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African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
African e health economics Forum: Amanda Brikmann Chair: 2 sessions:  Context for e-health, notes + actions to move forward: A discussion
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African e health economics Forum: Amanda Brikmann Chair: 2 sessions: Context for e-health, notes + actions to move forward: A discussion

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SESSION ONE: ASSESSMENT: THE MOST SUITABLE METHODS OF TRACKING SUCCESS AND …

SESSION ONE: ASSESSMENT: THE MOST SUITABLE METHODS OF TRACKING SUCCESS AND
ENSURING PROJECTS ARE GIVEN SUITABLE TIMELINES FOR SUCCESS
1.1 WORKGROUP OUTLINE/DIRECTIVES
1.1.1 Health system analysis: What have we learned and how do we do better?
1.1.2 What are the economic benefits to the various stakeholders in healthcare?
1.1.3 How is healthcare quality impacted
1.1.4 How do employers benefit?
1.1.5 What emphasis is being given in developing countries to cost-effectiveness and cost-benefit
of prevention versus curative treatment?
1.1.6 Use of outcomes measures, including Patient Reported Outcome Measures, in resource
allocation
2. SESSION TWO: FINANCIAL ASPECTS OF IMPLEMENTING EHEALTH AND HEALTH IT PROJECTS
2.1 WORKGROUP OUTLINE/DIRECTIVES
2.1.1 With the increased use of electronic medical records, what technology can be used to
ensure efficiency?
2.1.2 Understanding Cloud Computing – How can increasing flexibility reduce costs in urban
hospitals and rural areas?
2.1.3 Data Security – Ensuring the Increased Use of IT in healthcare does not affect security of
patient information.
2.1.4 Business Intelligence Software – Making the most of information gained from EMR‟s.
2.1.5 Productive Efficiency, Costs and Quality across National Health Systems.
2.1.6 Methods of containing costs.
2.1.7 Cost-effective organisation of hospitals.

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  • 1. AFRICAN E-HEALTH ECONOMICS FORUM 22 NOVEMBER 2012 ONE AND ONLY HOTEL: CAPE TOWN SUMMARY, NOTES, ACTIONS: PANEL DISCUSSIONS ONE AND TWO PREPARED BY THE CHAIR: AMANDA BRINKMANN NOVEMBER 2012 P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 1
  • 2. KEY ACTION POINTS, CONCLUSIONS AND RECOMMENDATIONS FOR IMPLEMENTATION: AFRICAN EHEALTH ECONOMICS FORUM 22 NOVEMBER 2012 1. Creating the proxies and measurement metrics within a framework: to measure the benefits and Return on Investment [ROI] of e-Health – including actuarial modelling. 2. Investigate the Beijing International Medical Centre model – as example of best practice. 3. Create clear eHealth policy for South Africa & SADC – including operational and implementation policies and plans – standardised as far as possible. 4. Sustainability – including sustainability planning and metrics within the framework – specifically related to maintenance, upgrades, upkeep and future budgeting 5. Institutionalise eHealth at the highest levels – Cabinet and Parliament – so that it becomes a national priority. 6. Reinforce the notion that we must first „ get the basics right‟ – including the use of LEAN/Sigma methodologies to deal with process and systems flow, strengthening the existing infrastructure, equipment backlogs and staff shortages – thereafter the technology must he developed to deliver the desired OUTCOMES. 7. Cost-Benefit analyses: Crowd local and global methodologies and case studies and present in a format – so as to agree analyses framework for South Africa and Africa. 8. Preparation Phase – pre the arrival of the technology: Include Change Management processes + the cost of initial reduction in productivity; include training, support and maintenance within implementation plans and budgets. 9. Basic computer literacy/skills – do a national assessment at all health facilities to establish levels of computer literacy – as baseline, to determine extent and range of training interventions that would be required pre-roll-out of an eHealth system. 10. Reiteration of the fact that we should: “ Describe what we WANT eHealth to do, draw the picture, iterate the desired outcomes – and design the system around those outcomes” 11. SATMA to investigate the Telemedicine Switch – which acts as an aggregator and therefore liberates the environment. 12. Connectivity audit – baseline study to be done at all health facilities – could be done simultaneously with computer literacy study/survey. 13. Technical assistants: 2 year apprenticeship for Out-of-School Youth who show the aptitude for ICT – accredited training and creation of micro-enterprises to serve clusters of medical facilities. 14. Consider Regional Implementation and Co-operation – in Africa – rather than countries implementing separately. 15. Formalise what we mean when we speak about „Partnerships‟ – what do these partnerships look like – define the range of possible partnerships clearly – from transactional to CSI. 16. Develop norms and standards – developers to work with clinicians/public and private health 17. Financing Methodologies MUST be agreed and developed – eHealth cannot be rolled out without a clear financial commitment and strategy. 18. Draw on existing Assessment Methodologies available – Dr Craig Fredericks – GSM Global – to provide study reports, including Bihar, India project – training 35 000 Community Healthcare workers, using technology 19. Define e-Health – what is it, how does each dimension or element fit into the system and how are each of these measured fairly? P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 2
  • 3. 20. Consider models where there is risk and cost sharing between the public and private sectors. 21. Structure expectations of all partners upfront – as part of collaboration. 22. Healthcare typically uses historical or incremental budgeting – suggestion that the „ new‟ model of healthcare should be clearly defined and a return to zero-based budgeting so as to reflect the „ new‟ needs of citizens and the system. 23. Operating Leasing – with finance partners – including the upfront purchase of maintenance contracts, to mitigate against and/or neutralise the cost of finance at fixed rate – over time. 24. Create a CENTRAL REPOSITORY to: * Leverage „ appropriate‟ IP/Best Practice/Success Modelling * National and International best practice and knowledge crowded – access of all interested parties so as to share knowledge, avoid duplication and created a shared vision and eHealth agenda. 25. Look at the connectivity Spine/Backbone and Cloud Computing – create definitive policies, norms and standards. 26. Advocate for eHealth as enabler to „get the basics right‟ and part of process of health systems strengthening. 27. Patient-centricity: Access anywhere, anytime – design the business processes and system to support patient-centricity and to ensure that value is added to the patient experience. 28. Inter-operability is vital – develop norms and standards. 29. INTEGRATED PLANNING – full stop. 30. Cost containment, maintenance, replacement, capital costs – all to be factored into the framework. 31. EHEALTH ENTERPRISE ARCHITECTURE – is at the core of being able to move forward – a national enterprise architecture must be completed – so that all provinces are able to align implementation accordingly. 32. Share South African eHealth strategy draft document – attached separately for circulation. [4] 33. South Africa and SADC partners to become members of Health Level 7 [ HL7][8], so as to draw on existing global best practice in respect of eHealth standards and frameworks. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 3
