Blogs posted for Asian Development Bank (ADB)

Without incentives, health data sharing systems don’t work for patients

Published July 1 2016

In the multi-payer systems that characterize primary health care in Asia and the Pacific, both developed and developing countries suffer a way of delivering care that works against data sharing.

Even in Hong Kong, China—which has one of the highest standards of health care in the region—services are rendered without a sharable electronic medical records system, as I witnessed in a recent encounter with the medical profession that gave me first-hand insight into the matter.

Like 70% of Hong Kong’s population, I get my primary health care in the private sector. After a recent well-woman check-up with my family doctor, she sent me to a specialist, with a printed letter and photocopies of my test results. The specialist subsequently typed up and posted back his reply, explaining his diagnosis and course of action. Now both doctors had the same sheets of paper in my medical records. Meanwhile, the specialist my doctor recommended was not the same one who had provided my obstetric care, as well as periodic check-ups, over the past 17 years.

Now there were three doctors, with consulting rooms within walking distance of each other, all of who know me, and had important information about my reproductive health (and illness)… and no formal way to share the data with each other.

So I shared the data myself – I delivered the referral specialist’s handwritten notes to my longstanding gynecological care provider so he could put them in his paper records. This is what happens in Hong Kong’s private medical sector, which delivers the most expensive—and arguably the most patient-centric—primary care in the territory. The only reason all three of these doctors are now up to speed on my health is because I took it upon myself to make that happen. This is not a typical way that patients in Hong Kong deal with their health records, if they even see them at all. Usually this data is simply not shared with them or anyone else because there is no mechanism for that to happen.

Had I been part of the minority who access primary care at a Hospital Authority (HA) outpatient facility, every encounter with any health worker would have been logged in the HA’s excellent electronic medical records system. My health data would be available for easy retrieval at any point in the future. What the HA’s system can’t do, though, is tap into private sector medical records, where the vast majority of primary care happens in Hong Kong.

In March 2016 the Hong Kong, China government launched its Electronic Health Record Sharing System. It didn’t seem to create much of a splash, so I was intrigued. There is a system for data sharing after all. But leaving aside the baffling instructions for patient registration, there is another major constraint – I can register as a patient, but there is no mechanism for me to check whether or not any of my private providers have signed up, and even participating providers may not be able to share all the data they have due to “technical constraints and readiness.”

When I asked my providers, one specialist supported the idea of patient data sharing and praised the HA system, but complained the registration process was onerous and the perceived benefit to him and his patients was minimal.

Hong Kong, China is a multi-provider, multi-payer health care environment where public hospitals compete with private primary and specialist care providers. There is thus a strong disincentive for the sectors to share patient data they consider to be their proprietary information. This lack of data sharing is one key reason why Hong Kong’s primary care financing model is poor value for money.

Patients are not in a position to drive the creation of a central medical records database. Public trust in the Hong Kong government, currently at its lowest level since the 2003 SARS outbreak, also undermines efforts to reassure patients that their data will be kept safe and confidential. Moreover, the government’s data sharing system only offers a (somewhat clunky) mechanism for sharing data, but does nothing to address the disincentives to sharing it.

A robust, genuinely population-wide medical data sharing system with strong and transparent governance helps identify patients uniquely and confidentially whenever and wherever they access health care. Providers can access the information they need–and only that information–to provide continuity of care. This has enormous positive implications for public health, and other Asian countries should be aware of this.

The problem can only be effectively addressed by government intervention that compels all public and private health service providers to share their data, promote continuity of care, and put their patients’ wellbeing first.

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Blogs posted for Asian Development Bank (ADB)

Health should not pay the price for infrastructure development in Asia

Published on ADB website on Monday, 16 May 2016

Written by Susann Roth and Jane Parry

“Health is not everything, but without health, everything is nothing,” said 19th century German philosopher Arthur Schopenhauer.

His words are as true as ever today, and nowhere more so than in megacities like Manila and Hong Kong, where we both have to live with heavy roadside pollution and a seemingly endless process of infrastructure development and construction. This creates at times a hostile living environment in which one is constantly assailed by noise, dust, traffic congestion and disruption to daily life.

