In the 2018-19 Budget, a sum of Rs 100 million was allocated for E-health and, on the occasion of “World Health Day” on 8 April 2019, the Prime Minister again made reference to the E-Health project. On 15 March 2019, Exim Bank in India launched an invitation for Indian companies to submit applications for pre-qualification for the development of E-Health System for Hospitals, Health Centres, and Mediclinics in Mauritius. This will be financed under Exim Bank’s GOI-supported Line of Credit extended to the SBM [Mauritius] Infrastructure Development Co. Ltd. [a nominated agency of Govt. of Mauritius]. The closing date for this invitation was on the 15th of April 2019, with a 12 month target completion period.
The E-Health project is ambitious and the document from Exim Bank included the following introduction: “Ministry of Health & Quality of Life [MOHQL], the Republic of Mauritius intends to improve the quality and responsiveness of healthcare services. The objective of this project is to implement e-Health Project in phased manner to enable the creation of standards compliant Electronics Health Records (EHRs) of the citizens on a pan-Mauritius basis along with the integration and interoperability of the EHRs through a comprehensive healthcare system. E-Health project is envisaged to enable better continuity of care, secure and confidential health data/ records management, better diagnosis of the diseases, reduction in patient re-visits and even prevention of medical errors, better affordability, optimal information exchange to support better health outcome, better decision support system and thus eventually facilitating improvement in the reforms of treatment and care of public health at National level. The e-Health project would cover all the hospitals, Area Health Centres (AHCs), Community Health Centres (CHCs).”
The reality is that this will be a project which will be developed by external consultants with a view to be integrated with the existing public health service in Mauritius. Internationally, there is ample evidence that many health IT implementations have not achieved their potential. In fact, many health IT projects fail, either falling short of intended improvements or leading to disuse or even cancellation of the project.
Globally, more than 50% of EHRs systems either fail or fail to be properly utilized. One of the most expensive failures has been in the UK where an ambitious national plan to computerise patients’ NHS records, initiated in 2002, was finally abandoned in 2011 at a cost to the taxpayer of over £10 billion. The reality is that resistance and opposition in changing from the paper-based systems to electronic systems often create difficulties at the implementation stage. Some other issues include the lack of preimplementation activities, lack of organizational readiness, unavailability of technology and funding and limited technical and computer skills of personnel.
In the Mauritian context, the following may be key barriers to successful implementation of the E-Health project:
- Lack of awareness of EHealth and HER systems and their importance;
- Inadequate training of staff
- Change in culture required to embrace technology;
- Lack of involvement of frontline clinicians in the design and implementation of E-Health;
- Lack of familiarity with software;
- Lack of IT resources and equipment;
- Resistance from end users: doctors, nurses and administrative staff;
- Illiteracy of some patients;
- Unreliable internet connectivity.
Experience from the United States has shown that the following are key elements of successful implementation of E-Health and EHR projects:
• People are the key and leadership is essential. The project should have an identified Chief Executive Officer who has national visibility, supported by Physician champions (e.g. at regional or hospital level). This senior executive team should be the engine that motivates others, provides the needed resources, clears the track of obstacles and backs the project through thick and thin.
• An extensive amount of planning needs to take place at the pre-implementation stage, identifying changes which need to take place at all levels of hospitals and clinics. For example, where to put computers in the wards, outpatient departments and clinics. The issue of existing medical records needs to be addressed well before any “go live” date: will all the existing records need to be scanned on to the IT system? This should ideally be the case but will involve a lot of extra work. The right electronic records storage system will need to be installed, with the right software for use by all clinicians.
• There should be a training strategy for all clinicians and administrative staff who will use the EHR system: we should not underestimate the amount of time and work which is necessary to become knowledgeable about using an EHR system.