  • 4. 1. SESSION ONE: ASSESSMENT: THE MOST SUITABLE METHODS OF TRACKING SUCCESS AND ENSURING PROJECTS ARE GIVEN SUITABLE TIMELINES FOR SUCCESS 1.1 WORKGROUP OUTLINE/DIRECTIVES 1.1.1 1.1.2 1.1.3 1.1.4 1.1.5 1.1.6 Health system analysis: What have we learned and how do we do better? What are the economic benefits to the various stakeholders in healthcare? How is healthcare quality impacted How do employers benefit? What emphasis is being given in developing countries to cost-effectiveness and cost-benefit of prevention versus curative treatment? Use of outcomes measures, including Patient Reported Outcome Measures, in resource allocation 1.2 PANELLISTS 1.2.1 1.2.2 1.2.3 1.2.4 1.2.5 1.2.6 1.2.7 1.2.8 1.2.9 Chair: Amanda Brinkmann – Indigo Business Consulting & Advisor to the Minister of Health as well as Leader of Government Business: Western Cape Government. Head: Strategic Partnerships: Western Cape Government [ Last effective day of tenure with WCGOV] Dr Simon Samaha – Physician Leader in Europe, Middle East and Africa – PWC Trish Dicks – Strategic Account Manager: ECM: Public Sector – Datacentrix Badie Niewoudt – New Business Development Manager – Eli Lilly Makano Mosidi – Public Sector Executive – Dimension Data Deputy Minister Makoae – Lesotho Department of Health Aphiwe Mazambo – Health ICT – Western Cape Department of Health Rosemary Foster – Division Manager: eHealth Strategy and Policy – Medical Research Council Bakang Oliphant – Senior Manager Strategic Planning, Monitoring and Evaluation – Free State Department of Health 1.3 SETTING THE SCENE AND CREATING CONTEXT – AMANDA BRINKMANN – CHAIR In conversation with Andrew Bell, Programme Director of the African e-Health Economics Forum, it was agreed that the panel sessions would be completely interactive and that firm action points would emerge from these sessions. The Chair felt that given the fact that the same questions seem to be asked annually at a global level and seem not to have been definitively answered or dealt with, that this particular forum should take the lead in moving forward on a more action-oriented process, which is outcomes-driven. To set the tone of the conversation and to catalyse robust discussion and debate, the Chair made the following opening remarks: 1.3.1 1.3.2 1.3.3 Health system analysis [HSA] is a distinct methodology that should be developed and practiced in the design of policies and programmes for health systems strengthening. [1] In the Abstract of their discussion document, Health System Analysis for Better health System Strengthening, [1] Berman and Bitran confirm that health system strengthening and reform are actions that are necessary so as to achieve better overall outcomes. What is required is health systems strengthening for RESULTS. Essentially, HSA should identify key elements of health systems analysis and situate these within a logical framework, supported by a wide range of data and method – including P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 4
  • 5. 1.3.4 1.3.5 1.3.6 1.3.7 1.3.8 1.3.9 1.3.10 1.3.11 1.3.12 1.3.13 1.3.14 1.3.15 1.3.16 1.3.17 1.3.18 1.3.19 1.3.20 1.3.21 1.3.22 within the sizeable global academic and scientific research literature that is readily available. The authors propose that HSA includes: * Evidence of health system inputs * Processes * Outputs – and the analysis of how these combine to produce the outcomes. [1] Robust HSA should consider the politics, history and historical context as well as current and future institutional arrangements. HSE should propose the causes of poor health system performance and suggest how reform policies and strengthening strategies could improve overall performance. [1] It therefore should contribute implementation as well as evaluation of methodologies to improve performance. The authors cite examples of best practice and successes achieved in Mexico, Ethiopia and Turkey – these examples demonstrate the positive contributions of HSA to the development of successful health system strengthening policies. They further assert that HSA should be an integral part of good practice in health system strengthening – this includes: policy development, monitoring and evaluation. [1] The authors also remind us that HSA is a complex undertaking, requiring sound evidence and analysis, political skill and will and they even suggest that a bit of „good luck‟ for success in improving the outcomes is not uncommon. [1] They ask the very pertinent question that seems to be one that is globally perplexing – and that is: Do we have a framework? They furthermore wonder whether the health system is accelerating outcomes or indeed, as we suspect, impeding progress? There are multiple goals, objectives, outcomes and outputs within the health system – what are these variables and do we have the ability to measure them? They conclude that HSA has to be broad, inclusive, analytical, relevant and evidence-based – and should ideally include quantitative as well as qualitative data. One has to view the whole system first and then the various sub-systems, to understand their impact on one another. In their presentation entitled: “Assessing socio-economic and clinical benefits from eHealth solutions – approach and evidence [2], Stroetmann et al takes us a step further on the eHealth journey. The authors start of by asking the pressing question: “IS eHealth an enabler for better health?” They frame this question against the backdrop of the 40 year + history of huge investments in eHealth with what they describe as “limited” success. They also ask: “Will what is technologically feasible or desirable, be economically viable or organisationally implementable?” [2] We are reminded that the “new” model of healthcare focuses on health, rather than “sick care.” This should therefore translate to the provision of individualised health services at the patient‟s point of need and that this can be achieved only via a collaborative, integrated and seamless package of services and care. The question that therefore flows logically is: “Can eHealth help us to move from reactive to preventative to predictive medicine? “ [2] Can eHealth help us to reduce Polypharmacy – which is becoming a near global “ disease” category, which involves the Prescription Cascade, which becomes the Prescription Avalanche of medications, medicating chronic patients into an early grave. [3] The authors [2] look at the socio-economic impact of inter-operable eHealth record and eprescription systems in Europe and at the impacts. They propose generic methodology, methods and tolls for economic evaluation; this speaks to continued synthesis, vision and policy recommendations and adjustments. [2] They also demonstrate investment analysis methods for realistically assessing the business case for eHealth as well as what the different financing options could be. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 5
  • 6. 1.3.23 They demonstrate the business case for new eHealth investment, as follows: - 1.3.24 We are asked to consider whether we are estimating the benefits as well as the real costs attached to eHealth implementation and whether we are adjusting for our optimism bias. Do we include sensitivity analyses in our process of planning and evaluation? [2] 1.3.25 When ESTIMATING THE BENEFITS, they point us in the direction of a range of metrics: * Quality * Access – spatial and social inclusion * Overall economic efficiency gains * Appropriate treatment * Reductions in errors * Avoidance of unnecessary patient visits and examinations * Reducing polypharmacy[3] * Quality control in general. [2] 1.3.26 We are further asked to consider whether we assign monetary values to the benefits – and do we then use actual prices and/or proxies? 1.3.27 Do we consider time savings versus the cost of the full-time equivalents, before eHealth? Do we consider the Time Value of Money, Present Value and Discounted Cash Flows? 1.3.28 We are also pointed to the Markov Chain Approach, which lays the foundation for the creation of economic simulation models. [2] 1.3.29 What is most definitely required in the design, piloting, ideation and implementation of eHealth strategies are: flexibility, clinical leadership, risk management, solutions tweaking because eHealth is not an exact science and lastly, deep pockets and lots of patience. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 6
  • 7. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 7
  • 8. [2] 1.3.30 In summary: eHealth should be crucial to improving healthcare and ensuring quality of care as well as the continuum of care. 1.3.31 It should be viewed as an investment, rather than a cost. Non-financial impacts of eHealth should also be measured in order to make informed decisions – which includes finance deployment. 1.3.32 There is perhaps room to look at reimbursement mechanisms – this may be more difficult within the public health system, but is nonetheless an issue that should be investigated. 1.3.33 A summary of the potential benefits of e-Health: * Access * Quality Improvement * Quality of Life * Patient safety * Save time * Save costs * Modernise healthcare delivery * Improve efficiency of healthcare delivery * Secure transfer of patient information * Reducing the carbon footprint of healthcare. 1.3.34 The Chair opened the floor for discussion and debate: 09:00-11:30 P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 8