Infrastructure projects positively contribute to a country’s economic development and prosperity, but inevitably they also have negative social, environmental and health impacts. These impacts can be systematically assessed and mitigated, but first there has to be a political commitment to do so. For health, the concept of ‘health in all policies’ by conducting health impact assessments (HIAs) is fast gaining traction, and directly reflects Schopenhauer’s observation.

Using HIA tools and processes helps governments not only understand and mitigate potential negative health impacts of development projects – they can also seize the opportunity to attain positive health outcomes that would otherwise not happen.

HIAs are a huge challenge for countries in the Greater Mekong Subregion (GMS) undergoing rapid urbanization and infrastructure development. For instance, normally the first step is to have open lines of communication across the different government agencies involved such as the ministries of health, environment, or planning. Given the obvious common ground these ministries share, it is startling to find how little they talk to each other, although most countries actually have HIA policies and procedures in place.

At a recent workshop on HIA organized by ADB, we were astonished to find that senior staff from participating ministries in the same country had no previous contact with each other. Participants from Cambodia, the Lao People’s Democratic Republic, Myanmar, Thailand and Viet Nam all said that it was the preparation for the event that gave them their first point of contact. At the meeting itself, they were able to spend time face-to-face having practical, in-depth discussions about HIAs, with their national colleagues as well as their regional counterparts. The discussions were the beginning of a network, a community of practice that can share experiences and lessons learned, and offer mutual support and advice. This was very gratifying for us.

The meeting was part of a wider technical assistance program on HIAs already underway to expand leadership beyond the health sector in GMS countries by maximizing the health benefits of infrastructure projects, and minimizing their harm. It aims to strengthen HIAs of large infrastructure projects in the region, especially in areas where malaria and other communicable diseases are endemic.

The project also signals a sea change in ADB’s commitment to ensuring health in all policies regains its rightful place as a core part of impact assessment. Each infrastructure project that ADB supports undergoes a social and environmental impact assessment, but attention for comprehensive HIAs had dropped off the radar of ADB and other multilateral development banks. HIA is a mandatory part of the overall social and environmental impact assessment but only the bar minimum is often done.

This issue was also raised at this year’s International Association for Impact Assessment Conference in Nagoya, where HIA experts were glad to see that ADB’s increased commitment to health also includes a focus on improving health outcomes from infrastructure project, and how multilateral development banks, the private sector and regional and local training institutes are discussing how to join forces to establish capacity for HIAs.

With that goal in mind, we are now working with other departments to strengthen HIAs within the bank’s bread-and-butter business of infrastructure. Hopefully this means that communities affected by the massive drive for infrastructure development amid rapid urbanization across Asia and the Pacific is sustainable, and does not trade health for economic development.

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Blogs posted for BMJ

Organ donation is an emotive topic, and rightly so

Recently, there was a very moving piece in The Guardian about a doctor’s experience of a family donating their dead child’s organs for transplant. It got me thinking about organ transplantation here in Asia, specifically in Singapore, and why donation rates there are so low.

Singapore has an opt-out organ donation policy: a 2009 amendment to the Human Organ Transplant Act (HOTA) allows for “the kidneys, liver, heart, and corneas to be recovered in the event of death from any cause for the purpose of transplantation, applicable to all Singapore Citizens and Permanent Residents 21 years old and above, who don’t have mental disorders, and who have not opted out.” Opting out of HOTA means that you are lower priority on the waiting list for an organ transplant.

It sounds rational and fair on the surface: if you want to benefit from a public good, you should be ready to equally contribute to that public good. It is actually deeply flawed. Assuming that the state is a benevolent organism under the democratic control of the people it is designed to serve, then perhaps it can be trusted make these kind of life or death decisions on behalf of its citizens. But the state is not like this in most countries in Asia, Singapore included. Singapore retains the death penalty: the legal power to end the life of its citizens. Opt-out or go to the back of the queue organ donation is another example of the state holding too much power over how citizens live and die.

