Ehealth in Latin America: Challenges & Opportunities

E-HEALTH IN LATIN AMERICA
AND THE CARIBBEAN:

CHALLENGES AND OPPORTUNITIES
Roberto J. Rodrigues
eHealthStrategies.com, Bethesda, MD
and
The Institute for Technical Cooperation in Health Inc. (INTECH), Potomac MD
Adjunct Professor, Science, Technology, and International Affairs Program

E. Walsh School of Foreign Service, Georgetown University, Washington, D.C.
8th International Congress in Nursing Informatics

June 22-25, 2003
Rio de Janeiro, Brazil
E-HEALTH PERSPECTIVES IN LATIN AMERICA AND THE CARIBBEAN
! DRIVING FORCES AND BARRIERS
! HEALTH SECTOR CHARACTERISTICS
! ICT INFRASTRUCTURE AND MARKET
! IMPLEMENTATION ISSUES
eHealthStrategies.com
HEALTH SECTOR TREND-SETTERS IN LAC (1)
SATISFACTION, QUALITY, AND EFFICIENCY
n DISSATISFACTION WITH HEALTHCARE SYSTEM (CHOICE, ACCESS,

QUALITY, CONTINUITY, LONG-TERM PROVIDER RELATIONSHIP)
n INCREASING DEMAND (DEMOCRATIZATION PROCESSES)
n ANTICIPATION OF NEEDS, DEMAND FOR CUSTOMER SERVICE,

“MADE TO MEASURE” CARE, AND CONVENIENCE
n EFFICIENCY OF ADMINISTRATIVE PROCESSES (ELIGIBILITY,CLAIMS,

REIMBURSEMENT, PROCUREMENT AND SUPPLY MANAGEMENT)
n LOGISTICS OF HEALTHCARE / COOPERATION IS A PRIORITY

(DYNAMIC SCHEDULING, DATA COMMUNICATION)
INCREASING DATA REQUIREMENTS OF HEALTH PRACTICE
n NEED FOR DETAILED DATA AND INFORMATION (DISTRIBUTED

MULTIDISCIPLINARY PRACTICE, IMPROVED DOCUMENTATION,
ERROR REDUCTION, ACCOUNTABILITY, AND TRANSPARENCY)
n RETRIEVAL OF STRUCTURED AND UNSTRUCTURED HEALTH DATA
n ACCESS TO BIOMEDICAL KNOWLEDGE (REFERENCE,

PROTOCOLS OF CARE, REGISTRIES, KNOWLEDGE BASES,
EVIDENCE-BASED PRACTICE, CONSUMER PARTICIPATION)
n INTERNET-BASED APPLICATIONS (INFORMATION DISSEMINATION,

DISTANT EDUCATION, EHR, REMOTE CARE)
COST RECOVERY AND CONTAINMENT
n HEALTH IS ONE OF THE LARGEST SECTORS OF THE ECONOMY
n LIMITED NUMBER OF CONDITIONS ACCOUNT FOR MOST

HEALTHCARE EXPENDITURES
n IN HIGH INCOME AND MIDDLE INCOME COUNTRIES 40% OF THE

POPULATION HAVE ONE OR MORE CHRONIC CONDITIONS
n CHRONIC CONDITIONS ACCOUNT FOR MORE THAN 2/3 OF

HEALTH CARE EXPENDITURES
n HEALTH PROBLEMS ARE MAJOR IMPEDIMENT TO SOCIAL AND

ECONOMIC DEVELOPMENT
n URGENCY TO CONTAIN HEALTHCARE COSTS
THE GLOBAL MARKET FOR HEALTH GOODS AND SERVICES (1)
1990-1998
1990-1998 Middle East & North
South Asia Africa
2% 1990-1998
5% Sub-Saharan Africa
1990-1998 1%
Eastern Europe &
Central Asia
6%
1990-1998 1998
East Asia & Pacific United States
10% 44%
1996-2000
Latin America &
Caribbean
9%
2000
1996-2000
Canada
European Union
3%
20%
Source: Casas, JA Trade in Health Services in the Americas:

Trends and Opportunities, PAHO/WHO, 2001
Total Health Expenditure x GDP Per Capita (191 Countries)

HEALTH EXPENDITURES PER CAPITA 1998-2000;

in 1999 International US dollars (Purchase Power Parity)
4,500
3,978
4,000
3,500
3,000
US Dollars (PPP)
2,500
2,206 WORLD
1,868
2,000
1,500
1,000
346 452
500
324 216
144 91 48
-
World U.S. Canada European LA & East Asia E Europe South Middle East Sub-Saharan
Union Caribbean & Pacific & C Asia Asia & N Africa Africa

THE CHANGING PRACTICE ENVIRONMENT
Current Approach New Model
n Care based on visits n Continuous relationships

n Professional autonomy n Customized patient care
n Professionals control care n Patient is source of control
n Provider “owns” records n Information flows freely
n Decision based on experience n Evidence-based decisions
n Safety is individual issue n Safety is a system property
n Privacy is individual issue n Privacy is a system property
n No transparency of operations n Transparency is necessary
n The system reacts to needs n Needs are anticipated
n Cost not controlled n Control costs
n Independent providers n Cooperation is required
THE “CONNECTED CONSUMER”
! WELLNESS AND MEDICAL INFORMATION
! SHOPPING FOR PROVIDERS AND SERVICES
! RISK ASSESSMENT TESTING
! BUYING PHARMACEUTICALS AND HEALTH PRODUCTS
! COMMUNICATION WITH SPECIAL INTEREST GROUPS
! E-MAILING TO PROVIDERS AND INSURERS
TECHNOLOGY BARRIERS (1)
INFORMATION TECHNOLOGY INFRASTRUCTURE
! TECHNICAL RESOURCES AND WEB DEMOGRAPHICS
! DATA AND COMMUNICATION STANDARDS
! TECHNOLOGICAL INNOVATION X ACTUAL USE GAP
! OPEN x PROPRIETARY ARCHITECTURE
! COST-BENEFIT JUSTIFICATION
THE DEVELOPMENT / ANALOG / DIGITAL DIVIDES BY INCOME
Percentage of World Total