  • 9. 1.4 PANEL AND OPEN FLOOR DEBATE/ISSUES RAISED/DISCUSSION POINTS 1.4.1 ACKNOWLEDGEMENTS I did my best to record all delegates who participated and provided inputs to the discussions – but in the first instance, acknowledge all who made the time to attend, to provide inputs during comfort breaks, make new connections, share information and network – and I apologise if I have left anyone out in respect of what I was able to record in respect of specific delegates who provided questions, input and information during Session One: In no specific order: * Rosemary – MRC * Simon – PWC * Minister Makoae – Lesotho * Dr Ivan Bromfield – City of Cape Town * Marago – Lesotho DOH * Prof. Van Greenen – Nelson Mandela University * Aphiwe – WCDOH * Bakang – OFS DOH * Theunis Hurter – Nova * Ethel – Stellenbosch University Nursing Faculty * Alan – Video streaming * Paul Davis * Trish – Datacentrix * Bernard – SITA * Dr Solly Lison – Qualicare * Dr Craig Fredericks – GSM Global * Makago Msidi – Di-Data * Etienne Dreyer – PWC * Cynthia – Botswana Health Informatics * 1.4.2 POINTS RAISED AND DISCUSSED 1.4.2.1 The South African National eHealth strategy has been published and speaks to partnerships and collaboration. It is felt that there is enough global and local research available so as to implement sustainable eHealth solutions. [4] 1.4.2.2 There are strong institutions, such as the Medical Research Council [MRC], SAHIA, SATMA and others – who are and should be working together more closely to establish standards. 1.4.2.3 There is most definitely a requirement for a National eHealth Standards Board. 1.4.2.4 There is a sense, from certain quarters, that eHealth has become “lost in complexity” and that there are no definitive proxies to measure or ways of showing benefits. 1.4.2.5 When implementing eHealth, immense patience and will are required – it could take up to one generation to tweak and adapt a system; persistence is paramount. 1.4.2.6 Mediocre solutions are sometimes better than have no solution at all – at least one can improve on a solution – but to improve, there must be „something‟ in place to start with. 1.4.2.7 Mention was made of the Eastern Cape Telemedicine project, which worked via cloud computing – and how, because of no further budget being allocated, it has ground to a halt – compromising patients and the healthcare system. From that, the conclusion was drawn that one has to insulate eHealth projects against political change and plan for sustainability over the mid and longer terms. 1.4.2.8 The fundamental problem is the healthcare system and health itself – not eHealth on its own. 1.4.2.9 According to Simon Samaha – there are a range of eHealth solutions and it not one industry. He goes on to describe 3 distinct areas of health: 1. Wellness and health –which he feels sits more in the retail space and has to with patient/consumer behavioural changes/modification. 2. Chronic Disease Management. 3. Hospital-based – Diagnostic. 1.4.2.10 Chair: In the South African context with specific reference to the public healthcare system and then more specifically, the Western Cape Department of Health [WCDOH], the care pathways have been specified and the referral pathways have been strengthened over the past 10 years, as part of Vision 2010. This means that 93% of patients [approximately 17 million patient contacts] are seen at Primary Health sites. It is at these sites as well as via the 2800 Home Based Care Workers [ who are responsible for another approximately 4 million patient contacts], as well as in partnership with Non-Governmental Organisations [ NGO‟s] and the private sector, that health and wellness education is at present, to some degree, happening.[5] P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 9
  • 10. 1.4.2.11      In its Draft Discussion Document, 2020 – a Vision for Healthcare in the Western Cape [6], WCDOH deals with a range of issues: It looks at the case for change – and concludes that the compelling motivation for change includes changes in provincial demography, socio-economic determinants of ill health and the burden of disease [BOD], advances in technology and global, national and provincial policy environments that are in the process of change. Sustaining existing good practice and improving in other areas, are seen as key to becoming a world-class health organisation and provider. The focus will be on key priorities and the most cost-effective interventions, given the limited resources available. Planning for Vision 2020 does include policy frameworks, such as the „green paper‟ on the National Health Insurance [NHI], the national Human Resources for Health framework and the provincial Strategic Objective 4 – Improving Wellness. [The purview of wellness falls mostly outside that of the WCDOH and so a whole-of-government and whole-of-society approach and interventions are assumed so as to create future generations that are well and healthy.] WCDOH will focus on prevention and the downstream promotion within the health service delivery platform – this is an important conceptual shift to take note of. Seven [7] principles are proffered to guide the 2020 Strategy: 1. Patient-centred quality of care. 2. A move towards an outcomes-based approach. 3. The retention of a Primary Health Care philosophy. 4. Strengthening of the District Health Services Model. 5. Equity. 6. Affordability. 7. Building Strategic Partnerships.[6] [6] [Source: 2020 – A vision for Health Care in the Western Cape] 1.4.2.12 Simon continues, by pointing out that the solution must be taken to where the problem actually is – and that it must be understood that eHealth can be key n value creation within the healthcare system. 1.4.2.13 Optimised resource allocation could reduce existing waste within the healthcare system by up to 30%. 1.4.2.14 The Honourable Deputy Minister of Health in Lesotho shared the fact there are elements of eHealth in Lesotho, but that for things to move forward and be sustainable, government commitment and policies are required to be put in place. 1.4.2.15 She also spoke to the changing of mindsets within the healthcare system as a whole – also on provider side. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 10
  • 11. 1.4.2.16 She mentions that there was an upgrade and at attempt at instituting an eHealth patient record system, that this was done via donor funding and so after the donor has exited, the equipment is there, but not being used at all – because there was no sustainability planning. 1.4.2.17 Dr Ivan Bromfield pointed out that in the Cape Metro region and WCDOH there is a basic eHealth system or platform – he raised his concern that providers try to „ sell products into the system‟, rather than getting back to basics, understanding where the gaps are and partnering towards finding solutions to plug the specific gaps. 1.4.2.18 Marago from Lesotho Department of Health [LDOH], felt that there has to be a robust framework so as to enable clear cost-benefit analysis of eHealth systems. 1.4.2.19 She also expressed the concern that is universal – capacity of healthcare professionals to firstly, design eHealth systems and secondly, to work within such a system. Training of eHealth professionals is evidently offered in KZN, but the sector should be looking at what is required so as to structure qualifications within the eHealth space. 1.4.2.20 Prof Van Greenen [Nelson Mandela University] pointed out that a national survey of MHealth and Telehealth was done – to establish what is wrong with eHealth in South Africa? The question asked was: Is the technology inefficient? The conclusion from the survey is that a great many health departments and suppliers are coming at eHealth from a „technology push‟ perspective, rather than being patient-centred and designing for the patient and the desired outcomes. 