The major global health issues require an approach at various domains and levels. One of the challenges: translating the possibilities of scientific progress, biomedical technologies, and digital health technologies into applications that work in the field.

The most vulnerable are still too often deprived of access to quality health care, especially in poorer countries that lack many resources that are considered evident in more prosperous regions.

How can we solve this, taking into account the significant differences between countries and cultures? After all, you can’t just apply a vision from the West to the health systems of poorer countries. First and foremost, you have to understand these systems well, says Dr. Elies Van Belle.

Elies is the general manager of Memisa and was one of three speakers at “The 5th Table on Health Tech.” At the event, which focuses on global health, she debated the topic with Dr. Paul Stoffels and Dr. Alain Widdowson. In this interview, Elies provides some insights into what is going on in the field and what factors make access to modern health care and health tech more challenging in low- and mid-income regions.

As in the interviews with the two other speakers, data, electronic medical records, and infrastructure are never far away.

It is necessary to know the other’s system before trying to change it and consider ALL the different elements required to make a system function.

Integrated support of local health structures

Elies, you have been working at Memisa for almost ten years and are the general manager for a year and a half. Memisa is a medical NGO working in medical development cooperation and has its roots with the Belgian missionaries. But today, so many decades later, it is no longer about charity at all. What is it about then?

Elies Van Belle: With Memisa, we try to support local health structures and their staff sustainably over the longer term.

There is a district health system in most African countries where healthcare is organized based on where people live, a bit like the NHS in the UK. The local health system consists of health centers that constitute the first line and hospitals to which patients are referred for anything beyond the capacity of the first line. Each district is managed by a management team, the district health team, which coordinates the system, and among other things, ensures that medicines are supplied so that they are available in each structure.

Our mission is to support that whole system, together with the management team (the local health authorities) and the staff of those health structures.

The largest pillar in that mission is to improve the supply of health and medical care. That means infrastructure, medical and other equipment, medicines, transport, and consumables.

In other words, everything that is needed to organize health care physically, including water and electricity. For the latter, we are increasingly working with sustainable solutions such as solar panels.

In addition, we support personnel who have to organize and provide health care. So it’s not only about the supply and quantity of health services but also about quality.

And that’s where support for the ongoing training of personnel is essential. This primarily concerns medical and paramedical personnel but also technical personnel such as biomedical staff to maintain the equipment.

This component is organized in collaboration with the government and local health authorities. However, here we also work with organizations such as Doctors Without Vacation, the development cooperation of Gasthuisberg (LUMOS-UZ Leuven, the largest university hospital in Belgium), and local experts to try to get specialists on the ground to provide practical and theoretical training.

We also look at good governance at all levels of the health system. That starts with the local community, society, organization of the health center, and how the population is involved in it. It further includes support of the local health authorities, and the feedback to the Ministry of Health, so that experiences about the implementation of the health policy can help adjust and improve it.

This involvement of local civil society is essential to our work. In this way, as an international NGO, we try to strengthen the local NGOs, which is anything but evident in the most fragile states.

The third pillar of our work concerns better responding to the population’s demand for healthcare and increasing international solidarity.

On the one hand, we are looking at financial accessibility and solidarity mechanisms to lower the threshold for access to care. On the other hand, we raise awareness among the Belgian population about the great inequality in access to quality health care.

Among the activities and projects we have here is our “Hospital for Hospital” program (“Ziekenhuis voor Ziekenhuis“), a network of some fifteen Belgian hospital umbrella organizations committed to supporting a hospital or health zone in Africa, both financially and by mobilizing and raising awareness among their surroundings.

For historical reasons, we work mainly in Congo, where we support twenty-five health zones, but we are also active in Burundi, Guinea, Mauritania, and Benin. And we have a project in India.

You are using medical infrastructure that has been in place for some time. Sometimes it gets modernized, and occasionally additional/new infrastructure gets built?

Elies Van Belle: In the first instance, we have to try and improve what already exists, but quite a few health centers are literally mud huts, and you can’t organize healthcare in them properly.

