Reporting from GIZ’s regional health and social protection conference in Kyrgyzstan
On May 27-28, GIZ staff, counterparts and guests from 20 countries gathered in Bishkek to explore the latest trends in digital health and social protection. E-governance and artificial intelligence were high on the agenda. The success of the meeting shows that the Silk Road retains its power as a conduit for exchange and innovation.
Have a look at the the conference programme and download the conference booklet
Nestled against the dramatic backdrop of the Ala-Too mountain range and bathed in bright sunlight, the city of Bishkek, Kyrgyzstan was a memorable location for the latest regional meeting of the GIZ Sector Network Health and Social Protection for Asia and Eastern Europe. Over the course of two days, approximately 100 GIZ project staff, counterparts and guests from 20 countries engaged in intensive discussions about digitalisation and the future of health and social protection – and also gained some first impressions of a little-known country in the heart of Central Asia. The impeccably organised conference was overflowing with local flair: children reciting the Epic of Manas, energisers featuring Kyrgyz ‘kara-jorgo’ dancing, ample supplies of local walnuts and honey, and traditional music and singing.
Jost Wagner, the facilitator of the meeting, opened the proceedings and warmly welcomed all present, including counterparts from the Kyrgyz government, the German Ambassador to Kyrgyzstan, Monica Iwersen; the Head of Cooperation in Kyrgyzstan for the Federal Ministry for Economic Cooperation and Development (BMZ), Casjen Ohnesorge; the GIZ Country Director for Kyrgyzstan, Joachim Fritz; the directors of the Division Economic and Social Development, Employment at GIZ, Kerstin Nagels and Axel Klaphake; and the director of the Division South Asia at GIZ, Corinna Küsel.
The conference kicked off with welcoming remarks from Dr Kosmosbek Cholponbaev, the Minister of Health for the Kyrgyz Republic. Digitalisation is high on the political agenda in Kyrgyzstan and in the heath sector efforts are underway to move towards a national e-health system. ‘Digitalisation can increase the quality of health services, reduce the number of drugs being prescribed and decrease corruption,’ said Cholponbaev. ‘Within Kyrgyzstan we want the Ministry of Health to be at the forefront in the introduction and use of digital tools.’ One such tool, the Safe Motherhood App for midwives and birth attendants, was launched at the conference directly following the Minister’s speech.
Dr Cholponbaev expressed his appreciation to Germany for its long-standing support of health system reforms in Kyrgyzstan, including in the area of digitalisation, and welcomed the opportunity for Kyrgyz participants to exchange experiences about digitalisation in health and social protection with experts from other countries.
In her opening comments Monica Iwersen, the German Ambassador to Kyrgyzstan, described the long-standing collaboration between Germany and Kyrgyzstan in the areas of health and social protection and the relevance of these topics for societal cohesiveness and well-being. ‘Through its national health strategies the Kyrgyz government works with a range of partners to make services fit for the future,’ said Iwersen, ‘and by definition this means looking at digitalisation and e-health.’ Noting that it is the first time that a Sector Network meeting is being held in the region, she expressed the hope that the conference will ‘permanently inscribe Central Asia on the mental maps’ of guests from abroad and provide them with insights and inspiration for their work.
Why here? Why now?
‘We’re here to reflect on some of the most radical changes in the history of humankind,’ said Jean-Olivier Schmidt, co-speaker of the Sector Network and head of the Promotion of Perinatal Health in Kyrgyzstan project, welcoming participants on behalf of the Steering Committee. ‘And although GIZ has many digital approaches underway, the changes are happening so fast that we need to come together from time to time to see whether we’re capturing the major trends in the field and to look ahead to the next “big thing”.’ Face-to-face meetings may seem paradoxical in a digital age, he continued, but trust is the basis of successful collaboration and is notoriously difficult to establish at a distance.