1.4.2.21 Aphiwe [WCDOH] highlighted the need for effective and well-planned change management and issues related to basic computer skills; this has given rise to the action point related to doing a national baseline survey in respect of levels of computer literacy of healthcare professionals within the system – so as to inform a training and implementation plan. Aphiwe again reiterated that an integrated approach is required. 1.4.2.22 Key decision-makers within government must be convinced about the value of ICT in general and then eHealth specifically. 1.4.2.23 There is no specific budget allocation for eHealth for provinces. This is echoed within the South African eHealth Strategy document. [4] 1.4.2.24 Chair: Within the SA eHealth Strategy [4] mention is made that provinces and municipalities have to budget for eHealth – there is no specific budget within National Department of Health for the implementation of eHealth systems. In the opinion of the Chair, this status quo will have to change and specific budget allocations, over a phased number of years, will have to be set aside, once the norms, standards and Enterprise Architecture are in place. Without a separate and dedicated budget or financing strategy, it will be extremely difficult to implement a coherent eHealth strategy and platform on a national basis. 1.4.2.25 Theunis Hurter from Nova highlighted the success of the Anti-Retroviral [ARV] patient record; Nova has worked with government to put this system in place. He indicated that when developing the platform, they gained an understanding of the various healthcare settings with SA and also, what would stop an ARV system from working – and then designed and implemented a system that is practical and operationally implementable. 1.4.2.26 Chair: Expanded on the National Tiered Strategy for ART Monitoring [4] and shared the 3 tiered approach that NOVA had managed to implement within the SA Healthcare system: Tier 1: ART Register: Paper-based – at facilities with no electricity, no computers and less than 500 patients. Tier 2: Electronic Register: TIER. Net – facilities with regular electricity and computers, but no network infrastructure and between 500 and 2000 patients. Tier 3: EMR System – SMARTER – at facilities with network infrastructure and more than 2000 patients. Information is still collated and cascaded upwards into a central repository. This is an example of designing for the unique idiosyncrasies‟ of the South African and African healthcare context. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 11
  • 12. 1.4.2.27 Ethel from Stellenbosch University, Nursing Department, pointed out that when she visited and worked in the United States in the 1990‟s, nurses were already using eHealth systems and it was second nature. 1.4.2.28 She furthermore pointed out that the new generation of healthcare professionals who are coming into the healthcare system, are what is known as „ digital natives‟ – “A digital native is a person who was born during or after the general introduction of digital technologies and through interacting with digital technology from an early age, has a greater understanding of its concepts. Alternatively, this term can describe people born during or after the latter 1960s, as the Digital Age began at that time; but in most cases, the term focuses on people who grew up with the technology that became prevalent in the latter part of the 20th century and continues to evolve today. Other discourse identifies a digital native as a person who understands the value of digital technology and uses this to seek out opportunities for implementing it with a view to make an impact.” [7] These “digital natives” were most born after 1985 – and so there is a tension between these multiplatform, digital savvy generation and the digital immigrants – those of us who were born before the existence and advent of digital technology and who, at best, have managed to adopt use of certain technologies into our life, to some extent. 1.4.2.29 Ethel goes further and postulates that apart from the potential benefits and efficiencies that eHealth brings into the healthcare system, it is becoming vital to have the latest technologies available so as to attract and retain young talent. In her opinion, eHealth will support the system in general and can be designed to be user-friendly. 1.4.2.30 We are again reminded that there are a plethora of technology solutions – video streaming was mentioned specifically – but that these are at best “ islands of systems”, which is one of the issues that needs to be resolved. The industry has to start working together so that there is a continuum of technology. 1.4.2.31 The question was asked whether one could not allow the system to build itself – given the range of technologies available. 1.4.2.32 It was also suggested that an eHealth system or platform could be an “enforcer of compliance” within the healthcare system – nearly as the conscience of the system as a whole. This is based on the notion that “The system is King” and all will work with it – full stop. 1.4.2.33 It was pointed out that the adoption of new technology platforms in smaller organisations are far less complex – the CEO has to adopt a change in style – from firstly achieving consensus of which system would be appropriate, then putting a directive in place and thereafter, become autocratic in respect of the implementation of the system. At a National Health level, such a process would be very different and far more complex. 1.4.2.34 Trish from DataCentrix started off by stating that she had been involved in the eHealth space, conferences, workshops and workgroups for the past 7 years – and that she felt that there was no significant change or forward movement. This is why DataCentrix decided to “take the Nike approach and just do it.” 1.4.2.35 WCDOH and DataCentrix worked together to understand all of the limitations, capacities and requirements and desired outcomes. The secret to the success of the PHCIS system [which has recently won an international award] relates to the open, honest relationship between the provider and WCDOH, as well to content lifecycle management, the fact that they used a web-based patient record – which pharmacists could also access. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 12
  • 13. 1.4.2.36 The system is ICD10 enabled and is HL7 integrated. 1.4.2.37 HL7 also known as Health Level Seven is a non-profit organisation involved in the development of international healthcare informatics interoperability standards. HL7 and its members provide a framework and related standards for the exchange, integration, sharing and retrieval of electronic health information. There is a 2.x version of standards, which supports clinical practice and management, delivery and evaluation of health services – and are the most commonly used globally.[8] 1.4.2.38 WCDOH and DataCentrix analysed the environment, identified what was most needed so that the eHealth platform would be patient-centric and then designed and allowed the system to evolve over time. This was about keeping the patient at the centre and putting personal feelings or agendas aside. 1.4.2.39 Dr Lisson from Qualicare pointed out that they, as a General Practitioner network [600 members all over the province] were not aware of the PHCIS and that it would be very useful to understand the system, so that private GP could make appropriate referrals and even have access to the system so as to make referral notes on the system. 1.4.2.40 Rosemary Foster [MRC] pointed to the “dark side” of eHealth. As a specialist within the eHealth space, she is not in favour of allowing an eHealth system to develop “organically.” It is her contention that allowing for such a process would do more harm than good. Enterprise Architecture is required as the basis of departure. 1.4.2.41 She furthermore indicated that there were very few problems related to the adoption and use of new technology, but that because of the many “false starts” of the past, there was of course some disillusionment. The implementation of an eHealth system, in line with the National eHealth strategy MUST therefore NOT be fragmented. 1.4.2.42 Dr Craig Fredericks, GSM Global [ The platform that enables all mobile communications globally] pointed out that there are already best practice models in place and made mention of the use of mobile and ICT to train 35 000 Community Healthcare workers in Bihar, India. He felt strongly that the implementation of eHealth could be fast-tracked by drawing from existing models and best practice and specifically, the transferability related to technologies that are being used in other developing countries. 