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Population Television Telephone GDP Internet
Low Lower Middle Upper Middle High
Source: Digital Opportunities Taskforce (DOT Force), 2000
Ownership of Personal Computers in 155 Countries Categorized by Level of Income
(Data from: International Telecommunication Union, World Telecom Indicators 2002)
100
Number of Personal Computers x 100 Persons (Log Scale)
m = 31.30
10
m = 10.08
HIGH INCOME
m = 3.64
1
UPPER MIDDLE
INCOME
m = 0.68 LOWER MIDDLE
INCOME
0.1
LOW INCOME
m = Arithmetic Mean
0.01
THE RESEARCH & DEVELOPMENT DIVIDE BY REGION
SELECTED TECHNOLOGY INPUTS BY REGION (1992-1997)
Region R&D as Technicians Scientists GPD per

6 6
% of GDP per 10 pop per 10 pop capita
OECD 1.8 1,326.1 2,649.1 20,113.5

Eastern Europe & FSR 0.9 577.2 1,841.3 4,027.4
East Asia 0.8 235.8 1,026.0 6,270.6
Latin America & Caribbean 0.5 205.4 656.6 5,635.8
Middle East 0.4 177.8 521.0 8,941.5
Sub-Saharan Africa 0.2 76.1 324.3 1,971.5
South Asia 0.8 59.5 161.0 1,764.3
Source: Rodríguez F and Wilson E ( InfoDev , World Bank 2000 ) modified
NATIONAL INVESTMENT CAPACITY IS A MAJOR PROBLEM
Expenditure on Information and Communication Technologies in Selected Countries
ICT ICT ICT ICT

Expenditure Expenditure Expenditure Expenditure
Country Country
Per Capita in as % of GDP Per Capita in as % of GDP
US$ (2000) (2000) US$ (2000) (2000)
Argentina 317 4.1 Hungary 431 8.7

Australia 1,992 9.7 Italy 1,068 5.7
Austria 1,697 7.2 Japan 3,118 8.3
Belgium 1,769 8.0 Mexico 189 3.2
Brazil 289 8.4 Norway 2,445 6.9
Canada 1,911 8.4 Russia 63 3.7
Chile 360 7.8 Singapore 2,104 9.7
China 46 5.4 Spain 731 5.1
Colombia 228 12.0 Sweden 2,674 10.4
Finland 1,835 7.8 United Kingdom 2,187 9.1
France 1,916 8.7 United States 2,296 8.1
Germany 1,798 7.9 Venezuela 196 3.9
Source: World Bank, 2002 World Development Report
GLOBAL INTERNET USERS
Millions of Users
350
28%
300
250 21%
Penetration
200
15%
150
9% 1.6%
100
6% 1%
4%
50 0.3% 0.5%
0.1%
0.1%
0
1995 1996 1997 1998 1999 2000
Developed 30 47 77 124 180 232
Developing 3 7 13 25 51 83
Source: International Telecommunication Union, 2000
GLOBAL INTERNET USERS (APRIL 2001)
TOTAL NUMBER OF USERS 427,213,610
North America
0.78% 47.95% South America
Central America
Europe
Asia
4.56% Oceania
Africa
4.12%
18.58%
0.38%
23.63%
Source: www.netsizer.com
NETWORKED READINESS INDEX (75 Countries)
Access & Infrastructure) / Policy & Business Environment / Learning & Opportunities / Economy)
6.5
IN THE TOP THIRD
IN THE TOP THIRD USA
6 • 14 in Western Europe (best in Scandinavia)
FIN
• 14 in Western Europe (best in Scandinavia)
• 7 in Asia and Oceania (led by Singapore)
• 7 in Asia and Oceania (led by Singapore) NET SWE
• 2 in North America (U.S. and Canada)
• 2 in North America (U.S. and Canada)
5.5 • 1 in Middle East (Israel)
• 1 in Middle East (Israel) GBR SGP
AUT
GER CAN
5 IN THE MID THIRD
IN THE MID THIRD JPN
FRA
• 10 in L America/Caribbean (led by Argentina)
• 10 in L America/Caribbean (led by Argentina)
• 6 in Western Europe (led by Portugal)
4.5 • 6 in Western Europe (led by Portugal) SPA
• 4 in Eastern Europe (led by Slovenia))
• 4 in Eastern Europe (led by Slovenia))
• 1 in Asia (Malaysia)
• 1 in Asia (Malaysia)
• 1 in Africa (South Africa) CHI
• 1 in Africa (South Africa) ARG
4 BRA
EGY IND BUL PAN TUR POL
PAR COL SAR URU
3.5 CHN MEX
JOR IN THE BOTTOM THIRD
BOL IN THE BOTTOM THIRD
PER VEN
3 ELS • 1O in Latin America (led by Peru)
• 1O in Latin America (led by Peru)
NIC GUA JAM • 7 in Asia (led by India)
RUS • 7 in Asia (led by India)
HON • 4 in Eastern Europe (led by Bulgaria)
ECU • 4 in Eastern Europe (led by Bulgaria)
• 3 in Sub-Saharan Africa
2.5 BAN
• 3 in Sub-Saharan Africa
• 1 in the Middle East (Egypt)
VIE • 1 in the Middle East (Egypt)
NIG
2
Source: The Global Information Technology Report 2001-2002 (Modified to shown only selected countries)
World Economic Forum and Harvard University Center for International Development
TELEPHONE LINES DENSITY AND INTERNET USAGE
Source: The Global Information Technology Report 2001-2002

* Fixed and mobile subscriptions

** Based on individual user who access the Internet at least once a month
TELEPHONE LINES DENSITY AND INTERNET USAGE
Source: The Global Information Technology Report 2001-2002