A successful implementation of EHR in public hospitals and health centres will involve a significant culture change and will need the “buy-in” of staff at all levels. So, in this budget, it is proposed that funds be allocated to develop and implement a coherent strategy to prepare the organisation for EHR, with the creation of a small core team at the MOHQL to provide leadership, and the identification of enthusiastic physician champions at all regional institutions. A clear training strategy will need to be formulated and gradually implemented, so that by the time the EHR system is about to be launched, most frontline staff have a working knowledge of the systems in place.
The above is being proposed to ensure that the E-health and EHR project in Mauritius becomes a success, unlike the experience of many other countries.
Mobilising against diabetes and noncommunicable diseases (NCDs)
The Mauritian population should be well aware of the extent and severity of the problem of Diabetes and NCDs in Mauritius. The complications of diabetes, including the risk of blindness and leg amputations should be common knowledge. On the occasion of the recent World Health Day on 8 April 2019, the Minister of Health pointed out that around 220,000 adults in Mauritius have diabetes and another 200,000 are pre-diabetic. On the same occasion, the Prime Minister also rightly stated that “nous avons une population qui est gravement malade”, with an alarming situation of NCDs causing 85% of deaths.
Going beyond the Prime Minister’s encouragement for the population to engage in more physical activities, a clear strategy is proposed to develop anticipatory care and community mobilisation against diabetes and NCDs:
• Local community health centres, staffed by trained doctors and diabetes specialist nurses can deliver essential preventive care for the local population;
• Local health centres can operate as “Pôles Santé”, working in collaboration with local volunteers trained as “Health Champions” to deliver a systematic outreach programme, going door-to-door: the aim would be to identify people suffering from, or at risk of, diabetes and NCDs, provide advice and support and inviting them to attend the nearest health centre for expert monitoring and follow-up;
• In line with the E-Health project, electronic health records can be set up at the local health centres, enabling easier monitoring of patients, and follow-up/recall, making full use of mobile technologies (SMS or WhatsApp).
This initiative can progress with an allocation of funds in the forthcoming budget, together with an enthusiastic and dedicated Health team under the MOHQL.
A charter of patients’ rights and responsibilities
Many countries have introduced documents which stipulate the rights of persons who access local health care, as well as their responsibilities. For example, in September 2018, the Ministry of Health in India released a draft document, prepared by the National Human Rights Commission, which stipulated 17 rights of patients. Key elements which could be relevant to Mauritius are: the right to communication (i.e. an explanation of diagnosis and treatment from the doctor or nurse); right to medical records and reports within 24 hours of hospital admission or 72 hours of discharge; right to emergency medical care; right to informed consent (with adequate explanation before any surgery or procedure, before any document is signed); right to confidentiality, human dignity and privacy; right to non-discrimination (e.g. on basis of age, race, gender, HIV status or sexual orientation); right to safety and quality of care.
In other countries, during the drafting of Patients’ Rights documents, medical professionals have requested that a separate section should include Patients’ Responsibilities, such as a responsibility to promote their own health, to fully disclose their medical history to providers, and to treat providers with respect.
In parallel with drafting a charter of patients’ rights and responsibilities, some countries have also implemented a system for complaints from patients to be investigated without delay, such as an “Independent Health Ombudsman”. Indeed, in some countries, patients’ charters with dedicated complaints procedures have enabled complaints to be resolved at an early stage by informal means, averting the need for litigation or formal disciplinary proceedings.
PHM-Mauritius proposes that the next budget includes provision for the drafting of a charter of patients’ rights and responsibilities in Mauritius, to include the creation of an Independent Health Ombudsman, with the authority to investigate complaints from patients in relation to care in both public sector and private clinics.
PHM-Mauritius is proposing for the above three initiatives to be part of the Prime Minister’s Budget Speech, with an appropriate budgetary allocation in each case. Being aware of constraints on the national budget, with competing funding needs, the above three initiatives will require relatively modest budget allocations. What they will require is enthusiasm and commitment at all levels in the health sector, with an inspirational leadership from the highest level of government. It is possible to initiate visible changes in the delivery of preventive health care at a local level within months, showing early tangible and palpable results to the local population.