ASEAN havebeen targeted as the top priority sectors with accelerated target years of 2010.52 Presently,the Healthcare Services Sectoral Working Group, under the ASEAN CoordinatingCommittee on Services, has the responsibility to prepare initial offers for the package ofcommitments in health services. The working group is also responsible for drafting the

mutual recognition arrangements of health professionals, including nursing services andmedical practitioners, to facilitate their movement.53

The South Asian Association for Regional Cooperation (SAARC) has also started takinginitiatives in e-Health at the subregional level. For example, a project to connect one ortwo hospitals in each of the SAARC countries with several super specialty hospitals inIndia by the end of 2007 has been started. This project has been developed as anexemplary model to implement projects at the subregional level.

3.2.2 e-Health in ICT policiesNot only international trade polices, but also ICT policies have recognized the significanceof e-Health. For example, e-Health was included in the Geneva Plan of Action54 of theWorld Summit on Information Society in 2003. Action Line 7 promotes the adoption of e-Health, including medical training and research through the use of ICT, the developmentof international standards for the exchange of health data and the creation of reliable,timely, high quality and affordable health-care and health information systems. A statedgoal is to connect health centres and hospitals with ICT by 2015. The World Summit on theInformation Society Plan of Action also urges the use of ICT to achieve the MillenniumDevelopment Goals and other internationally agreed development goals. The

International Telecommunication Union (ITU) established ITU-T Study Group 16 Work one-Health to handle the standardization of multimedia systems to support e-Healthapplications.55

51 Ministry of Public Health, Health Policy in Thailand, 2007 , pp. 61-63 [electronic version],<http://203.157.19.191/HealthPolicy7.pdf> accessed on 27 September 2007.52 ASEAN CCS, Report of the 16th ASEAN Healthcare Sectoral Working Group, Bali, Indonesia, 2007.53

Ibid.54 World Summit on the Information Society, “Plan of Action“,<http://www.itu.int/wsis/docs/geneva/official/poa.html#c7-18> accessed on 12 December 2007.55 International Telecommunication Union, “ITU-T Study Group 16 Work on e-Health”,<http://www.itu.int/ITU-T/studygroups/com16/e-health/index.html> accessed on 12 December 2007.



23

4. Factors regarding further expansion of e-Health

For further expansion of e-Health to improve the quality and efficiency of health-careservices, certain factors are critically important. This section briefly summarizes some ofsuch factors.

4.1 Clearer direction on the role of e-Health

4.1.1 Policy framework

Many countries in the region still lack a clear policy direction of the role of e-Health,coupled with a lack of political commitment and a clear legal framework. A clear-cutpolicy framework is essential for systematic and coordinated development of e-Healthinitiatives. Especially in a sensitive field like health care, where patients' data is essentiallyprivate and sensitive in nature, this poses a major impediment towards the adoption of e-Health.

In setting up a policy framework for e-Health, multi-disciplinary collaboration, with theactive participation of both telecommunication operators and health-care professionals,should play a significant role. In most countries in the Asian and Pacific region, therecurrently exists a need to bridge the gap between the telecommunication and health-carecommunities at all levels. National ministries of health and telecommunications also needto work together towards the introduction of an e-Health policy and the achievement of aunified service system which covers emergency services and health and social informationsystems. A national level organization with a multi-disciplinary composition is necessaryto bring together all stakeholders and to raise awareness of the new technologies as well as

the need for collaborations.56

4.1.2 Legal framework

A legal framework also plays a significant role in encouraging the wider use of e-Health.e-Health allows services to be delivered at a distance, oftentimes outside of standardhealth-care settings and with a preservation of anonymity if the patient so wishes. Thus, itcan have serious implications for health-care regulators and lawyers, as well as formedical professionals. For example, liability is a major fear for many medical actors, andcan influence the speed and manner of adoption of new technologies, including electronic

medical records and other functionalities.57 A clear legal framework is critically needed toallow practitioners and institutions to understand the legal risks and rewards of moving toe-Health functionalities. The following are three of the most significant clusters of legaland regulatory issues, affecting the use and deployment of e-Health:

56 L. Androuchko and I. Nakajima, “Developing countries and e-health services”, Enterprise Networkingand Computing in Healthcare Industry, 2004, HEALTHCOM 2004. Proceedings 6th International Workshopon 28 29 June 2004, pp.211-214,

<http://ieeexplore.ieee.org/Xplore/login.jsp?url=/iel5/9246/29313/01324524.pdf?tp=&isnumber=29313&arnumber=1324524> accessed on 27 September 2007.57 R. Boybjerg, R. Miller and D. Shapiro, “Liability’s Influence on e-Health Initiatives”, Abstr AcademyHealth Meet, 2003, <http://gateway.nlm.nih.gov/MeetingAbstracts/102275453.html> accessed on 27 September2007.



24

• Data protection, confidentiality and security in the context of the collection andsharing of data, which can identify individuals, for health care and advice;

• Product liability and consumer protection in the use of e-Health tools, devices andservices both traditional health-care delivery and e-Commerce and distancecontracting (including e-Pharmacy and advertising).

• Trade and competition in the context of using e-Health tools in health serviceplanning and delivery in traditional, remote or cross-border health-care delivery.

4.2 Human resources

Human resource development through appropriate education and training plays a crucialrole for providers to make the most use of the wider application of e-Health. Thenurturing of competencies and skills and the introduction of new working methods havebecome key factors in the successful re-engineering of service suppliers. Changes tostrategies, structures and methods of service delivery are dependent upon a creative and

innovative workforce. Such a workforce needs to adapt its skills, competencies andmindset to new ways of working that are more responsive to the needs of citizens. At thesame time, it is significant that patients have the appropriate literacy in ICT to fully benefitfrom the new service methods through e-Health.

One of the biggest impediments towards the wider use and the universal acceptance of e-Health is the lack of awareness among patients in general towards ICT innovations andmethods. This is especially problematic with ICT initiatives in health informationdissemination. People may not be aware of such initiatives, or they may not haveappropriate access to computers or the internet.

e-Health requires service providers to be equipped both with technical skills and certaininter-personal skills. Thus, the availability of an appropriate mix of competencies andskills is central to the wider diffusion and adoption of e-Health. Technical skills,concerned with communication technologies and clinical processes enabled by thosetechnologies, are necessary to set up e-Health applications. At the same time, the deliveryof these applications to citizens requires strong inter-personal and managerial skills, as e-Health often requires providers to manage staff over networks. The inter-personal skillsare concerned with relationships between system personnel, providers and patients, andthe way in which those relationships are organized. Furthermore, e-Health requires the

incorporation of customer relations management approaches, efficiency measures andmodern management techniques.

In the past, health education and training in ICT rarely fitted in the busy schedule ofhealth professionals. Now, many countries have included information technology skills intheir curricula. However, it is still a low priority in other countries. In the currentenvironment characterized by rapid technological and organizational changes, the abilityof physicians to use ICT is acknowledgeably vital for the effective management of medicalinformation. Thus, the introduction of e-Health and medical informatics into the curriculaof medical schools at both undergraduate and postgraduate levels is gaining wider

support. Courses in these areas are designed to equip medical students and other healthprofessionals with the necessary formal informatic competencies to the following functionas users and producers of medical data.