1.4.2.43 The concept of “TeleNurse” access in more rural settings would be a huge benefit flowing from eHealth. 1.4.2.44 Makago Msidi from Di-Data spoke about the frustration that she has noticed in healthcare workers, with specific reference to Limpopo province, where she is from. She believes that eHealth would help to re-ignite these healthcare workers, by making the process of care swifter and more practical. 1.4.2.45 1.4.2.46 In her opinion, building a robust business case for eHealth is essential. Emphasis was also put on the process of registering patients onto an e-patient system – it was agreed that there has to be an implementation plan around this aspect, so as not to create more frustration at facilities‟ level, where patients are already exposed to long queues, waiting periods and other inefficacies. It was suggested that there could perhaps be a timeframe for voluntary registration at multiple points. The session ended at 11:30. The content of the discussion has been pulled into the Action points contained within this document. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 13
  • 14. 2. SESSION TWO: FINANCIAL ASPECTS OF IMPLEMENTING EHEALTH AND HEALTH IT PROJECTS 2.1 WORKGROUP OUTLINE/DIRECTIVES 2.1.1 With the increased use of electronic medical records, what technology can be used to ensure efficiency? 2.1.2 Understanding Cloud Computing – How can increasing flexibility reduce costs in urban hospitals and rural areas? 2.1.3 Data Security – Ensuring the Increased Use of IT in healthcare does not affect security of patient information. 2.1.4 Business Intelligence Software – Making the most of information gained from EMR‟s. 2.1.5 Productive Efficiency, Costs and Quality across National Health Systems. 2.1.6 Methods of containing costs. 2.1.7 Cost-effective organisation of hospitals. 2.2 PANELLISTS 2.2.1 .Chair: Amanda Brinkmann – Indigo Business Consulting & Advisor to the Minister of Health as well as Leader of Government Business: Western Cape Government. Head: Strategic Partnerships: Western Cape Government [ Last effective day of tenure with WCGOV] 2.2.2 Dr Simon Samaha – Physician Leader in Europe, Middle East and Africa – PWC 2.2.3 Trish Dicks – Strategic Account Manager: ECM: Public Sector – Datacentrix 2.2.4 Deputy Minister Makoae – Lesotho Department of Health 2.2.5 Aphiwe Mazambo – Health ICT – Western Cape Department of Health 2.2.6 Bakang Oliphant – Senior Manager Strategic Planning, Monitoring and Evaluation – Free State Department of Health 2.2.7 Daniel Jaganath – Snr Account Manager BT Global Services 2.2.8 Marius Conradie – e/MHealth – Vodacom 2.2.9 Riaan van Tonder – Business Development Manager: Solutions: Philips Healthcare 2.2.10 Neil Jordan – Worldwide GM – Health Industry: Microsoft 2.2.11 Francois Pierre De Villiers – Snr Manager – Financial Planning OFS Health 2.3 SETTING THE SCENE AND CREATING CONTEXT – AMANDA BRINMANN – CHAIR 2.3.1 2.3.2 2.3.3 2.3.4 According to a KPMG report [9], Electronic Health Record [EHR] implementation costs are still generally seen as being far too high. According to a survey done by KPMG, mostly in developed settings, more than 50% of respondents, who were already halfway in the process of eHealth implementation, felt uncomfortable with the costs related to implementation. One of the outcomes of the research study clearly shows that healthcare executives miscalculate the real costs of HER. There is a tendency to under-estimate the impact and effort required to fully implement HER and the magnitude of the process is not fully understood – and therefore not planned and costed for. In the United States, the Health Insurance Portability and Accountability Act [HIPAA] compels all medical institutions and practitioners to maintain and store terabytes of data [9] – have we and are we considering similar provisions in South Africa – and do we understand the implications from an ICT infrastructure perspective? P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 14
  • 15. 2.3.5 2.3.6 2.3.7 2.3.8 2.3.9 2.3.10 2.3.11 2.3.12 2.3.13 2.3.14 2.3.15 2.3.16 2.3.17 2.3.18 2.3.19 There is a huge shortage of skilled healthcare IT professionals – do we understand the impact and how are we planning to capacitate the healthcare system with the necessary skills to manage eHealth strategies and implementation plans? Is it possible for us to customise, cheap, off-the-shelf platforms, rather than having to design whole new systems? Do we understand all that is „out there‟ on open source and freeware platforms? What are all of the financing options for eHealth – what about vendor/leasing contracts, where the risk is carried by all of the partners? Cost and Return on Investment – ROI – are recurring themes – how do we measure these issues and how do we compensate for the inevitable lost productivity during implementation + the additional staff or maintenance costs required? [ As with LEAN or any other change management process, it is widely known that „ things become worse, before they become better‟ during the transitional, implementation phases] The National Health System [NHS] in the United Kingdom, has partnered with the MRC, and has created four national eHealth research centres. This has been done based on the understanding that the co-ordination and analysis of huge amounts of information, with the intent to design better treatment protocols, improve drug safety and optimise resources, is an extremely complex and difficult task. No one organisation can achieve these outcomes on its own. This project will combine the NHS patient health records with other research data, social and clinical data so that a fuller picture of each individual is formed – so as to move towards true patient-centricity. Is this something that we should build in at inception of an eHealth platform in SA – overlaying Home Affairs and other databases and creating individual profiles of every South African – beyond just their health status? Cloud computing: - this is hardware and software available over the Internet. Central to using cloud computing services is the notion of entrusting remote services with users‟ data, software and computation. There are various service offerings in the cloud: * Infrastructure as service * Platform as service * Storage as service * Security as service and so on. The end user requires a web browser, light weight desktop [thin client] of mobile device to work in the cloud. Cloud computing allows for economies of scale – cost sharing and savings – and essentially amounts to being converged infrastructure and shared services. It furthermore has the following potential benefits: * Agility * Cost savings * Device and location independent * Reliability * Scalability * Elasticity * Security – this seems like an option that requires deeper investigation and a policy decision within the eHealth context. In their research article titled: The Economics of eHealth and mHealth [10], the authors point out that there is currently no global consensus about what Productive Efficiencies actually mean and how it should be measured. There is no consensus on what constitutes efficiency, how to measure it and what actions should then be taken to improve efficiencies. There is a very definite need for a universal framework, definition of terms, uniform sampling methods and the recognition and there not necessarily direct causality between cost and quality in the healthcare system in general. A decision must be taken about which elements of healthcare we value – those must be agreed and measurement metrics put in place accordingly. The key economic and financial questions to be answered in developing countries are directly related to the ability to measure outcomes and ROI. There is growing evidence of the potential benefits of eHealth and mHealth – but little or no research available of the economic impact of such investments in lower and middle-income countries. [10] P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 15