So we primarily focus on refurbishing and modernizing, but we have also built many new structures, but of course, this requires a considerable budget. So if the resources allow, we put fixed structures equipped with solar panels and a system for water collection or a borehole nearby.

Digital applications can motivate people to collect better data and process that data better so that the margin of error is smaller and analysis becomes easier (Elies Van Belle)

Digitization for development: data as asset and challenge

Memisa is also committed to health tech, the theme of the event, and digital transformation. You won the ‘Digitalization for Development’ (D4D) prize for a ‘smart glasses’ project in the fight against maternal mortality.

Elies Van Belle: That’s right. For us, digitalization is mainly about how we can improve quality through technology.

Our mission is to improve access to quality health care for all, and in this context, the fight against maternal mortality is a priority for Memisa.

Last year, together with Iristick, Avanti, and the Institute of Tropical Medicine, we set up a project with smart glasses in the Democratic Republic of the Congo.

The initiative allows a doctor to follow along remotely and assist the nurse or midwife who is wearing smart glasses to refer to the hospital in time to perform a C-section if necessary. We tried this out with the intention of testing whether or not, and under what conditions, a high-tech solution that is very performant in “lab” conditions can contribute to improving the quality of care in the context of rural Congo.

Memisa Director Elies Van Belle (right) receives the D4D prize for the Smart Glasses 4 Health telemedicine project in DR Congo – picture source and courtesy Memisa

What do you see as critical issues and challenges related to digitization in the field?

Elies Van Belle: There are many issues, but data quality is a critical one. Wrong data remains wrong, whether it is on paper or available in the cloud. I noticed that Paul and Marc-Alain also mentioned data in their interviews.

Digitization is not the solution to that problem, but it is a means. Digital applications can motivate people to collect better data and process that data better so that the margin of error is smaller and analysis becomes easier. If data can be shared and analyzed more quickly, mistakes can also be discovered more quickly.

We use a software system that organizes various data around health, such as statistics on diseases and medications. I am talking about Congo now, but many other countries use the same system at the level of the Ministry of Health – District Health Information System or DHIS2 (note: the open-source health information management project is used in more than 60 countries)

We analyze the data in DHIS 2 and use it to collect our own data, results, and indicators of interventions. In this way, they become visible to everyone, can be easily analyzed, and we can link  them to geographical data to visualize them in maps.

A second challenge concerns data at the patient management level. In most Western countries, we take that for granted. In Belgium, we even have access to our medical data through our national register number. But in Africa, that is a huge challenge and very rare. Moreover, if it is set up in a hospital, it often doesn’t last either because the technology doesn’t evolve, computers need to be maintained, networks are often not stable, etc.

Better access to digital resources – so that it is possible to work everywhere only with computers or mobile applications – is therefore certainly also a challenge.

Marc-Alain pointed out the challenge of diagnostics and a lack of data for long-term analyses, finding links between diseases, excess data, and so on. How could this be addressed?

Elies Van Belle: We only have the figures from the health structures, but that gives an incomplete picture because there is no central register of deaths and births.

For example, we cannot link mortality to pregnancy or other data based on health statistics because many deaths occur outside the health structure. Currently, you can only get ‘a posteriori’ data by punctually conducting extensive population surveys.

For shorter-term data, it is best to work with samples and to set up a high-performance system in a few places. But you also need to deploy people and resources for this because it does not exist in most areas.

There are certainly more mHealth opportunities, but training healthcare providers and patients is essential to succeed since people need to understand the added value of an application.

Mobile solutions: searching for locally supported applications

In Africa, mobile penetration is generally high. To what extent are you focusing on mobile health applications and mobile in general?

Elies Van Belle: Mobile phones are indeed an opportunity because just about everyone has one. We work with them a lot ourselves, and not only for medical purposes.

There are also many logistical and financial follow-up opportunities, such as scanning, uploading, and sharing supporting documents and receipts, because this is an essential requirement when working with external funding. And the same goes for continuing education in health. For example, the Institute of Tropical Medicine Antwerp has developed the Wanda application used in training.

