Learning, evaluation, health communication, living practice, lessons learned

The UAHI video conference brought together more than 100 people from ten countries at five different sites around the world, to look at ways of working to improve the access to health information, in particular for those in developing and transitional countries. The conference was jointly organised by Exchange, INASP-Health and the Interactive Health Network, with support from the Department for International Development (DFID).

The conference was organised around the six priority areas for action elaborated by the World Health Organisation (WHO) and the Health Information Forum: to strengthen the local production, translation and adaptation of information; to strengthen library and information services in developing countries; to facilitate the sharing of lessons learned; to improve access to information about existing materials; to maximise the impact of ICTs; and to develop an enabling environment for health information activities.

Participants from developing countries highlighted the problems with connectivity and communications infrastructure faced in many poor and remote areas. Attempts to provide health information need to take the baseline reality of under-resourced health systems and lack of health personnel into account.

Many conference participants stressed the need to put the use of the Internet in perspective. Only a tiny proportion of the world's population is connected (the figure of 6% was quoted by many), and an even smaller proportion of those living in poverty. This means that we still need to consider a range of different technologies, and particularly for the many who don't have Internet access, bridging technologies, such as CD-ROMs, and ultimately paper.

A focus on connecting health personnel could perhaps amplify any benefits of connectivity, but there was a strong recognition of the continued importance of supporting paper-based materials. A number of conference participants also reported interesting experiences with the convergence of technologies.

The use of the Internet in combination with radio, meant that queries about health issues could be channeled to radio stations that were connected to the Internet, and answers broadcast on the basis of the information obtained. It was also suggested that greater use could be made of e-mail to search and retrieve information from the Internet. There was widespread recognition of the value of combining a range of different technologies as part of the 'information waystations' approach.

A number of people noted that their organisations already work in this way and are effectively 'waystations' themselves, since they take information from various sources, including those accessed electronically, and repackage them for various local audiences. Such 'facilitated access' to information is a key part of any strategy. Librarians or informed intermediaries, have a key role in helping health workers, or other end users, filter the vast amount of information available to find the relevant information they need.

The importance of also being 'listening posts' was emphasised, to ensure a two-way process of communication, including the upward flow of locally applicable and culturally appropriate information. Much of the information flowing from North to South is not relevant to local needs, since applicability usually depends on 'fine grained structure of information use'.

A number of people also stressed the need to raise awareness of existing information resources. It is important to get the basic clinical guidelines and primary health care information that are already available out to as many people as possible. Whether a ring bound file of paper that could be updated and amended, a version of the blue trunk library, or a CD-ROM containing key health reference materials, these core resources are not getting to the places most needed at present. It is vital that any initiatives around Internet connectivity, build on the need for such appropriate solutions to information access in remote or unconnected localities.

Different constituencies have clearly different needs. The conference noted some tension between top-down international efforts and building local capacity and even demand, for good quality health information, the latter being crucial.

It is important to have synthesised information wherever possible; clinicians need instant applicable information, a need which is quite different from the researcher, who needs all the information available, linking to wider questions. These different needs should not be confounded.

We have to begin from realities on ground, and find tools for specific problems. In this context, while the announcement of major publishers to provide on-line access to major medical journals free to developing countries was widely applauded, it was noted that in some developing countries this would have little impact, as most clinicians spent less than half an hour a week reading. What is vitally needed is high quality and relevant summaries.

In the provision of locally appropriate information a number of issues were identified. While most stressed the need for local relevance, this was perceived to be in tension with the need for information to be 'evidenced based'. In this context, the notion of 'validity' of information was usefully expanded: in addition to being reliable, sound and scientifically accurate, information needed to be relevant to target audiences and their health priorities, and ultimately it needed to be 'useable'.

A number or participants stressed the need to start from where people were on the ground in settings of poverty. It is important to begin with the existing skills and knowledge, the channels and technologies of communication that are in place, and the particular local needs and priorities. Training and capacity building are vital, to build on and strengthen the good practice that already exists, but also to allow any introduction of new technologies to be effectively taken up. It is equally important to support local publishing and information production so that increasing access to the flow of information from the North does not damage and undermine the development of information infrastructure locally and regionally.

Starting with the local setting also means bringing processes of communication and education to the fore, so that we need to look beyond information to the social processes of communication in which it is engaged. Information can also not be seen in isolation from the health systems infrastructure and the wider political contexts of development as a whole.

In the light of this, the conference reiterated the need for a multifaceted approach, and co-operation and sharing between organisations locally, regionally nationally and internationally. There was much to learn from different experiences across sector and discipline, and the need for more sharing and exchange of lessons learned was recognised as important.

On the issue of beginning with local experiences and understandings, Andrew Chetley of Exchange quoted a friend, Gerry Pantin, a priest in Trinidad, whose lifetime of development work in poor communities in Trinidad had revolved around listening to the people in those communities. He once said: "You listen until you are tired of listening and then you listen some more".

The information overload brought with the Internet was described by Richard Smith from the BMJ as being "like trying to drink water from a fire hydrant, when you really wanted a glass".

Ann Philpot from Worldview International Foundation highlighted the importance of help from a sympathetic librarian to identify relevant information from the mass available: this was akin to "helping you search through an air-craft hanger full of junk looking for a useful part".

The importance of not neglecting the development of computer based ICT infrastructure in developing countries, despite the acknowledged importance of other technologies was highlighted by Barbara Kirsop from the Electronic Publishing trust, who said we should not condemn developing countries to the "world wide wait". From South Africa the same point was made with the image of making people walk a long way to get water rather than introducing the benefits of the technology of a tap.

Finally, the disparity of flow of information and experience from North to South and lack of real understanding of the needs of those in developing countries who the information was supposedly being produced for was characterised by Richard Smith from the BMJ as "having a conversation using a megaphone at volume while not listening".

Universal Access to Health Information