Although Central Asia is unknown to many, the decision to hold this year’s meeting here reflects both the high priority German development cooperation places on health in the region and a renewed recognition of Central Asia’s role as a vibrant crossroads between countries, cultures and worldviews. The region which produced pathbreaking ancient thinkers such as Avicenna and Al-Chwārizmī is in some ways the ideal place to discuss developments in digitalisation and flows of information which have become the most valuable commodities on the ‘contemporary Silk Road’.
Digitalisation is radically changing the way health and social protection services are delivered and accessed, giving rise to new platforms and solutions. Some of these new potentials, such as artificial intelligence (AI), remain very new for GIZ – and indeed for Germany – but are already being applied in areas ranging from review of patient records to diagnosis and research. By putting some of these new trends at the heart of the conference programme – and by shining the spotlight on experiences from China and Estonia, which are at the forefront of digital change – the Steering Committee hopes to increase awareness among GIZ projects and staff of some of the driving forces of digitalisation and their application to development cooperation. ‘I hope that by the end of the conference each of us will leave the Silk Road with at least one new insight that will make our work more productive,’ said Schmidt.
Reflections on digital health in China
The first keynote was given by Megan Lam, CEO of the Hong Kong-based digital health company Neurum Health. In her presentation Lam explained how China is leveraging the technological expertise of its largest IT companies to address the country’s unmet healthcare needs using artificial intelligence.
The Healthy China 2030 framework, launched by President Xi Jinping in October 2016, singles out health as a precondition for the country’s further social and economic development. And while China has made great progress in public health in recent decades, it also faces fundamental challenges: an ageing population, a rise in non-communicable diseases, high costs of research and development, and a growing rural-urban divide in access to healthcare. Hospitals are the main providers of preventive and primary care, but while urban hospitals have improved as a result of large public investment, rural ones are understaffed and underutilised. Many Chinese, including those in rural areas, choose to seek outpatient care at tertiary hospitals (‘medical migration’), a fact which has led to severe overcrowding and consequent health system inefficiencies.
This contrasts with huge efficiency gains which have been realised across China’s other industries. Well established as global digital player, China has a 40% share of the world’s e-commerce market. It also has a 1.4 billion inhabitants who generate huge amounts of data which can be harnessed by artificial intelligence technologies. The Chinese government has recognised this potential and is actively nurturing AI innovation in the country with the goal of becoming the world’s leading AI power by 2030. Although a relatively late bloomer in the digital age, the health sector has now become part of this transformative process and investments and start-ups in China’s healthcare industry are soaring.
According to Lam, the Chinese government is effectively leveraging this momentum, enabling its three largest digital players to help address the country’s unmet healthcare needs. Whilst the e-commerce platform Alibaba provides access to healthcare products, the search engine Baidu offers individually-tailored health information and the Tencent platform applies artificial intelligence to diagnostic decision making. Examples of effective digital healthcare provision include the Chinese Artificial Intelligence Medical Innovation System (AIMIS) which has a 90% accuracy rate in diagnosing esophageal cancer, outperforming junior and some senior physicians. The portable device WeDoctor, used by 2,700 Chinese hospitals, can run 11 tests, including blood pressure, urine and blood tests. It uploads results automatically to a data system that allows for further consultations via the messenger service WeChat, thus creating a seamless digital healthcare experience.
As promising as these developments are, Lam cautioned that the potentials of these new technologies within the heathcare system will not be fully realised unless attention is also paid to factors outside the health sector, such as air pollution and other environmental concerns, which impact upon public health. ‘Sustainable solutions can’t emerge from siloes,’ said Lam.
Estonia’s e-health journey
The second keynote address was delivered by Dr Madis Tiik, the former head of the Estonian E-Health Foundation and one of the driving forces behind the Estonian approach to e-governance. Tiik took participants through the successive stages of Estonia’s e-health journey, which began in 2005 with digitisation – transitioning from paper to digital data collection (‘Health 1.0’) – and advanced in 2008 to integration – sharing health data from different sources through a secure data exchange layer (‘Health 2.0’). Like other elements of Estonia’s renowned e-governance framework – which offers 2,600 different e-services to the country’s 1.3 million inhabitants – the e-health system was initially launched with the aim of making the health system more efficient. Over time, however, it has become clear that e-systems also promote greater accountability and transparency and empower citizens by giving them ownership and control over their personal data.
Estonia’s integrated e-health system is one of the most advanced in the world. Based on data collected from patients’ electronic medical records and joined up with data from the population registry, health insurance registry and other data sources, the e-health system provides Estonia’s residents and health practitioners with a range of services. These include ePrescriptions (since 2010 99.9% of scripts in Estonia are digital), eReferrals and eConsultations, eAmbulance (patient data can be accessed by medics, who can also send information about incoming patients ahead to hospitals), and automated alerts for potential drug interactions. Through a user-friendly portal, patients can access their full medical records, can monitor the cost of the health services they have received (i.e. payments made by national health insurance), can see who has looked at their health records and when, and can lock any document they do not wish health providers to view.
The system follows the same principles as the rest of Estonia’s e-governance system: secure authentication; digital stamping of all documents; maximum accountability (secure log of who has viewed files); separation of clinical and personal data; encryption using blockchain; and social monitoring by patients, who are the owners of the data under Estonian law.
Health policymakers sometimes question the return on investments in digitalisation. However according to Tiik, who has accompanied Estonia through Health 1.0 and 2.0 and is part of the drive toward Health 3.0, each successive ‘version’ of an e-health system yields greater returns. ‘Health 1.0 is by far the most expensive and time-consuming, but without digitisation you can’t go further,’ he explains. ‘If Health 1.0 cost us about $100 per capita to achieve, Health 2.0 cost $10 per capita.’ Estonia is now moving towards ‘Health 3.0’: the development of individual health accounts bringing together medical and personal health data, which patients fully manage and whose information they can share with whomever they choose. Apart from two specific technical requirements for data portability, the technology is all available. Tiik predicts that Health 3.0 will cost $1 per capita and will be in place in Estonia by 2022. Health 4.0 – merging individual health accounts with AI-based decision support for patients – will not be far behind.
‘I often hear that this has worked in Estonia because the country is so small, but that it can’t work elsewhere. I don’t think this is true,’ said Tiik. ‘Right now, integration is the main target for countries around the world; so far only a few have succeeded. It’s true that many things can be done more quickly and easily in a small country, but this approach can be scaled up. And we can show how it can be done.’
On promises and challenges of digitalising health and social protection
Following a short break, Saurav Bhattarai, GIZ Nepal, moderated a panel discussion involving the two keynote speakers; Nuria Kutnaeva, the head of Tunduk in Kyrgyzstan; Clayton Hamilton of WHO Europe; Paul Rückert of GIZ Nepal; and Amit Paliwal of EPOS Health Management.
Nuria Kutnaeva opened the discussion by highlighting her country’s efforts to build an e-governance system, called Tunduk, based on the Estonian model. Tunduk digitally connects 53 government agencies, 74 information systems and 187 services. Between March and April 2019 alone, the monthly data transactions between these systems increased from 415,000 to 718,000 and continues to develop at the same rate. Kutnaeva proudly reported that Kyrgyzstan recently won an award in Estonia for the best inception and implementation of e-governance among more than 100 countries.
According to Kutnaeva the three main challenges for the Kyrgyz digitalisation process are an outdated legal framework; poor coordination between development partners regarding digital equipment and data systems; and a lack of digital skills amongst Kyrgyz civil servants.
Clayton Hamilton, who has accompanied digitalisation processes in many different countries on behalf of WHO Europe, described a number of supportive factors for successful digitalisation of healthcare systems. Where e-governance structures, digital identity systems or national health insurance funds are already in place, a certain amount of data already exists about citizens and can be used as a building block. Next, according to Hamilton, ‘successful countries are infatuated with optimising processes,’ legislating, for example, as has been done in the Nordic countries, that citizens may only be asked once to provide specific data. Having an effective communication strategy is essential, as is a governance structure for e-health which is insulated from changes in governments and their political priorities.
Bhattarai asked Paul Rückert, as an experienced GIZ team leader, what works and what doesn’t in supporting partners in digital health. The one thing all the countries he worked in had in common, said Rückert, was fragmentation and a lack of coordination in digital health systems: ‘People have different ideas and aims and these often get mixed up. In such situations we see it as our job to help partners figure out what their digital health system should look like and to enable them to start steering the process in that direction.’ Rückert stressed that, while having a digital health strategy was a good thing, it isn’t a precondition for progress. In many cases strategies are in place and implementation is missing. GIZ is well-placed to work with partners on implementation: applying its established capacity development approach, it can strengthen political frameworks, build institutional and individual capacity, and promote networking.
Amit Paliwal, who has worked on digital health and health protection in German-supported programmes in Bangladesh, India and Kyrgyzstan, raised the issue of access as a challenge that digital approaches had not yet fully solved: ‘We talk about countries where mobile penetration is high, internet is cheap, the digital infrastructure is there and the population is young. Based on this we assume that digital approaches provide full coverage, but in fact we miss out on the last 10%. It is very difficult to reach them with our digital initiatives.’
Megan Lam concurred. One group that is particularly hard to reach is the elderly, who do not always use digital tools themselves. In her view, however, approaches do not necessarily need target the elderly directly, but can take a systemic approach by reaching those who care for them, such as children or caregivers.
Asked how his country had managed to overcome such challenges, Madis Tiik replied that Estonia made lots of mistakes along the way. ‘Estonia as a country works like a start-up. You try, you take risks, if you fail, you get up and go further. We didn’t pilot anything, we just did it.’ He underscored that Estonia had managed to leapfrog technological stages other European countries had gone through: ‘We never used faxes. We jumped directly to laptops and tablets. Why use the old-fashioned thing?’ Tiik explained that Estonia has gotten to the stage where it now offers pre-emptive, or invisible services, meaning that it is no longer necessary to actively apply for benefits one is eligible for. ‘If a child is born, the government assigns an ID number to the new citizen. Why not deliver the money to the mother at the same time? A good digital service should be delivered before you’ve even thought about it.’
Artificial intelligence in global health: more than hype?
With both of the keynote addresses touching directly or indirectly upon artificial intelligence, it was time after lunch to take a step back and look more closely at AI, its promises and potentials for global health. In his input Kelvin Hui of the GIZ Sectoral Department and GIZ Cambodia sought to demystify AI and put it into a practical context. ‘Many of us working in development cooperation are still struggling with Health 1.0 – digitising and modernising health systems – in places where there sometimes isn’t electricity, or where people aren’t used to using computers,’ said Hui. ‘Is AI as far away from our work as it sometimes seems? Or are there potentials we need to be aware of?’
Hui’s session was structured around the findings of a recent study, commissioned by USAID, the Rockefeller Foundation and the Bill and Melinda Gates Foundation, which explores examples of AI applications in low- and middle-income countries and seeks to understand the role that development partners can play in strategically supporting and investing in AI in a coordinated manner. Before taking participants through the study’s main conclusions, Hui screened a brief pre-recorded video greeting from Adele Waugaman, Senior Digital Health Advisor at USAID’s Global Health Bureau, who was part of the team who commissioned the study and who was unfortunately unable to be at the meeting in person.
At a basic level AI can be understood as the use of computers for automated decision-making to perform tasks that normally require human intelligence. The study identified 240 different applications of AI in health settings, and then focused on 27 with high potential to improve health quality, cost and access in low- and middle-income countries. These clustered into four broad categories: AI-enabled population health (using population health data); patient virtual health assistant (data-driven diagnostic and care recommendations); frontline health worker virtual health assistant (augmenting health worker expertise); and physician clinical decision support tools (specialist support to general practitioners, e.g. reading diagnostic images).
The study concluded that AI has the potential to address some of the entrenched problems which affect health service delivery in many countries, but that there are a number of specific and cross-cutting challenges which may hamper the successful use of AI. These range from problems with data availability and quality to regulations and integration into health systems. As with other forms of digitalisation, it is imperative that development partners interested in supporting AI coordinate their efforts, in line with the donor principles for digital health, to leverage expertise and resources and reduce duplication. Hui ended his input by recommending the report to anyone who wants an accessible introduction to this ‘next big thing’. His takeaway? ‘AI is not that far away and it’s relevant to what we do. Have a read!’
WHO’s perspective on digital health
The next presentation came from Clayton Hamilton, who is responsible for the digitalisation of health systems at WHO Europe. The WHO sees digital technologies as holding great promise to address some of the main challenges which, as Hamilton put it, ‘keep health decision-makers awake at night.’ These include demographic change and ageing, changing burdens of disease, increasing costs, growing patient demands, ensuring health security and health workforce sustainability.
The extent of digitalisation among the 53 member states in the WHO European region varies widely, from sophisticated AI-based solutions in some countries to rudimentary SMS-based exchanges in others. Despite this, Hamilton explained, the core digital health challenges are remarkably similar from country to country. These include the set-up, scale-up and governance of digital health services; communications; privacy, security and consent; tackling data fragmentation and interoperability; sustainable financing; and establishing and maintaining trust relationships. Hamilton pointed to financing as the greatest barrier to progress at present, and singled out trust as an issue that can either be a critical enabler (as it is, for example, in Estonia), or a barrier.
Hamilton also listed the main questions which decision-makers are grappling with in relation to digital health – some of which were already alluded to in the cases from Estonia and China and in the discussion which followed: Is the return on investment in digitalisation real? Is digitalisation creating an unwanted digital divide? How do we strike a balance between access to and protection of data for different purposes? What can we do when poor data quality limits the ability drive decision-making? In his recommendations to development partners active in the field of digital health, Hamilton mentioned a number of areas which align well with GIZ’s core competencies and approaches, including: support to national initiatives on digital identity, health data digitisation and integration; brokering linkages between partner activities; strengthening the role of national public health institutions; advocating for the inclusion of patients and special interest groups in strategy development and solution design; and increasing communications and advocacy for digital health.
A chance to dive deeper
During the remainder of the conference, participants had the opportunity to choose among six ‘deep dive’ sessions which presented detailed experiences from particular approaches or country contexts, as well as to rotate through eight presentations in a marketplace. Highlights from some of the deep dive sessions are available here.
An epic ending
In ancient times the Silk Road was a crossroads for cultures and worldviews. On the final morning of the meeting it played this role again as Dr Klaus Hornetz, an emeritus colleague from GIZ health programmes who is currently living in and consulting from Kunming, China, provided a thought-provoking input about the role of digitalisation in Chinese life. Drawing upon his ‘outsider/insider’ status, he offered a humane and sensitive interpretation of modern China, encouraging participants to reevaluate dominant Western narratives about China and digital technology.
On the final morning of the meeting participants also had a special opportunity to witness the recitation of part of the Epic of Manas, Kyrgyzstan’s 500,000-line national epic poem, by a group of children. This captivating and moving performance deepened the respect and sense of connection many participants felt towards the country which hosted the meeting and instilled a desire to return and explore further.
Asked for his impressions of the conference, Casjen Ohnesorge, BMZ’s Head of Cooperation in Kyrgyzstan, remarked that in his position he attends many conferences, and that this one clearly stands out. ‘If GIZ continues to pursue opportunities in digital health as it has thus far, it is positioning itself well for the future.’
Karen Birdsall & Anna von Roenne