* Fixed and mobile subscriptions

** Based on individual user who access the Internet at least once a month
TECHNOLOGY BARRIERS (2)
INFORMATION TECHNOLOGY DEPLOYMENT
! INTEGRATION IN THE WORK ENVIRONMENT
! PROJECT MANAGEMENT AND EDUCATION / TRAINING OF

HEALTH PROFESSIONALS
! ACCESS TO RELIABLE APPLICATIONS PRODUCTS AND

SERVICES (INTEGRATION, CUSTOMER SUPPORT, TRAINING)
! VENDOR DEPENDENCY
Technology Exports, Royalties, and Licenses Payments for the Year 2000
for Selected Countries. (Source: World Bank, 2002 Development Indicators)
H ig h T e c h n o lo g y R o y a ltie s a n d
R o y a ltie s a n d R o y a ltie s a n d G ro s s R o y a ltie s
E x p o r ts a s % o f L ic e n s e s
L ic e n s e s L ic e n s e s N a tio n a l a n d L ic e n s e s
C o u n tr ie s A ll M a n u fa c tu r e d B a la n c e in
In c o m e in P a y m e n ts in In c o m e in B a la n c e a s
P r o d u c ts M illio n s o f
M illio n s o f U S $ M illio n s o f U S $ B illio n s U S $ % of G N I
E x p o r te d US$
A rg e n tin a 9 13 458 -4 4 5 2 7 6 .2 -0 .1 6
B o livia 2 5 -3 8 .2 -0 .0 4
B ra z il 19 126 1 ,4 1 5 -1 ,2 8 9 6 1 0 .1 -0 .2 1
C h ile 3 102 44 58 6 9 .8 0 .0 8
C o lo m b ia 7 4 71 -6 7 8 5 .3 -0 .0 8
C o s ta R ic a 1 31 -3 0 1 4 .5 -0 .2 1
D o m in ic a n R e p u b lic 30 -3 0 1 7 .8 -0 .1 7
Ecuador 6 62 -6 2 1 5 .3 -0 .4 1
E l S a lva d o r 6 2 20 -1 8 1 2 .6 -0 .1 4
H o n d u ra s 2 0 10 -1 0 5 .5 -0 .1 8
J a m a ic a 0 6 41 -3 5 6 .9 -0 .5 1
M e xic o 22 43 407 -3 6 4 497 -0 .0 7
Panam a 0 0 30 -3 0 9 .3 -0 .3 2
P e ru 3 57 -5 7 5 3 .4 -0 .1 1
U ru g u a y 2 11 -1 1 20 -0 .0 6
W o rld
L o w a n d M i d d l e In c o m e 16 1 ,8 7 3 1 1 ,0 6 4 -9 ,1 9 1
E a s t A s ia & P a c ific 25 784 5 ,4 0 9 -4 ,6 2 5
E u ro p e a n d C e n tra l A s ia 10 313 1 ,7 5 3 -1 ,4 4 0
L a tin A m e ric a & C a rib b e a n 16 501 2 ,6 6 6 -2 ,1 6 5
M id d le E a s t & N o rth A fric a 1 106 614 -5 0 8
S o u th A s ia 3 87 338 -2 5 1
S u b -S a h a ra n A fric a 8 82 283 -2 0 1
H i g h In c o m e 22 7 0 ,3 2 1 6 2 ,9 8 8 7 ,3 3 3
E u ro p e a n C o m m u n ity 16 1 1 ,0 1 9 2 3 ,4 2 2 -1 2 ,4 0 3
U n ite d S ta te s 34 3 8 ,0 3 0 1 6 ,1 0 0 2 1 ,9 3 0
Japan 28 1 0 ,2 2 7 1 1 ,0 0 7 -7 8 0
HEALTH SECTOR BARRIERS (1)
NEED RECOGNITION
! DISSEMINATION STILL LIMITED = HEALTH SECTOR

LAGS BEHIND OTHER SECTORS
! MANY PUBLIC HEALTH ORGANIZATIONS ARE NOT TAKING

ADVANTAGE OF ICT OPPORTUNITIES
!ROLE IN COMPETITIVENESS AND ORGANIZATIONAL

SURVIVAL IN THE NEW HEALTHCARE ENVIRONMENT
! MOST EXISTING INFORMATION SYSTEMS ARE INADEQUATE

TO THE NEW MODELS OF HEALTHCARE = “STATISTICAL-
EPIDEMIOLOGICAL PARADIGM”
REQUIREMENTS SPECIFICATION
! LOW DEFINITION LEVEL OF CONTENTS (DELIVERABLES)

OF HEALTH INTERVENTIONS
! DETERMINATION OF OBJECTIVES AND FUNCTIONALITIES

(COMPLEXITY AND VARIETY OF TECHNICAL CONTENTS)
! CONFLICTS IN DEFINING MINIMUM DATA SETS FOR OPERATIONAL

MANAGEMENT AND CLINICAL DECISION-MAKING
! HEALTHCARE ORGANIZATIONS AND PROVIDERS TEND TO

SEE THEIR OWN DATA AS THE ONLY GOOD AND VALID DATA
ORGANIZATIONAL AND POLICY-RELATED
! INFRASTRUCTURE, INVESTMENT SUSTAINABILITY, AND

DEPLOYMENT CAPABILITY
! DISTRUST OF HEALTH PROFESSIONALS IN OFF-SITE DATA

STORAGE AND ACCESS CONTROL
! NATIONAL POLICIES AND STRATEGIES FOR THE STANDARDIZATION

AND COST-EFFECTIVE USE OF TECHNOLOGY AND INFORMATION
! CONSISTENCY AND CONTINUITY OF POLITICAL SUPPORT
AREAS OF KNOWLEDGE MANAGEMENT APPLICATIONS
Collaborative Professional Work

Intranet Content Management
Intellectual Asset Management
Customer Relationship Management
Competitive Analysis and Intelligence
Research and Development
Call Center Support
Proposal Development
Corporate Portals
Corporate Operations
Electronic Commerce
Case Management Current Planned
Function-Centered Desktops
Other
Litigation Support
Medical Records Management
0 10 20 30 40 50 60 70 80 90
PERCENT
Source: U.S. Market, The Delphi Group, 2000
U.S. PHYSICIANS USE OF COMPUTERS (2000)
Billing
Scheduling
Patient Reminders
Managed Care Apps
Patient Records
Treatment Alerts
Referrals
Telemedicine
Prescriptions
0 20 40 60 80 100
PERCENT
Source: Pricewaterhouse Coopers Modern Physician 2000
SOURCES OF INFORMATION ABOUT NEW HEALTH WEB SITES
HOW THE PUBLIC LEARNS ABOUT HEALTH INFORMATION IN THE WEB
Health Professional 0.5

Billboards 1.2
Radio 6.3
Media Story 10.2
Newsprint 17.4
TV 19.1
Web Banners 26.5
Friends/Family 32.9
Internet Search 40.3
Web Links 45.7
E-mail 61.3
0 20 40 60 80 %
U.S. Survey by Gómez Advisors, Inc. , 2000
HEALTH SECTOR IN LATIN AMERICA & THE CARIBBEAN
! WESTERN BIOMEDICAL / SOCIAL SECURITY MODELS
! 80% URBANIZATION / LARGE URBAN AREAS
! BURDEN OF DISEASE: COMMUNICABLE DISEASES, MATERNAL AND

PERINATAL CONDITIONS, LIFE-STYLE (HIV/TOBACCO/ALCOHOL),
CHRONIC-DEGENERATIVE AND CARDIOVASCULAR DISEASES,
RESPIRATORY CONDITIONS, INJURIES
! INADEQUATE INFRASTRUCTURE, FACILITY AND SERVICES

DISTRIBUTION, POOR ACCESS, AND LOW QUALITY
! LOW INVESTMENT AND INCREASING COSTS ARE A MAJOR

IMPEDIMENTS TO THE DEVELOPMENT OF THE HEALTH SECTOR
! HEALTH SECTOR REFORM
DISTRIBUTION OF GROSS DOMESTIC PRODUCT BY SECTOR, 1999
80
70
60
Percentage of GDP
50
40
30
20
10
Sector
0 ARG BOL BRA CAN CHI COL COR DOR ECU ELS GUA HAI HON J AM MEX NIC P AN P AR P ER TRT US A URU VEN
Agric ult ure 6 16 9 3 8 14 14 11 12 11 23 30 18 8 5 26 8 26 8 2 2 9 5
Ind/ Ma nufc 22 17 23 18 16 12 17 16 22 22 13 7 18 15 19 14 9 16 24 8 18 19 12
Ind/ Non-Ma nufc 11 13 6 15 17 13 5 19 11 6 6 13 12 18 8 7 9 6 14 32 8 10 12
S e rvic e s 61 54 62 64 59 61 64 54 55 61 58 50 52 59 68 53 74 52 54 58 72 62 71
Source: World Bank, World Development Indicators 1999
HEALTH CONTRIBUTION TO THE SERVICES SECTOR
% HEALTH SERVICES AS PERCENTAGE OF THE SERVICE SECTOR

25
NIC
23
20
USA
18 ARG COL HON URU
CAN
15
13 PER
ELS
BOL COR
10 HAI
BRA CHI JAM PAN PAR
8 DOR TRT
ECU GUA MEX
VEN
5
0
Source: World Bank, World Development Indicators 1999
THE LATIN AMERICAN & CARIBBEAN MARKET
Latin America & Caribbean, 1998-2000:

National Health Expenditures Per Capita in US$
US$ (Countries Grouped by Income Levels)
800
700
HIGHEST INCOME
600
MID INCOME
500
LOWEST INCOME
400
300
200
100
ANG
ARG
GUY
CUB
ECU
BRA
URU
BAR
NEN
BAH
GUT
NIC
HON
DOR
PAR
PER
PAN
VEN
COR
SVG
HAI
CHI
JAM
BOL
COL
BLZ
TRT
ELS
MEX
THE LATIN AMERICAN & CARIBBEAN MARKET
PUBLIC AND PRIVATE COMPOSITION OF HEALTH EXPENDITURES (1998-2000)
Private Insurance
18% Central Government
23%
Local Governments
8%
Direct Out-of-Pocket
Expenditure
37%
Social Security
14%

HOSPITAL MARKET
Hospital Size in Latin America and the Caribbean by Number of Beds
(Source: PAHO Directory of Latin America and Caribbean Hospitals, 1996-1997)
Hospitals Beds Available

Number of Beds
Number Percent Number Percent
1-50 10,027 60.5 219,383 20.0
51-100 2,615 15.8 189,559 17.3
101-200 1,703 10.3 242,770 22.1
201-300 544 3.3 133,225 12.1
301-400 242 1.5 84,811 7.7
401-500 133 0.8 58,951 5.4
501-1000 186 1.1 126,169 11.5
>1000 29 0.2 43,097 3.9
Sub-Total 5,479 93.4
No Data 1,087 6.5
Total 16,566 100.0 1,097,965 100.0
HOSPITAL MARKET
Legal Ownership of 16,566 Hospitals and Computerized Information Systems
in Latin America and the Caribbean, period 1995-1997
(Source: PAHO Directory of Latin American and Caribbean Hospitals Database)
HOSPITAL GROUPS
ALL FACILITIES NO COMPUTERS WITH COMPUTERS