There are many possibilities for transmitting information via cell phone, and this is still underutilized.

There’s an increasing number of ‘real’ mHealth applications in Western countries that allow patients to be monitored, for example. Are there also more possibilities here in Africa, or are there obstacles that we perhaps know less about here?

Elies Van Belle: We have experience with simple mobile applications. For example, for diabetes, a growing problem in Africa, we have developed a project to remind patients via SMS to go for a check-up on time.

There are certainly more opportunities, but training healthcare providers and patients is essential to succeed in this regard. People need to understand the added value of such an application. In our society, we have much more access to information and knowledge from the medical world. But here, patients and providers need to be sensitized, educated, and given the necessary information about why you are doing something and how it is used. Don’t forget that education is often low, and there is very little access to technology per se.

You also don’t have a mobile network everywhere, especially in rural areas, so you have a group that you don’t reach. When introducing new technologies like mobile applications, you have to pay extra attention to reaching the most vulnerable. Because they either don’t have a cell phone at all, or they fall by the wayside for other reasons. You then only reach people with your application whom you would reach anyway. That’s definitely a focus, also in terms of other technologies.

You almost have to go and look on the spot and find out in each specific situation what the needs are and what the people themselves propose. If you make an effort to talk to the people involved, from the nurses and the population to the village leader, you sometimes come up with solutions that you would never have thought of. The reality of these people is entirely different from ours. 

The importance of a strong foundation and a solid understanding of other systems

How has the current pandemic been experienced in the countries where you are active?

Elies Van Belle: When COVID broke out, we were distraught. What would happen in Africa if even our Western performing health systems came under such pressure? It seemed like a disaster was hanging over our heads.

Fortunately, that didn’t really happen, for various reasons, including that there are far fewer older people and people mainly live outside. With Memisa, we have been able to move quickly in our projects and bet on preventing transmission and protecting medical personnel. But the measures issued by the government to prevent the spread often had more pernicious consequences than the disease itself.

The vast majority of the population lives on what they earn each day, so that system came under great strain when all circulation and retail sales were suddenly banned. The most significant number of deaths are in the major cities among the more affluent middle classes.

The epidemic has also shown again that it is essential to have a strong base. Where you don’t have primary health care and a system that can take care of the population for the diseases they have now, you can’t cope if there is a higher demand in case of an epidemic as we experienced in the past, for example, with Ebola in West Africa. 

What is most needed in DR Congo at this time?

Elies Van Belle: Like everywhere else in the world: vaccination! At first, we were cautious about raising awareness about vaccination because resistance is very high, and social media and anti-vax campaigns are powerful.

That has improved, there is more political will, the president of DRC, for example, recently publicly vaccinated himself and called on his countrymen to do the same. But there are other factors to consider, first of all, the availability of vaccines. In West Africa, this is already the limiting factor, and no doubt it will soon be the same in most African countries.

Where you don’t have primary health care and a system that can take care of the population for the diseases they have now, you can’t cope if there is a higher demand in case of an epidemic.

The event is partly about making scientific innovations accessible simply and inexpensively in poorer countries worldwide. However, we must also look at the specific situation, as you nicely demonstrated. In the conversation with Marc-Alain, we identified lessons that we in the West can – at least – think about by looking at other countries. What do you think?

Elies Van Belle: Definitely. We often look far too little at the win-win situation, at what we can learn from how others do it. It’s about such different health systems, and yet too often, we want to improve another system by exporting our system.

It is necessary to know the other’s system before trying to change it and also consider ALL the different elements required to make a system function. Just think of what it takes to make a small hospital function: it’s not just medical staff, equipment, and medicine, but also water, electricity, a job to make it, a school for the clinician’s children, and so on.

No doubt we will hear more about that at the event. Elies Van Belle, thank you for your time and insights.

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Top picture source Memisa, all other pictures property of their respective mentioned owners.

Other interviews at the occasion of “The 5th Table on Health Tech” 2021

Interviews conducted at the occasion of previous 5Th Conference events on healthcare: