Harnessing the potential of digital health in the WHO South-East Asia Region: sustaining what works, accelerating scale-up and innovating frontier technologies Poonam Khetrapal Singh, Mark Landry WHO South-East Asia Journal of Public Health 2019 8(2):67-70

Bangladesh’s digital health journey: reflections on a decade of quiet revolution Muhammad Abdul Hannan Khan, Valeria de Oliveira Cruz, Abul Kalam Azad WHO South-East Asia Journal of Public Health 2019 8(2):71-76 Bangladesh has made remarkable progress in digital health in recent years. Through one of the world’s largest deployments to date of the open-source District Health Information Software 2 (DHIS2), the country now has a national public sector health data warehouse. Information from previously fragmented data systems is now unified in a common data repository, enabling data exchange for health information systems and decision-making. Work is ongoing to create lifetime electronic health records for all citizens that can be transferred between health facilities. Extensive customization of open-source software has laid the foundations for a national digital networking system. Initiatives have focused on producing digital solutions to aid priorities such as strengthening the health system as a whole as well as supporting specific technical interventions, for example improving the civil registration and vital statistics system. Digital solutions have also supported the Bangladesh health workforce strategy through a set of registries that electronically captures and maintains human resource information for the entire public health sector, including monitoring staff attendance through the use of low-cost biometric fingerprint time-attendance machines. Citizens are encouraged to engage in shaping health services via a web-based complaints and suggestions system, and a new system to raise health awareness via public digital displays has started in Dhaka. Strong support at the highest political level has been critical to the success of efforts to introduce these innovations. The endeavour has also generated a cadre of enthusiastic eHealth proponents, who are focused on further strengthening and expanding the existing systems and on harnessing the vast amount of information amassed at the central data repository through big data analysis, artificial intelligence and machine learning.

Transforming health care through Bhutan’s digital health strategy: progress to date Mongal Singh Gurung, Garab Dorji, Sonalini Khetrapal, Sungsup Ra, Giridhara R Babu, Ramesh S Krishnamurthy WHO South-East Asia Journal of Public Health 2019 8(2):77-82 Bhutan, a landlocked country in the eastern Himalayas with some of the most rugged and mountainous terrain in the world, is actively engaged in digital health strategy reforms aimed at improving the efficiency of the health information system. Aligned with Bhutan’s e-Government master plan, the National eHealth strategy and action plan aims to improve health by empowering health-care providers and citizens through technology and by enabling data exchange for service delivery. The strategy has four primary areas of focus: (i) ensuring digital health governance arrangements; (ii) concentrating on strong foundations in terms of infrastructure and standards; (iii) prioritizing improvements in the current health system in a phased, selective manner; and (iv) building the digital skills and knowledge of health workers. With support from the Asian Development Bank and the World Health Organization, phase 1 of the strategy has been completed and the blueprint for the digital health information system is in development. Phase 2 of the strategy will be implemented during 2020–2023 and will include work on (i) identity management for the health workforce; (ii) the implementation of a master patient index and a secure longitudinal patient information system; and (iii) enabling all health facilities to access the systems. Bhutan’s eHealth strategy has the potential to fundamentally transform the delivery of health services, strengthen primary health care and enable the development of a “One Health” public health surveillance system.

Working towards a master patient index and unique identifiers to improve health systems: the example of Myanmar Lori Thorell, Joseph Dal Molin, Justin Fyfe, San Hone, Su Myat Lwin WHO South-East Asia Journal of Public Health 2019 8(2):83-86 In the health systems of many countries, there is neither a requirement to collect a minimum set of demographic information during patient registration nor a standard way of identifying patients. This impedes the provision of integrated, good-quality care for individual patients and, at the system level, prevents generation of the high-quality data necessary for effective management and continuous improvement. Assigning each patient a unique identifier (UID) to create a master patient index (MPI) is therefore essential to ensure data interoperability across all the points of patient care within a health system. Although advances in technology are shifting the boundary between civil registration and personal identification, the additional value of an MPI/UID system lies in the technical and operational capacity to ensure that clinical data are safely and securely managed. Moreover, operationalization of MPI/UID data enables the establishment of an evidence-based, constantly improving “learning health system” with feedback loops that allow measurement, evaluation and visualization of performance over time. The Ministry of Health and Sports of Myanmar is actively engaged in a multistakeholder collaborative process working towards a nationwide MPI/UID system. Demonstration pilots are planned for both online and offline modes of operation for HIV/AIDS, mother and child health (including eliminating mother-to-child transmission of HIV and syphilis) and hospital settings, which are expected to open up the potential for expansion to all health interventions and facilities. With the implementation of the MPI/UID system under way in Myanmar, the Ministry of Health and Sports is laying the foundation to put individuals at the centre of care and deliver a lifelong service for all.

Strengthening health systems through informatics capacity development among doctors in low-resource contexts: the Sri Lankan experience Pandula Siribaddana, Roshan Hewapathirana, Achala U Jayatilleke, Sundeep Sahay, Vajira HW Dissanayake WHO South-East Asia Journal of Public Health 2019 8(2):87-94 In the process of strengthening health systems, a lack of health-informatics capacity within low- and middle-income country settings is a considerable challenge. Many capacity-development initiatives on health informatics exist, most of which focus on the adoption of eHealth tools by front-line health-care workers. By contrast, there are only a few programmes that focus on empowering medical doctors in low- and middle-income countries to become champions of digital health innovation and adoption. Sri Lanka has a dynamic eHealth ecosystem, resulting largely from the country’s community of medical doctors who are also health informaticians. They are the result of a decade-long programme centred on a Master of Science degree course in biomedical informatics, which has trained over 150 medical doctors to date, and has now been extended to a specialist training programme. This paper evaluates this unique capacity-development effort from the perspective of strengthening health systems and how those in other low- and middle-income country contexts may learn from the Sri Lankan experience when implementing capacity-development programmes in health informatics.

Digital possibilities in the prevention and early detection of oral cancer in the WHO South-East Asia Region Om Prakash Kharbanda, Anupama Ivaturi, Harsh Priya, Gampo Dorji, Shalini Gupta WHO South-East Asia Journal of Public Health 2019 8(2):95-100 Cancers of the lip and oral cavity are the most common cancers among men in the World Health Organization (WHO) South-East Asia Region. Most cancers of the oral cavity are attributable to tobacco smoking, smokeless tobacco use and areca-nut product use, alone or in combination, and excessive consumption of alcohol. These risk factors are highly prevalent in parts of the region. This paper outlines an integrated framework for oral cancer prevention, which includes a strengthened primary health-care workforce, enhanced community engagement and a positive policy environment. Operationalizing this framework could be greatly facilitated by the application of digital technologies. Robust evidence exists for the effectiveness of using appropriately trained primary health-care workers to screen for oral cancer by oral visual examination; this can be combined with counselling for risk-behaviour modification as part of an overall strategy on noncommunicable diseases. This needs to be supported by greater overall community engagement, for example to tackle low levels of awareness of the harmful effects of smokeless tobacco and areca-nut products. A strong policy environment that supports and promotes these efforts is essential, along with the enforcement of the measures required by the WHO Framework Convention on Tobacco Control. Despite the burden of disease, oral cancer has been a neglected area of public health. This paper considers how the positively disruptive effects of digital technology may enable much-needed acceleration in prevention and control efforts.

BehavioR: a digital platform for prevention and management of behavioural addictions Yatan Pal Singh Balhara, Nazneen Anwar WHO South-East Asia Journal of Public Health 2019 8(2):101-103 Behavioural addictions have been identified as an emerging public health problem. The unprecedented pace of the digital revolution, resulting in an ever-increasing use of internet-based technologies, provides the opportunity to create a unique resource to assist in offering public health interventions in the World Health Organization South-East Asia Region. The ability to deliver evidence-based treatment and preventive programmes that can be accessed by mobile phones, for example, increases access to a wide range of populations, including hidden or hard-to-reach populations. BehavioR (the Behavioral addictions Resource hub) has been established with the aim of offering a one-stop resource centre for behavioural addictions. The expected end-users of this digital platform include patients, caregivers, the general public, health-care providers, academics, researchers and policy-makers. The platform can be used to offer digital health interventions to patients; strengthen the capacity of health-care providers for early detection of, screening for, intervention in and management of behavioural addictions; and serve as an online repository for reliable information on behavioural addictions for the general public.

Gendered perceptions of physical activity and diabetes in rural Bangladesh: a qualitative study to inform mHealth and community mobilization interventions Joanna Morrison, Hannah Jennings, Kohenour Akter, Abdul Kuddus, Jenevieve Mannell, Tasmin Nahar, Sanjit Kumer Shaha, Naveed Ahmed, Hassan Haghparast-Bidgoli, Anthony Costello, A K Azad Khan, Kishwar Azad, Edward Fottrell WHO South-East Asia Journal of Public Health 2019 8(2):104-111 Background Diabetes prevalence is increasing rapidly in Bangladesh, and there is an urgent need to promote preventive behaviours for type 2 diabetes, such as maintaining a healthy body weight, eating healthily, avoiding tobacco and being active for 150 minutes per week. Methods We used a qualitative methodology informed by the capability, opportunity, motivation theory of behaviour change to explore the factors affecting physical activity among men and women in rural Bangladesh. We conducted semi-structured interviews and focus group discussions with 64 purposively sampled participants with and without diabetes, and five health workers. From the results of descriptive content analysis, we identified key capabilities, opportunities and motivations to engage with in our mHealth and community mobilization interventions. Results Men and women without diabetes lacked awareness about the need to remain physically active to prevent diabetes, and most felt that their activity levels were sufficient. Housework was not commonly perceived as physical activity among all respondents. These knowledge and capability gaps could be addressed through mHealth messaging and community mobilization providing information on sufficiency and types of physical activity to prevent and control diabetes. Men were physically active while working outside the home, whereas women felt unsafe and conspicuous, and were constrained by family commitments and social expectations of appropriate behaviour. Women engaged in strategies to protect their own and their family’s reputations. These opportunity factors affecting physical activity indicated the need for strategies developed through participatory processes to challenge unhealthy gender norms and increase women’s safety. Conclusion Formative research data can enable the development of contextually relevant interventions. Data show that mHealth interventions should consider gendered barriers to physical activity, tailoring information to meet men’s and women’s needs, and that community mobilization interventions should enable unhealthy, gendered community norms to be challenged. Participatory interventions can enable communities to push the boundaries of socially acceptable behaviours to increase physical activity, helping to prevent and control diabetes.

Measuring outcomes of hypertension treatment in primary care in resource-limited settings Ayush Lohiya, Roy Arokiam Daniel, Sitanshu Sekhar Kar, Swaroop Kumar Sahu, Baridalyne Nongkynrih, Cherian Varghese WHO South-East Asia Journal of Public Health 2019 8(2):112-114

Follow-up data on patent expiry and atorvastatin price: experiences in Brunei Darussalam, Malaysia, the Philippines and Thailand Anna Kemp-Casey, Joyce Ceria-Pereña, Anna Melissa Guerrero, Netnapis Suchonwanich, Salbiah Mohd Salleh, Elizabeth E Roughead WHO South-East Asia Journal of Public Health 2019 8(2):115-117