  • 16. 2.3.20 It is felt that there is insufficient data/research in developing country settings, to reach “generalizable” conclusions so as to guide investment decisions. [10] 2.3.21 The authors call for a roadmap to be created in respect of how research could be used as a tool to establish the true cost and benefits of eHealth systems. [10] 2.3.22 In general, we HAVE to plan, cost out and understand the potential impact of eHealth on healthcare costs in general – what will the short term increase in costs be and how do we measure these short-term costs/investments against the long term benefits and how are we apportioning value throughout the delivery chain? 2.3.23 Are there low-cost eHealth technologies that are suitable to low resource settings? 2.3.24 In respect of the Drivers of costs, we need to consider and plan for the following: * Upfront investment in infrastructure - as a fixed or variable cost * Cost of connectivity and telecommunications * Economies of scale – can it be achieved and how? * PPP‟s – not necessarily in the traditional format – more in line with partnering related to end-to-end systems, where risk and responsibilities are shared * Clinical as well as social outcomes – we have to create reliable conversion factors. 2.3.25 In conclusion – there is a need build an evidence-base, research case, economic studies and a framework within which to function – to which all role players should continue and „ subscribe‟. 2.3.26 The Chair opened up the discussion – by asking each of the panellists to „ state their position‟, where they feel they could contribute and then opened the debate for the floor. Session time: 11:30-13:00 2.4 PANEL AND OPEN FLOOR DEBATE/ISSUES RAISED/DISCUSSION POINTS 2.4.1 ACKNOWLEDGEMENTS I did my best to record all delegates who participated and provided inputs to the discussions – but in the first instance, acknowledge all who made the time to attend, to provide inputs during comfort breaks, make new connections, share information and network – and I apologise if I have left anyone out in respect of what I was able to record in respect of specific delegates who provided questions, input and information during Session Two: In no specific order: * Rosemary – MRC * Simon – PWC * Minister Makoae – Lesotho * Marago – Lesotho DOH * Prof. Van Greenen – Nelson Mandela University * Aphiwe – WCDOH * Bakang – OFS DOH * Riaan Van Tonder * Ethel – Stellenbosch University Nursing Faculty * Trish – Datacentrix * Bernard – SITA * Dr Solly Lison – Qualicare * Dr Craig Fredericks – GSM Global * Makago Msidi – Di-Data * Etienne Dreyer – PWC * Cynthia – Botswana Health Informatics * Daniel Jaganath – BT Global * Prof Jutz Marks * Lionel Benting – ICT – Department of the Premier – WCGOV * Ian de Vega – Health ICT: WCDOH * Amano Majobakwana – Ghana * Pearl – SA Legal Association 2.4.2 POINTS RAISED AND DISCUSSED 2.4.2.1 Marius from Vodacom opened the discussion by agreeing that the cost and complexity of eHealth implementation is most definitely under-estimated. In his opinion, eHealth is reaching a tipping point, which will nearly force the 3 industries or component parts to come together: P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 16
  • 17. ICT – EHEALTH + MHEALTH – DECISION SUPPORT AND PATIENT CENTRED, QUALITY HEALTH OUTCOMES ENABLER HEALTH FACILITIES AND PROFESSIONALS – PRIVATE AND PUBLIC SECTORS – DIAGNOSE AND TREAT – BASED ON EHEALTH AS ENABLER ELECTRONIC HARDWARE + DIAGNOSTIC EQUIPMENT – LINKED TO MOBILE – LOWER COST HARDWARE AND EQUIPMENT CONVERGENCE AROUND 3 LAYERS: COMMUNICATIONS, INFORMATION, MANAGEMENT – INTERCHANGE OF KNOWLEDGE TO ADD VALUE – THIS „RELATIONSHIP‟ MUST BE CONFIGURED AND A BASIC TOOLKIT DEVELOPED, WHICH COULD BE CUSTOMISED FOR DIFFERENT SETTINGS 2.4.2.2 Riaan van Tonder – Philips Healthcare, stated that one has to look at the national health plan and determine what would be “appropriate technology” for the specific market. 2.4.2.3 He wondered, out loud, whether there is a true and real will to partner, that such partnerships are ill-defined and raised concerns regarding risk sharing, the cost of leasing equipment and the fears of providers related to dependable payment – given the less-than-good financial track record of the majority of health departments in South Africa. Without financial security, eHealth systems could be „switched off‟ in the event that payment is stopped. This is a risk that needs to be mitigated and securitised. 2.4.2.4 Trish from DataCentrix focused on the issue of African-centricity – rather than importing solutions from abroad, custom designing and creating knowledge in Africa for Africa. 2.4.2.5 In her opinion, the cost-benefit is “easy to measure – by asking, what is the level of service as experienced by the patient.” 2.4.2.6 She furthermore stressed the fact that to design and implement successful eHealth systems, planning and budgeting with your partners are essential – this is what has made the DataCentrix/WCDOH partnership work. 2.4.2.7 There continues to be a strict and rigorous programme management and all deliverables have been clearly defined up-front. 2.4.2.8 She also reminded all delegates that, “if you can‟t explain it in simple terms, then you don‟t understand what you‟re doing or what it is.” 2.4.2.9 Minister Makoae – Lesotho Department of Health felt strongly that the private sector must be more empowered by government to do the things that governments are not good at – she felt that eHealth is one of the areas where the private sector should play the leading role. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 17
  • 18. 2.4.2.10 2.4.2.11 Simon from PWC reminded us that health and healthcare are indeed local issues. In his opinion, ObamaCare is not causing any to change materially within the United States, with reference to the eHealth systems requirements and incentives offered by the US Government. Some hospitals and health facilities are not prepared to make the investment and see no value, besides the fact that the government incentives do not come close to covering the actual cost of implementation. 2.4.2.12 In other cases, health facilities and professionals simply view eHealth as a “must have” – and rather than expecting a direct ROI, view eHealth as part of the cost of doing business and as a driver of mid- to long-term efficiencies and savings. 2.4.2.13 He also briefly spoke about the EPIC eHealth platform – where the brand owners do a due diligence on the clients they are prepared to work with and only then, will they partner and implement their system. 2.4.2.14 Daniel Jaganath – BT Health – spoke to the fact that BT Health has been involved in operationally functioning health systems for quite some time. There is Framework – modelled on the work done for the NHS – and that there are possibilities to partner with BT Health so that the mistakes that were made during the genesis of their eHealth implementation process, are not repeated in South Africa and Africa. He essentially recommended that the existing Intellectual Property [IP] should be leveraged, so that there is no duplication. 2.4.2.15 He agreed that there will always be a need for customisation, but that the basics can be drawn from best practice. 2.4.2.16 He also spoke to the Virtualisation environment, with specific reference to Cloud Computing and the integration with GSM networks – and indicated that technology to deliver patient care exists, via an entry network, spine or health cloud – and that the framework or platform is built off the spine. 2.4.2.17 Aphiwe – WCDOH – reiterated the fact that patient-centricity remains at the heart of how WCDOH will be moving forward in strengthening the eHealth platform. He invited all delegates, but specifically the Minister from Lesotho, to visit the Khayelitsha Hospital, so as to experience, first-hand, the impact of the best practice in design, construction, lay-out, structuring of services and efficiencies related to a comprehensive eHealth system that is functioning. 2.4.2.18 He felt that moving to Cloud computing is a very real and practical option in eHealth. He also indicated that the roll-out of ECM could be made cost-effective, using cost-sharing models, which combines outsourcing with the use of internal staffing. 2.4.2.19 Bakang – OFS DOH – stated that in his opinion in the healthcare system, there are 2 elements: 1. Those whom render patient care 2. Everything and everyone providing support to those that render care. 2.4.2.20 He therefore felt that eHealth must “fit into” the system so as to mitigate against the costs and inefficiencies related to the current paper-based system and that it must be viewed as an enabler of improved healthcare delivery. 2.4.2.21 Prof Van Greenen – Nelson Mandela University – confirmed that they have been working with the CSIR and DOH to create standards for inter-operability. There is however a concern about the isolated manner in which various projects, programmes and issues are being dealt with – this echoes the sentiments expressed by a great many of the delegates and is furthermore supported by global research and academic reviews. 2.4.2.22 Prof Jutz Marks discussed an application called “Fear Fighter” which assists in the treatment of anxiety disorders. According to Prof Marks, we are at the place in time where it is all about “the birth of new solutions.” 2.4.2.23 He added that when looking at cost-benefits and cost containment, it becomes sensible to partner with the private sector, with specific reference to risk sharing models and technical support. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 18