OWNERSHIP
CLASS Percent Percent
Number Percent Number Number
In Class In Group In Class In Group
Public Non-Social Security 6,498 39.22 5,099 78.47 44.98 1,399 21.52 26.74
Public Social Security 876 5.29 438 50.00 3.86 438 50.00 8.37
Private 7,783 46.98 4,924 63.26 43.43 2,859 36.73 54.66
Philanthropic 1,284 7.75 779 60.66 6.87 505 39.33 9.65
Military 125 0.75 96 76.80 0.84 29 23.20 0.55
Total 16,566 100.0 11,336 --- 100.00 5,230 --- 100.00
31.6% HAVE COMPUTERS, OF THOSE ABOUT 54.6% ARE PRIVATE
HEALTH INFORMATION TECHNOLOGY DEVELOPMENT INDICATORS
LIMITATIONS OF INFORMATION TECHNOLOGY METRICS
! LACK OF STANDARDIZED DEFINITIONS FOR IT COMPONENTS
! DATA ON IT RARELY COLLECTED ON A SYSTEMATIC BASIS
! ABSENCE OF COST DATA
! INFORMATRION ON HOW IT IS BEING ACTUALLY USED
! LACK OF EVALUATION OF POSITIVE AND NEGATIVE IMPACTS
! RAPIDLY CHANGING TECHNOLOGY
THE INCOME BARRIER (1)
PERCENT OF U.S. HOUSEHOLDS WITH COMPUTER
BY LEVEL OF INCOME (1998)
90
90
80
80 U.S.
U.S.
70
70 Rural
Rural
60
60 Urban
Urban
50
50
40
40
30
30
20
20
10
10
00
Under
Under 5,000-
5,000- 10,000-
10,000- 15,000-
15,000- 20,000-
20,000- 25,000-
25,000- 35,000-
35,000- 50,000-
50,000- 75,000
75,000
5,000
5,000 9,999
9,999 14,999
14,999 19,999
19,999 24,999
24,999 34,999
34,999 49,999
49,999 74,999
74,999 ++
U.S.
U.S. 15.9
15.9 12.3
12.3 15.9
15.9 21.2
21.2 25.7
25.7 35.8
35.8 50.2
50.2 66.3
66.3 79.9
79.9
Rural
Rural 11.9
11.9 8.1
8.1 13.8
13.8 22.1
22.1 24.7
24.7 34.0
34.0 51.0
51.0 64.2
64.2 76.5
76.5
Urban
Urban 16.9
16.9 13.6
13.6 16.6
16.6 20.8
20.8 26.1
26.1 36.5
36.5 50.0
50.0 67.1
67.1 80.8
80.8
Source: U.S. National Telecommunication and Information Agency, DOC, 1999
SELECTED COUNTRIES - GNP PER CAPITA BY POPULATION QUINTILES (1999)
BRA CAN CHI COL DOR ECU GUA HON MEX NIC PAR URU USA VEN
Hi Q 14,105 37,661 14,629 7,563 5,404 3,307 5,013 2,265 13,021 1,298 5,079 14,539 70,190 9,938
4th Q 4,046 22,041 4,341 2,285 2,073 1,417 1,480 769 4,296 470 1,522 6,472 33,885 3,968
3rd Q 2,211 16,483 2,614 1,378 1,318 945 835 457 2,640 296 871 4,455 23,598 2,545
2nd Q 1,216 12,362 1,583 820 835 625 462 277 1,611 188 480 3,010 15,883 1,572
Lo Q 553 7,187 839 373 433 359 167 133 805 99 187 1,626 7,866 692
Source: Data from the World Bank Development Report, 2000
SELECTED COUNTRIES - GNP PER CAPITA BY POPULATION QUINTILES (1999)
25,000
22,500
20,000
17,500
15,000
12,500
10,000
7,500
5,000
2,500
0
I
I
G
N
N IC
A
U
L
X
S
M
CH
HA
PE
VE
BO
CO
EC
ME
AR
BR
GU
PA
PA
UR
CO
DO
EL
HO
JA
Hi 10% 5th Quintile (Hi 20%) 4th Quintile 3rd Quintile 2nd Quintile 1st Quintile (Low 20%)
Source: Data from the World Bank Development Report, 2000
BRAZIL - CELLULAR TELEPHONY AND COMPUTERS USE BY SOCIAL CLASS
PERCENT
60
50
51
CLASS
40
40.8
A/B
30
30.2 C
20 24.1 D/E
17.9
10
11 2
8.5
3.8
0
CELLULAR MICROCOMPUTER INTERNET
Source: Ministry of Health, Brazil (1999)
THE EDUCATIONAL BARRIER
PERCENT OF U.S. HOUSEHOLDS WITH COMPUTER
BY LEVEL OF EDUCATION (1998)
80
70 U.S.
60
Rural
50
Urban
40
30
20
10
0
Some High High School Some
Elementary B.A. or more
School or Equiv Collegue
U.S. 7.9 15.7 31.2 49.3 68.7
Rural 6.3 17.2 33.2 51.7 69.7
Urban 8.7 15.0 30.3 48.6 68.5
Source: U.S. National Telecommunication and Information Agency, DOC, 1999
THE GENERATION GAP
BRAZIL - CELLULAR TELEPHONY AND COMPUTERS USE BY AGE GROUP
PERCENT
30
AGE GROUP
25
20
14-19
15 20-35
36-45
10 46 +
5
0
CELLULAR MICROCOMPUTER INTERNET
0 10 20 30 40 50 60 70 80 90
BER
UVI
USA
CAN PERCENT
ANT
SKN
GDL
MAR
BAR
BAH
NAT
ARU
PUR
GRE
FGU
URU
SLU

DOM
CHI
TRT
COR
ARG
SVG
*
JAM
SUR
PAN
No Data
COL
BRA
BEL
MEX
VEN
DOR
ECU
ELS
TELECOM INFRASTRUCTURE
GUY
PER
BOL
PAR
GUA
HON
CUB
NIC
WIRED (FIXED) TELEPHONE LINES X 100 PERSONS (1998)
HAI
ANG
BVI
CAY
*
MON
TUC
10
12
14
16
18
20
00
22
44
66
88
10
12
14
16
18
20
ANG
ANG
ANT
ANT
ARG
ARG
ARU
ARU
PERCENT
BAH
BAH
BAR
BAR
BEL
BEL
BER
BER
BOL
BOL
BRA
BRA
BVI
BVI
CAN
CAN
CAY
CAY
CHI
CHI
COL
COL
COR
COR
CUB
CUB
DOM
DOM
DOR
DOR
ECU
ECU
ELS
ELS
FGUY
FGUY
GRE
GRE
GDL
GDL
GUA
GUA
GUY
GUY
HAI
HAI
HON
HON
JAM
JAM
MAR
MAR
MEX
MEX
Source: International Telecommunication Union and PAHO Basic Indicators

MON
MON
NAT
NAT
NIC
NIC
PAN
PAN
PAR
PERCENTAGE OF GNP x CAPITA (1997)
PAR
COST OF WIRED CONNECTION
PER
ANNUAL RESIDENTIAL SUBSCRIPTION AS
PER
PUR
PUR
SKN
SKN
SLU
SLU
SVG
SVG
SUR
SUR
TRT
TRT
TUC
TUC
USA
USA
URU
URU
UVI
UVI
VEN
VEN
INTERNET USE - PHYSICIANS IN BRAZIL (1)
SAMPLE SIZE: 42,744 PHYSICIANS *
60
50 58
40 User
% Non User
30 42
20
10
0
Group
1999 SURVEY (In 1996 there were 205,828 physicians)
INTERNET USE - PHYSICIANS IN BRAZIL (2)
SAMPLE SIZE: 24,603 PHYSICIANS

LOCATION FROM WHERE INTERNET IS ACCESSED
90
80
85
70 Home
University
60
Office
50 Hospital
%
40
30
20
10 10
0
Site of Access
1999 SURVEY (In 1996 there were 205,828 physicians)
0 5 10 15 20 25 30 35 40 45 50
USA
CAN
UVI
PERCENT
GDL
SLU
SKN
BEL
FGU
GRE
MAR
BAH
URU
SVG
DOM
BAR
CHI
TRT

MEX
ARG
VEN
JAM
COR
BRA
*
PAN
COL
GUY
No Data
ECU
PER
ELS
PAR
GUA
HON
BOL
NIC
ANG
DIGITAL INFRASTRUCTURE (1)
ANT
ARU
BER
BVI
PERSONAL COMPUTERS X 100 PERSONS (1998)
CAY
CUB
*
DOR
HAI
MON
NAT
PUR
SUR
TUC
DIGITAL INFRASTRUCTURE (2)
PERCENT (LOG SCALE) INTERNET CONNECTIVITY X 100 PERSONS (1999)

100.0
10.0
1.0
0.1
*
0.0
BER
GRE
URU
PER
HON
DOR
SKN
PUR
SUR
FGU
ECU
BEL
GUY
BAH
BRA
BAR
CUB
ARU
VEN
COR
GUA
ARG
ELS
ANG
USA
PAN
GDL
BOL
PAR
SLU
NIC
CHI
HAI
MEX
CAN
DOM
MON
ANT
NAT
TUC
UVI
TRT
BVI
SVG
COL
CAY
MAR
JAM
No Data
Source: International Telecommunication Union, 2000 *
INTERNET USERS IN LATIN AMERICA & CARIBBEAN (2000) IN MILLIONS
TOTAL POPULATION CONNECTED 17,135,000
0.300 0.150 0.520

0.400
0.400
BRA
MEX
0.600
ARG
CHI
0.625 COL
PER
9.840 VEN
0.900 URU
COR
OTHER
2.500
Source: NUA Internet Surveys
INTERNET HOSTS IN SOUTH, CENTRAL AMERICA & CARIBBEAN
TOTAL NUMBER OF HOSTS 1,825,760 (APRIL 2001)
43.58%
1.49%
Brasil
2.23%
Mexico
Argentina
2.95%
Chile
Colombia
3.18% Uruguay
Venezuela
5.45% Other
14.69% 26.43%
Source: www.netsizer.com
INTERNET USE - LANGUAGE
NUMBER OF NATIVE SPEAKERS ONLINE (MARCH 2001)
Dutch Other
Russian 2.1% 6.2%
2.3%
Portuguese
2.5%
Italian
3.1%
French English
3.7% 47.5%
Korean
4.4%
Spanish
4.5%
German
6.1%
Japanese
8.6% Chinese
9.0%
Source: Global Reach, Internet Statistics
NETWORK ACCESS SPEED
Connectivity Speed in Selected Countries of Latin America

(Source: Harte-Hanks CI Technology Database, 2001)
Organizations with
Countries
Access > 56 Kbps
Mexico 42%
Peru 39%
Chile 37%
Brazil 33%
Argentina 31%
Colombia 31%
Venezuela 27%
Ecuador 22%
Regional Average 35%
DEVELOPED COUNTRIES / BROADBAND PENETRATION
E-MARKET IN LATIN AMERICA
SHARE OF REGIONAL e-MARKET PERCENTAGE OF e-COMMERCE SPENDING
Other
Mexico 6%
6%
Other
10% Brazil
40%
Venezuela
5%
Colombia
5%
Chile
6%
Brazil
88%
Argentina Mexico
12% 22%
Source: www.xplane.com, 2000
E-MARKET IN LATIN AMERICA
MILLIONS OF US DOLLARS, LOG SCALE
Other
Peru
Chile
Colombia
Venezuela
Argentina
Mexico
Brazil
10,000 1,000 100 10 1

Brazil Mexico Argentina Venezuela Colombia Chile Peru Other
2005 4,256 1,542 1,094 348 336 312 164 277
1999 121 25 15 7 7 4 5 8
Source: www.xplane.com, 2000
THE FUTURE OF THE TELECOM INFRASTRUCTURE
LATIN AMERICAN AND CARIBBEAN TELECOMMUNICATIONS MARKET
Millions
Mobile Subscribers
70 Main Lines
69
60
50 54
50
40
30
25.3
20
10 12.7
7
0
1995 1997 2000
Source: International Telecommunication Union, Jan 2000
THE FUTURE OF THE TELECOM INFRASTRUCTURE
TELEPHONY INSTALLATION - BRAZIL

Privatization of Telecommunication Markets have Resulted in Expansion of Infrastructure -
In Brazil, in a Period of Four Years the Telephony Density Increased from 13.6 Fixed
and 4.5 Mobile Lines per 100 People to 28.5 and 26.2 Respectively
Millions of Lines
50
45 Fixed Lines
Mobile
40
35
30
25
20
15
10
5
0
1998 1999 2000 2001 2003*
Source: ANATEL, 2000
BRAZIL - MAGNETIC/BAR CODE/SMART CARD USE
No Card
Credit Card
Store Card
Health Plan
Card
Bank Card
0 10 20 30 40 50
PERCENT OF POPULATION
EXPERIENCES IN LATIN AMERICA & THE CARIBBEAN
! MANY UNCOORDINATED PRIVATE AND PUBLIC SECTOR INITIATIVES
! MAJOR PUBLIC SECTOR PROJECTS

(ARGENTINA, BRAZIL, CHILE, COSTA RICA, CUBA, MEXICO, PERU)
! POORLY ALIGNED TO INSTITUTIONAL GOALS, IMPROVEMENT OF

HEALTH AND EXPECTATIONS OF PROVIDERS, CLIENTS,
PAYERS, AND REGULATORS
! SUMMIT OF THE AMERICAS 1996 AND 2000, FLORIANÓPOLIS (2000),

BRASÍLIA (2000), RIO GROUP/EUROPEAN UNION (2001)
STAKEHOLDERS HAVE DIFFERENT PERSPECTIVES AND MOTIVATIONS
Constrained
Need by statistical /
Recognition epidemiology
paradigm Need Recognition
5
4
Highly
aggregated
Vision of
data of 3
Required
mortality,
Applications
morbidity, and
utilization Involvement/Commitment Vision of Applications Required
2
1
Lagging
Context of
behind all
Utilization
other sectors
Uninformed
Expectations regarding ICT
opportunities
Expectations Context of Utilization
Lack of
Involvement continuity and
and sustainability
Commitment Staff not Government Health Authorities
engaged
Focus on
Need personal
Recognition health needs
and beliefs Need Recognition
5
4
Poor
recognition of
3
Vision of interactions
Required and limited
Applications recognition of Involvement/Commitment Vision of Applications Required
2
managerial
applications
1
Context of Big picture

Utilization lacking
Excessive
Expectations
expectations
Economic,
Involvement
cultural and
and
Commitment
educational General Public
barriers
Focus on
specialized
Need clinical
Recognition applications
or utilization Need Recognition
niches 5
4
Poor
recognition of
Vision of interactions 3
Required and limited
Applications recognition of Involvement/Commitment Vision of Applications Required
managerial 2
applications
Context of Big picture

Utilization lacking
Skeptical and
uninformed
Expectations
regarding ICT
opportunities
Involvement Passive and

and poorly
Commitment engaged
Healthcare Professionals
Clear and
Need
balanced
Recognition
perspective
Need Recognition
5
4
Vision of Excellent
Required recognition or
Applications requirements 3
Involvement/Commitment Vision of Applications Required

2
Understand
Context of the
Utilization complexity of 1
needs
Most vocal
Expectations
and optimistic
Involvement
Drivers for
and
adoption
Commitment
Health ICT Experts
Feel
restricted
Need due to lack of
Recognition broad
understandin
g of needs Need Recognition
5
Commercial
interest 4
Vision of
directs
Required
promotion of
Applications 3
own products
and services
2
Underestimat
Context of e complexity 1
Utilization of health
products
Pessimistic
regarding
Expectations progress in
next 5-10
years
Do not see
health
Involvement
market as
and
providing
Commitment
return on Health ICT Suppliers
investment
Fail to
distinguish
between
Need
clerical,
Recognition Need Recognition
administrative
, and clinical 5
processes
Perceive 4
applications
Vision of as
Required commodities 3
Applications supporting
standardized
processes
2
Poor
1
understanding
Context of
on how health
Utilization
systems
operate
Optimistic as
result of e-
Commerce
Expectations and other
sectors Expectations Context of Utilization
adoption of
ICT
Involvement
and
Drivers for Generic ICT Suppliers
adoption
Commitment
IMPLEMENTATION IN LATIN AMERICA & CARIBBEAN (1)
! RELIABILITY OF SERVICE DEPENDENT ON QUALITY OF NETWORK

AND INFORMATION TECHNOLOGY INFRASTRUCTURE
! ELECTRONIC TRANSACTIONS REQUIRE SUBSTANTIAL AMOUNT OF

DETAILED OPERATIONAL INFORMATION BEFORE AN
"E-ARCHITECTURE" CAN BE EFFECTIVELY IMPLEMENTED
! TECHNOLOGICAL BEGINNING-TO-END SOLUTION, LINKING

DIFFERENT PLATFORMS, LEGACY AND PROPRIETARY SYSTEMS
INVOLVING PROVIDER, INSURER, PAYER, PATIENT AND EMPLOYER
DATA
! ORGANIZATIONS AND PROVIDERS WITH COMPUTERIZED

INFORMATION SYSTEMS IN PLACE, MUST FIGURE OUT HOW TO
LINK INTO THE NEW APPLICATIONS, INCORPORATE ITS LEGACY
SYSTEMS, OR START ANEW
! INFRASTRUCTURE AND “PREPAREDNESS”: ANALOG/DIGITAL

DIVIDES ARE CONSEQUENCE OF INEQUITIES THAT MUST BE BRIDGED
! INCENTIVE THROUGH REGULATION

! MECHANISMS AND PROCESSES FOR CONSENSUS
AND ACTION WITH HIGH-LEVEL POLITICAL SUPPORT
! LEADERSHIP AND CONTINUITY AND SUSTAINABILITY OF INVESTMENT

! BEST PRACTICES, AVOIDANCE OF REDUNDANCIES AND
AVOIDANCE OF DOWNSIDE ASPECTS OF POWER CONCENTRATION
! RETURN ON INVESTMENT THAT JUSTIFIES CAPITAL INVESTMENT

AND OPERATIONAL COSTS
! GROWING MARKET WITH GREAT POTENTIAL BUT IDENTIFICATION

OF OPPORTUNITIES AND MARKET DEVELOPMENT MAY BE A
LONG AND DIFFICULT PROCESS
! E-HEALTH DEVELOPMENT NEEDS INTEGRATION OF TECHNOLOGY,

GEOGRAPHY, CULTURE, LANGUAGE, AND….HEALTHCARE SYSTEMS
! NO SINGLE “COOKBOOK” OR “TRANSLATED” SOLUTION

! COST-EFFECTIVE AND COUNTRY-DIFFERENTIATED SOLUTIONS
! PROACTIVE ROLE OF THE INTERNATIONAL COMMUNITY
G-8 Digital Opportunity Task Force (Okinawa Charter)
U.N. Health InterNetwork Initiative
World Bank InfoDev
U.N. Economic and Social Council (ECOSOC)
U.N. ICT Taskforce
INFORMATION
INFORMATION AND
AND COMMUNICATION
COMMUNICATION TECHNOLOGIES
TECHNOLOGIES
HEALTH
HEALTH SERVICES
SERVICES PLANNING
PLANNING AND
AND MANAGEMENT
MANAGEMENT
CLINICAL
CLINICAL CARE
CARE SYSTEMS
SYSTEMS
EMERGENCY
EMERGENCY AND
AND CRITICAL
CRITICAL CARE
CARE SERVICES
SERVICES
MEDICAL
MEDICAL TECHNOLOGY
TECHNOLOGY
CLINICAL
CLINICAL AND
AND ADMINISTRATIVE
ADMINISTRATIVE DOCUMENTATION
DOCUMENTATION
PROJECT
PROJECT MANAGEMENT
MANAGEMENT
RESEARCH
RESEARCH DESIGN
DESIGN
Web: http://www.ehealthstrategies.com
E-Mail: rrodrigues@ehealthstrategies.com

Ehealth in Latin America: Challenges & Opportunities

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Ehealth in Latin America: Challenges & Opportunities

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E-HEALTH IN LATIN AMERICA

AND THE CARIBBEAN:

Adjunct Professor, Science, Technology, and International Affairs Program

8th International Congress in Nursing Informatics

! DRIVING FORCES AND BARRIERS

! HEALTH SECTOR CHARACTERISTICS

! ICT INFRASTRUCTURE AND MARKET

! DRIVING FORCES AND BARRIERS

! HEALTH SECTOR CHARACTERISTICS

! ICT INFRASTRUCTURE AND MARKET

SATISFACTION, QUALITY, AND EFFICIENCY

n DISSATISFACTION WITH HEALTHCARE SYSTEM (CHOICE, ACCESS,

n INCREASING DEMAND (DEMOCRATIZATION PROCESSES)

n ANTICIPATION OF NEEDS, DEMAND FOR CUSTOMER SERVICE,

n EFFICIENCY OF ADMINISTRATIVE PROCESSES (ELIGIBILITY,CLAIMS,

n LOGISTICS OF HEALTHCARE / COOPERATION IS A PRIORITY

INCREASING DATA REQUIREMENTS OF HEALTH PRACTICE

n NEED FOR DETAILED DATA AND INFORMATION (DISTRIBUTED

n RETRIEVAL OF STRUCTURED AND UNSTRUCTURED HEALTH DATA

n ACCESS TO BIOMEDICAL KNOWLEDGE (REFERENCE,

n INTERNET-BASED APPLICATIONS (INFORMATION DISSEMINATION,

COST RECOVERY AND CONTAINMENT

n HEALTH IS ONE OF THE LARGEST SECTORS OF THE ECONOMY

n LIMITED NUMBER OF CONDITIONS ACCOUNT FOR MOST

n IN HIGH INCOME AND MIDDLE INCOME COUNTRIES 40% OF THE

n CHRONIC CONDITIONS ACCOUNT FOR MORE THAN 2/3 OF

n HEALTH PROBLEMS ARE MAJOR IMPEDIMENT TO SOCIAL AND

n URGENCY TO CONTAIN HEALTHCARE COSTS

Source: Casas, JA Trade in Health Services in the Americas:

Total Health Expenditure x GDP Per Capita (191 Countries)

Source: Casas, JA Trade in Health Services in the Americas:

HEALTH EXPENDITURES PER CAPITA 1998-2000;

Source: Casas, JA Trade in Health Services in the Americas:

Current Approach New Model

n Care based on visits n Continuous relationships

! WELLNESS AND MEDICAL INFORMATION

! SHOPPING FOR PROVIDERS AND SERVICES

! RISK ASSESSMENT TESTING

! BUYING PHARMACEUTICALS AND HEALTH PRODUCTS

! COMMUNICATION WITH SPECIAL INTEREST GROUPS

! E-MAILING TO PROVIDERS AND INSURERS

INFORMATION TECHNOLOGY INFRASTRUCTURE

! TECHNICAL RESOURCES AND WEB DEMOGRAPHICS

! DATA AND COMMUNICATION STANDARDS

! TECHNOLOGICAL INNOVATION X ACTUAL USE GAP

! OPEN x PROPRIETARY ARCHITECTURE

Percentage of World Total

Low Lower Middle Upper Middle High

Source: Digital Opportunities Taskforce (DOT Force), 2000

SELECTED TECHNOLOGY INPUTS BY REGION (1992-1997)

Region R&D as Technicians Scientists GPD per

OECD 1.8 1,326.1 2,649.1 20,113.5

Source: Rodríguez F and Wilson E ( InfoDev , World Bank 2000 ) modified

Expenditure on Information and Communication Technologies in Selected Countries

ICT ICT ICT ICT

Argentina 317 4.1 Hungary 431 8.7

Source: World Bank, 2002 World Development Report

Source: International Telecommunication Union, 2000

TOTAL NUMBER OF USERS 427,213,610

Source: The Global Information Technology Report 2001-2002

* Fixed and mobile subscriptions

Source: The Global Information Technology Report 2001-2002

* Fixed and mobile subscriptions