25

e-Health competencies and skills are particularly significant in relation to four major e-Health application areas:58

Public health policy and prevention: This area requires the collection of health,

environmental, and socio economic information that enables data mining forhealth-care strategy planning. Essential skills, for health-care professionalsinvolved in this area, include the ability to understand the functional design anduse of personalized web services and to understand the structure and informationneeds of public health policy and prevention to develop new algorithms to fit inemerging types of data;

Information services to citizens: This area encompasses activities providingpatients with information on health related topics, such as good health and lifestyle,when professional help is required, and where and how to obtain it. Essential skillsrequired in this area include abilities to contribute to the structuring and updating

of citizen information services and to design and use functional personalized webservices;

Integrated patient management and patient health records: These areas concernactivities surrounding the efficient and secure sharing of information betweenhealth and social care professionals and the establishment of an environment toprovide support for integrated client case management. Essential skills required inthis area include abilities to design and use evidence-based e-Health clinicalprotocols, to understand and operate integrated patient management systems andpatient health records and to efficiently manage personal and health informationsecurity and confidentiality.

Tele-care and independent living services: These areas include tele-consultations,tele-homecare, vital signs monitoring and other services for older people andpeople with disabilities that support their independent living. Essential skills forthis area include the basic technical knowledge on how to operate tele-care andindependent living services, the ability to form tele-care and independent livingservice level agreements with third parties, to evaluate equipment and servicesdelivery and to manage personal and health information security andconfidentiality.

Similarly, for patients, the ability to benefit from e-Health critically depends on their

familiarity and interests in ICT, especially on the internet. People without experience orinterest in computers and electronic devices would hardly be able to seek medicalinformation from internet sites or receive care and support from a distance using ICT. Bycontrast, people who are already using computers or are keen on learning newtechnologies are more likely to have a positive attitude towards e-Health applications andbenefit from their wider deployment.

58Anastasia Constantelou and Vasiliki Karounou, “Skills and Competencies for the Future of eHealth”, TheIPTS Report, Issue 8, 26 April 2005,<http://www.jrc.es/home/report/english/articles/vol81/ICT4E816.htm> accessed on 27 September 2007.



26

4.3 Financial and technical support

Other significant factors for e-Health expansion include financial and technical support.Countries in the Asian and Pacific region in general have very low public spending onhealth care. Naturally, this inadequate funding in general health care leads to a lack ofappropriate financial support to ICT in health care. Innovative initiatives may die an

unknown death for lack of financial support to be upgraded and mainstreamed. Rapidtechnological growth is a significant feature of the ICT sector. However, financialconstrains might prevent poorer nations from keeping up with the innovations and thelatest technologies available in the market. Similarly, ICT is a technologically intensivesector requiring heavy investment in the relevant infrastructure, including power supply,transport and internet connectivity. However, many countries in the region still haveinsufficient and widely disparate levels of infrastructure.

5. Conclusions and recommendations

The Expert Group Meeting ended with the following conclusions on the positive andnegative impacts of e-Health on health systems and barriers in the further expansion of e-Health, and the recommendations at both national and regional levels.

5.1 Positive impacts of e-Health on health systems

e-Health has the following positive impacts on health systems:

• Improving cost efficiencies by maximizing the effectiveness of available financialresources and by minimizing the costs involved in health-care delivery as well as

meeting increasing expectations for health care;• Improving the quality and safety of treatments by the provision of appropriate and

timely information leading to enhanced adherence to medication, targetconsultation and monitoring;

• Providing relief to strained health-care systems in disaster situations;

• Contributing to home care in societies with increased populations of older persons;

• Strengthening health-care delivery systems in isolated and remote areas throughmobile units and helping to address the shortages of health personnel in thoseareas;

• Enhancing educational opportunities for health personnel, administrative officials,

policy makers, politicians and the general public;• Stimulating the technology absorption and enabling the effective functioning of

public health systems through the use of ICT.

5.2 Negative impacts of e-Health

e-Health could also have adverse impacts. The following are such potential harms:

• If it is not implemented in a comprehensive manner which ensures access by allsections of society, e-Health does have a potential to create further inequity inhealth-care systems because of the existing digital divide;

• Unless it is effectively integrated within existing health-care delivery systems, e-Health implementation may result in shortages of resources leading toinappropriate or limited implementation.



27

5.3 Barriers in the further expansion of e-Health

Despite the potential to benefit health systems, various barriers still hinder the expansionof e-Health. These include the following:

• Limited evidence based research regarding e-Health initiatives, especially on itscost-effectiveness. There are no identified instruments and standards for gapanalyses of e-Health at national and regional levels. There is also a lack ofconclusive evidence of its benefits, and many existing studies are preliminary;

• A lack of communication between stakeholders, such as between providers andGovernment, between sectors in Government, e.g. ICT and health sectors, as well asamong providers, such as hospitals;

• The ad-hoc and unplanned nature of existing e-Health initiatives, resulting in a lackof sustainability and compatibility and failure to develop into a unified system;

• A shortage of manpower with appropriate skills, which is partly due to a lack orlimited awareness of the potential of e-Health at the governmental level, as well asthe absence of integration of e-Health in the education of medical personnel. Thenegative attitude and resistance of medical personnel towards the use of ICT inhealth care also inhibits its improved usage;

• Technical barriers at national and regional/global levels, such as non-interoperability of hardware, software and connectivity. There is also a lack of anaccepted standard in e-Health application and limited ICT infrastructure in ruralareas;

• Shortages of financial resources for e-Health, arising from a combination of factors

listed above;• A lack of policy coherence at national and international levels as well as an absence

of a legislative framework on e-Health.

5.4 Recommendations at the regional level

5.4.1 Regional vision

There is a need for a clear vision on the application of e-Health at the regional level. This

vision should take into account capacities and gaps at the national level and how regionalcooperation could help fill some of these gaps.

5.4.2 Needs and preparedness at the regional level

The vision should be based on an assessment of e-Health preparedness at the regionallevel, taking into account an assessment of the e-Health status in each country. Theassessment could include an analysis of cost-effective models which could be applied ineach country, based on different levels of health system development.

5.4.3 Role of regional/international cooperation

Regional cooperation can contribute to enhance the following:



28

• Collecting and sharing of technology and strategies. This sharing of experiences atthe regional level could also be in the area of policies and standardization of normsas well as guidelines for ethical practice in the area of e-Health.

• Utilization of e-Health across borders in disaster situations in the region.

• Encouraging each country to develop specialization in certain areas taking into

account the comparative advantage of each country. This would make moreeffective use of the complementary strengths that are presently found acrossmember countries.

• Promote public-private partnerships for development of indigenous e-Healthtechnologies and strategies for implementation.

• Integrating human resource development by, inter alia, identifying regional trainingcentres for development of human resources in the field.

• Closer cooperation and coordination between regional and subregionalorganizations working in the field of e-Health to support member states adequatelytowards development of their e-Health capabilities.

5.5 Recommendations at the national level

At the national level, countries should consider the following steps:

• A national vision for e-Health. It is essential to have a comprehensive nationalvision on e-Health which takes into account financial and human resources, and aclear plan for implementation in a manner that promotes inter-operatibility using aglobal standard.

• The national vision should be based upon an assessment of available resources andinfrastructure in the country, and focus on the aspects of e-Health that would be the

most beneficial considering the above limitations. The assessment should includeissues that address sustainability as well as impacts on vulnerable groups.

• A study should be made on factors that influence the readiness of physicians andpatients, as well as hospital managers.

• Multi-stakeholder cooperation is essential. Public-private partnerships should bepromoted with close communication between health, ICT and trade officials as wellas those among health-care providers and between health-care providers andpolicy makers.

• Development of a strong policy and regulatory framework for balanceddevelopment of e-Health. Policy initiatives should include those that addressstandards and guidelines governing quality of e-Health, integrating e-Health in ICTpolicy in general and building in reimbursement for expenditures for servicesavailed through e-Health within health schemes. Regulations could also be used todevelop increased used of ICT in drug retailing.

• The creation of a Universal Service Fund for development of the e-Health sector, ashas been done in some member countries, is an option that could be explored byothers.



United Nations Economic and Social Commissionfor Asia and the Pacific

United Nations Building

Rajadamnern Nok AvenueB k k 10200 Th il d