  • 19. 2.4.2.24 He pointed the delegates to the very successful Lesotho PPP model, where an honest, independent, intermediary or broker was used to facilitate the process and to ensure that there was no political interference, corruption and that the project was rolled out as effectively and efficiently as possible. 2.4.2.25 Lionel Benting – DOTP WCDOH – pointed out that unfortunately, not all browsers are equal. This is however not an insurmountable problem. He also indicated that a thin client solution was currently being rolled out in the province and that cloud computing is most definitely a viable option. 2.4.2.26 Amano Majobakwana from Ghana stated that eHealth has not been leveraged in Ghana at all, due to financial constraints. 2.4.2.27 She spoke to donor funding that led to a Teleconsultation pilot project – but that, in her opinion, one starts suffering from what she called, “ pilotitus” after a while – and that sustainability remains one of the central issues with these projects. Once donors withdraw, the projects fall flat. 2.4.2.28 Pearl from the SA Legal Association raised question around patient confidentiality and safety as well as the amount of information that would need to be captured. She approached this from the medico-legal perspective, so as to understand the implications of eHealth. 2.4.2.29 The Chair discussed the variety of ways in which patient information can be captured rapidly – from using digi-formats of documents with digipens, to touchscreen technology and in some instances, there might be a requirement for information to be manually captured. Whilst this may take time when the patient has to be registered, the once off inconvenience should be cancelled out by the convenience and benefits in the longer term. 2.4.2.30 Simon from PWC pointed out that “there is nothing LESS secure than paper-based charts” – and that electronic security platforms and systems have been proven as completely secure and safe. 2.4.2.31 He ended off the session by leaving the delegates with the realistic statistics – that they should allow for at least 25% decrease in productivity within the first 6 months of eHealth implementation, but that it is worth it in the long term, when the system starts to flow and the benefits start accruing. The session ended at 13:00. The content of the discussion has been pulled into the Action points contained within this document. 3. GLOBAL TRENDS IN MOBILE USAGE AND MOBILE HEALTH – ADDITIONAL BRIEFING: CHAIR 3.1 DIY HEALTH – GLOBAL TREND 2012 In 2012, Trendwatching [11] looked at the emergence of DIY Health care and set the tone of their report as follows: “ DIY goes „ good for you‟ in 2012: novel apps and devices will increasingly let consumers discreetly track and manage their health by themselves.” They predicted that the DIY trend in Health would not slow down during 2012. The report spoke about the two kinds of DIY health: 1. The kind that most consumer HATE and 2. The kinds that they love. It was predicted that the latter category would be driven by innovation driven by technology and very importantly, by the need of the consumer to be in control. At the time of issuing the report, there were 9000 mobile health applications [including nearly 1500 cardio fitness apps, over 1300 diet apps, over 1000 stress and relaxation apps, over 650 women‟s health apps and by mid-2012, the number of apps was expected to reach 13 000. [13] P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 19
  • 20. Countless new apps and devices are actively targeting consumers who are keen on preventing, examining, improving, monitoring and managing their health. Mobile health and these kinds of applications, where the patient or consumer takes an active role in their health status, of course also means that there is more than likely a reduction in the number of visits to medical professionals and facilities and these applications provide more convenient and accessible ways for a doctor to “keep a remote eye” on troublesome conditions and changes in patient health status. [11] EXAMPLES OF TECHNOLOGIES, APPLICATIONS AND DEVICES:.  Released in November 2011, Jawbone‟s Up is a wristband personal tracking device that tracks a user‟s moving, eating and sleeping patterns. The device syncs with an iPhone app, and users can set the device to vibrate when they have been inactive for a period, compete against friends and even earn real life rewards for completing activity challenges.  Pain Free Back, an interactive back pain relief product, lets users enter specific data as they‟re taken on a guided discovery about their back pain. Exercise solutions are offered afterwards. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 20
  • 21.   The Play It Down app enables users to test their hearing. The app offers several interactive features including 'The Ear Knob' that lets friends compare who can hear the highest frequencies, and 'The Volume Zone' which measures sound volume in decibels. The Digifit Ecosystem is a suite of Apple apps designed for those with an active lifestyle. It can record heart rate, pace, speed and power. Data can also be uploaded to and managed via training sites such as Training Peaks and New Leaf. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 21
  • 22.  Withings' Blood Pressure Monitor plugs into an iPad, iPhone or iPod Touch and takes the user‟s blood pressure. Data can be sent directly to a doctor or published (confidentially) on the Web.  Skin Scan is an app which allows users to scan and monitor moles over time, with the aim of preventing malignant skin cancers. The app tells users if a visit to their doctor or dermatologist is advisable.  Lifelens has created a smartphone app to diagnose malaria. The app can analyse a magnified image of a drop of blood (captured via a simple finger prick) and identify malarial parasites. As mentioned, these are a small selection of examples of the rise of mobile health technology and applications. Things start becoming rather more interesting, when looking at the 10 top consumer trends predicted for 2013. [12] 3.2 CONSUMER/PATIENT TRENDS – 2013 – TO KEEP A KEEN EYE ON In the report titled, 10 Top Consumer Trends predicted for 2013 [12], the tone is set by stating that the next 12 months will be the perfect storm of necessity combined with opportunity. The global economy has been remapped, new technologies are emerging, or the use of “old” technologies applied in new ways and new business models are emerging. I have attached a full copy of the report, separate to this P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 22
  • 23. briefing document – for the purposes of mobile and eHealth; the following predicted trends should be of interest and value in the eHealth space: 3.2.1 TREND 3: MOBILE MOMENTS “Lifestyle multi-if-not-hyper-tasking: why micro-convenience, mini-experiences and digital snacks will rule in 2013” [12] This trend predicts that consumers will be looking to their mobile devices to maximise every moment in their life. It embraces the notion of lifestyle multi and hyper-tasking. EXAMPLES OF MOBILE MOMENT TRENDS, APPLICATIONS AND PROJECTS: P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 23
  • 24. 3.2.2 TREND 5: APPSCRIPTIONS “digital technologies are the new medicine” This trend is premised on the fact that doctors and physicians are turning to health applications and services to improve healthcare delivery. There has been a huge rise in the use of DIY healthcare applications since 2012. As predicted in 2011, there are now, at the end of 2012, over 13 000 healthcare applications in the Apple AppStore alone and so now, the challenge for the patient/customer lies in finding those applications that are accurate and safe. These are important to patients, as this concerns their health. Consumers are therefore turning to medical professionals and medical institutions to certify and curate mobile health applications and doctors are increasingly „prescribing‟ mobile applications as part of the course of treatment for the patient. For health providers, these digital „medicines‟ hold the promise of cost reduction by making consumers more aware of their health status, improving compliance and treatment adherence as well as having the ability to monitor the patient and pick up early warning signals. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 24
  • 25. The under-lying trend remains: Mobile-driven service Delivery EXAMPLES OF APPLICATIONS: P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 25
  • 26. 3.2.3 TREND 7: DATAMYNING “why consumers want „good‟ data and not „big‟ data” Data is the new resource and the consumer will start demanding their share of its value. In the past, the “big data” discussion was focused on the value of consumer data to businesses and brands. Savvy consumers are now however starting to reverse the flowing, seeking for their own lifestyle data to be put to good use by brands and companies. It is predicted that consumers will increasingly expect, if not demand, that brands and companies use their personal data pro-actively, by offering the consumer assistance, advice on how to improve their behaviour and/or how to save money. The caveat here is that the consumer wants to feel served, in a real and personal manner – not watched, as though by some „Big Brother‟. EXAMPLES OF MOBILE APPS AND PROJECTS: P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 26
  • 27. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 27
  • 28. 4. IN THE FINAL ANALYSIS: PARTING SHOTS It is clear that eHealth and mHealth are not a nice-to-have, but rather must-have technologies in order to improve overall quality of healthcare services delivery, save costs, time and strengthen the health system. From the actions points, the knowledge that was in the room during the Forum, the plethora of global research, standards and frameworks that exist, that there is concerted effort required to pull together one South African and African Body or Organisation, which would act as the central repository of information and would crowd all of the existing knowledge, information, standards, case studies and best practice models and create frameworks, policies, enterprise architecture, cost-benefit analysis models and implementation plans, all of which would be appropriate for the South African and African context. My final recommendation is that all of the delegates review the action points, that we reach consensus on who is prepared to champion specific action points, that we set realistic timelines, given that doing such work would be over and above the daily duties of such „champions‟ and assemble workgroups to assist in moving the agenda forward in a practical manner. If we do not agree on firm action points, outcomes and timelines, we run the risk of following the global trend, which is to continue research, having on-going talk-shops in isolation of the larger systems view P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 28
  • 29. and not actually arriving at the place where we have all of the tools in place to move forward decisively. It has been my ABSOLUTE privilege and honour to chair these two panel sessions, to meet new minds, to reconnect with old friends and to be a small cog in the much larger engine that is driving the ICT/technology/eHealth agenda forward. In my opinion, we have the opportunity to take hands and to fast-track the process of using technology to empower growth and developmental outcomes in our country and region. Thank you again to all who attended and participated. I have learnt much – and that always makes me happy. Sincerely and with warm regards AMANDA BRINKMANN DIRECTOR: INDIGO BUSINESS, MARKETING, MANAGEMENT CONSULTING DEFINING, UNTANGLING AND SOLVING „THE MESS‟ *  “ A mess is the future implicit in the present behaviour of the system” P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 29
  • 30. REFERENCES: AFRICAN E-HEALTH ECONOMICS FORUM – PANELS ONE AND TWO [1] Berman, P; Bitran, R. May 2011. Health System Analysis for Better Health System Strengthening. World Bank Report . Health, Nutrition and Population Discussion Document. Appendix A: Excerpts Stroetmann, K, A; Dobrev, A; Jones, T. 3 November 2008. Assessing socio-economic and clinical benefits from eHealth solutions – approach and evidence. eHealth Planning and Management Symposium, Kopenhagen. [2] Brinkmann, A. November 2012. Concept Proposal: Empirical Pilot Project: Reducing and Managing the Burden of Disease, Chronic Medications and Improving Patient Quality of Life through a Training Partnership in Pharmacotherapy: Effecting significant immediate and long-term cost-savings to the healthcare system. [ Unpublished] [3] National Department of Health: South Africa. September 2012. eHealth Strategy South Africa. Full document appended. [4] [5] Western Cape Department of Health. Annual Performance Plan 2012-2013 [6] Western Cape Department of Health. November 2011. 2020 – the future of Healthcare in the Western Cape. A Draft Discussion Document. [7] Define: Digital Natives. Wikipedia.org. Accessed November 2012 [8] Define [9] Health Level 7: HL7. Wikipedia.org. Accessed November 2012 InformationWeek – Healthcare. July 2012 Schweitzer, J; Synowiec, C. 2012. The Economic of e Health and mHealth. Journal for Health Communication. [10] [11] Trendwatching. 2012. DIY Health – Trend Briefing [12] Trendwatching. November 2012. 10 Crucial Consumer Trends 2013. Full summary report attached. [13] MobiHealthNews. September 2011. Mobile Health Applications Research report. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 30
  • 31. [1] APPENDIX A: EXCERPTS HAS FOR BETTER HEALTH SYSTEM STRENGTHENING P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 31
  • 32. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 32
  • 33. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 33
  • 34. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 34
  • 35. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 35
  • 36. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 36
  • 37. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 37
  • 38. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 38
  • 39. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 39
  • 40. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 40
  • 41. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 41
  • 42. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 42
  • 43. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 43
  • 44. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 44
  • 45. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 45
  • 46. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 46
  • 47. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 47
  • 48. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 48
  • 49. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 49
  • 50. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 50
  • 51. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 51
  • 52. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 52
  • 53. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 53
  • 54. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 54
  • 55. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 55
  • 56. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 56
  • 57. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 57
  • 58. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 58
  • 59. P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625 Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663 E-mail: ab_indigo@iafrica.com Page 59

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