The opt-out/back of the queue policy looks purely logically and dispassionately at organ donation, but this is in no way a dispassionate decision for either an individual or their loved ones to make. It’s also a matter of how far the state should be allowed to reach into the personal decisions of individual citizens. That some people cannot countenance the idea of organ donation, but at the moment of need in a life-and-death situation gratefully receive one, is not surprising and should not be legislated against.

It also doesn’t even increase donation rates that much. Before HOTA was introduced in 1987, there were approximately three cadaveric kidneys available for transplant every year. Post-HOTA, the average rose to 13. In 2015, there were 17 cadaveric kidneys available for transplant (vs. 34 the year before). Better than nothing, perhaps, but given this is an opt-out system, the results are parlous compared to those in the top five countries for organ donation—Croatia, Spain, France, Austria, and Norway, where donation rates are 50 kidneys per million population. The annual per population rate equivalent for Singapore should yield 250 cadaveric kidneys available for transplant. The disparity is similar for cadaveric livers.

The system isn’t yielding stellar results because neither the public nor the doctors are on board with it. According to transplant surgeons cited in a 2015 Straits Times piece by the paper’s senior health correspondent Salma Khalik: “one common factor in countries with a low retrieval rate is the lack of buy-in by other doctors, particularly those working in the intensive care unit.

“To be usable, a liver has to be taken from the body before the heart stops beating. This means doctors must verify brain death in a patient and alert the transplant team. Instead, doctors often just tell the family there is no hope and, with their permission, pull the plug on the life support system and allow the heart to stop.

“By doing so, perhaps without realising it, they have also pulled the plug on a patient with imminent liver failure, and perhaps another patient facing heart failure. Both might have been saved if the doctor had done the right thing by ascertaining brain death and allowing the organs to be retrieved.”

Families in Singapore are resistant too and frequently do not give consent, despite the fact that the relative concerned had not opted out of HOTA. This may stem from religious objections to organ donation, or because they don’t trust that the doctors are not simply pressuring them to make a decision for the good of the many at the expense of their relative. Earlier consultation with the family and better explanation could help overcome this distrust.

Someone who has had such a transformative experience as organ donation is highly likely to become a strong and convincing advocate for opting into an organ donation scheme, especially among their family, friends, and social circle. This kind of highly personal advocacy can be part of a range of measures aimed at educating the public, rather than pushing them to defy their religious and subjective feelings about organ donation.

Countries like Singapore looking to improve donation rates would do well to study Croatia’s model, internationally recognized as highly successful. Although it too is a system based on presumed consent, those who opt out are not penalized, and the family’s decision is always respected. A review of Croatia’s organ donation system identified a range of factors that contribute to the transplant programme’s success, including “the appointment of hospital and national transplant coordinators, implementation of a new financial model with donor hospital reimbursement, public awareness campaign, international cooperation, adoption of new legislation, and implementation of a donor quality assurance program.” The public’s positive attitude to organ donation, its solidarity, and people’s willingness to help others is also key. This kind of social solidarity cannot be created by legislation alone.

But improving organ donation rates has to start with the doctors. It means that trauma surgeons dealing with traffic accident victims, for example, have an established line of communication with the transplant surgeons who could save their patients’ lives through the loss of the trauma doctor’s patient. It means that doctors have to engage with patients long before families are faced with a heartbreaking decision to be made with no time to spare. At that moment, families need to be treated sensitively by trained, in-house transplant coordinators. With the general public, education about organ donation can be done in the waiting room of family physicians or during routine medical examinations, including a clear explanation of how brain death is determined. It can happen in schools by sharing real-life stories of lives saved through organ donation.

The anonymous doctor who described his feelings so movingly writes: “I can never forget the generosity demonstrated by a family experiencing unimaginable pain and their solidarity; their story is an example to us all and I am sure there are several families who are forever grateful for their benevolence… I cannot forget my colleagues and the support they gave to the family, myself and each other. The night demonstrated how each person is one small part of a team without which no ward or hospital would function.” Such heartfelt and personal advocacy could never come about from a system that pushes its citizens to remain in an opt-out system, or else. Organ donation is a highly emotive topic and deserves a response that takes human emotion into account.

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Public health issues in Asia

Bangkok’s transgender community finally gets the health services it wants

At a HIV conference a while ago I was chatting to one of the other participants, a transgender woman, about why in the HIV world, transgender people are typically lumped in with men who have sex with men. This makes little sense. As my coffee break companion said, with a ‘look at this’ gesture from her high heels, to her fitted dress, all the way up to her long, wavy hair: “In what way does this say I am a man, having sex with men?”

Whilst both gay men and transgender people are known to be at especially high risk of acquiring HIV, for transgender people the risk is far more extreme: 49 times higher than for the general population, in fact. Moreover, they face a degree of marginalization and exclusion from the educational and employment opportunities that men who have sex with men rarely have to grapple with. The lack of a separate ‘key population at increased risk of HIV’ category for transgender people also does nothing to address the lack of data on the HIV epidemic, and what services the transgender community needs, making it difficult to get dedicated funding for HIV programmes for transgender people.

The highly restricted work options for transgender people in many countries see a disproportionate number entering into sex work .What sexual health and HIV prevention services there are tend to focus on transgender sex workers, while stigma and discrimination make the transgender community often extremely difficult to reach with HIV testing, treatment and care services.

Until recently, folding transgender people in with men who sex with men, despite the fact that the two communities have very different needs, was what was happening in Bangkok.

In 2008 the Thai Red Cross AIDS Research Center changed its approach from offering HIV testing to offering anal cancer screening, as a way to get gay men and other men who have sex through the door, and then offer them HIV testing too. It worked: client numbers went up and 80% who came in for anal cancer screening also accepted the offer of HIV testing. Five years on, it was clear that this approach was highly successful in increasing demand for the clinic’s services, but the number of transgender people accessing the clinic remained unchanged. The clinic was missing something if it wanted to appeal to transgender people.

“Through extensive consultations with the transgender community we understood the barriers they face when accessing health services,” Nittaya Phanuphak, Chief, Prevention Department, Thai Red Cross AIDS Research Centre told me. These extensive consultations were with diverse members of the transgender community – including those working as advocates, healthcare providers, within the fashion industry, as well as those working with transgender sex workers – revealed that transgender people face obstacles in accessing hormone level testing and therapy, the most basic health services that they regularly require to affirm their gender identity. What services there are typically are not from transgender-friendly providers, or even worse are provided outside the medical profession entirely.

Hormone therapy services were identified as the entry point to make the clinic attractive to its target population. The Tangerine Community Health Centre opened in late November 2015 and became the first clinic catering specifically to the needs of transgender people in Bangkok. The name was carefully chosen. “We knew the clinic’s name should be one that makes everyone feel comfortable, with nothing that can be considered stigmatizing, Tangerine is a play on transgender, and was chosen because it a fruit that is not too sweet not too sour, just the right blend.

Most of the clients have since come seeking hormone level testing and injections, but they are also offered a package of services including anal and neo-vaginal pap smears, cervical smear tests for transgender men, testing for sexually transmitted infections and a free HIV test (all Thai nationals are entitled to two free HIV tests a year). The centre provides both pre and post-exposure HIV prophylaxis and harm reduction interventions for safe injection.

Funding from USAID covered the costs of the community consultation, start-up, and sensitization training for staff, but services are fee-based, with the cost set at a level that makes them affordable to most clients. As the clinic becomes established, should the fees prove to be prohibitive to some, one option is to introduce a co-pay mechanism, but the aim of the clinic is to be self-financing. A clinic that covers its own costs is a sustainable and replicable role model for other cities trying to close the gap between their transgender communities and HIV services.

Tangerine’s catchment area is Bangkok and it surrounding four provinces, although approximately a fifth of its clients so far have travelled from other provinces to access services and a handful were from overseas. The clinic has a target to see over 400 clients in the first year of operation, with at least 600 consultations. From November 27 2015 to February 23 2016, it had seen 84 male-to-female clients, of whom 61 had received HIV testing, with 11% testing positive. Of the 25 female-to-male clients, 16 had been tested for HIV. Most clients also received testing for syphilis, over half of the transgender women requested hormone level measurement, as did four out of five transgender men.

The Tangerine Community Health Center’s key strengths are its foundations built on extensive community engagement, and its model of integrated health services with a self-sustaining funding model. The clinic’s two transgender staff have also proven essential to ensuring that the clinic continues to offer accessible, transgender-friendly services and remains in close contact with the needs of the community it serves. In time, its usage data will also become an invaluable database of the transgender community’s health profile, overcoming the current invisibility of transgender people in the national AIDS database, and this community’s unique HIV and other health-related needs will be better understood.

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Blogs posted for Asian Development Bank (ADB)

The art of interactive conference for knowledge sharing

 

Published on ADB website on Thursday, 12 November 2015

Written by Susann Roth and Jane Parry

Conferences are a great way to bring like-minded people together in one venue to learn from each other and share ideas. But they can also be deadly dull if they don’t break away sufficiently from the traditional plenary format. Fortunately, the recentConference on Measurement and Accountability for Universal Health Coverage in Asia-Pacific gave participants a multitude of innovative ways to engage with their peers.

ADB jointly organized the event, held in Bali in late October, together with the Government of Indonesia, BPJS Kesehatan (Indonesia’s largest social health insurance provider), the World Health Organization, UNICEF, the Asia eHealth Information Network (AeHIN) and other development partners such as NORAD, the Joint Learning Network, and PATH. During the conference, participants reviewed the current evidence on cost, benefit and impact of ICT-enabled solutions in the health sector, and then set about developing their own set of concrete priority actions to work on in the coming year at the country and regional levels.

A number of plenary sessions brought together high-profile speakers from around the region and beyond. The sessions became interactive with the help of the forum app Pigeonhole, through which the audience posted questions as they arose, and others could then vote on them. As questions bubbled up to the top of the list, the speakers were able to address the issues that most concerned their audience.

There were the usual breakout sessions, with feedback presented to the whole conference, and each group was tasked with a practical goal to achieve. In these smaller groups, national peers decided on the next steps appropriate to their unique circumstances that will help their country use ICT-enabled solutions to reach the goal of universal health coverage and transition their countries health sector M&E frameworks from the Millennium Development Goals (MDGs) to the new Sustainable Development Goals (SDGs).

By using a marketplace format—which is our personal favorite—the conference was able to present 22 different digital health architecture tools and solutions, with participants choosing the ones that interested them the most. Presenters engaged with smaller and strongly interested audiences, showcasing a wide range of innovations, including those for electronic health records, civil registration and vital statistics, geographical information systems, and open-source software solutions for health information systems.

Hearing about how ICT can be harnessed to make health systems interconnected and serve patients better is interesting, but the conference went a big step further.

A live demonstration showed in real time how even fairly basic computers and mobile phones can support existing open-source digital health solutions to deliver better care. Using a scenario of maternal/child health and malaria to illustrate the role for interoperable HIS in continuity of care, the live demo showed how a barcode-based unique health identifier can be created at any point of care. Information can then be shared not only with national databases, but also with other points of care in different locations and over time. Check out this video to learn more about digital health infrastructure.

The conference also got participants out of the meeting rooms with four site visits to a BPJS regional division office; a district hospital that had deployed integrated HIS and BPJS information systems, and two primary care clinics at different stages of implementing ICT-enabled HIS.

As the week drew to a close, it was clear that the transition from the MDGs to the SDGs was an over-arching theme. Whereas the MDGs fostered a silo-ed approach to specific health issues, the health-related SDGs have a clear focus on equity and they demand measurement and accountability for achieving specific targets. Both these factors put the role of ICT at the forefront.

This event was an excellent forum to build a regional response to the global call to action made at the Measurement and Accountability for Results in Health Conference held in Washington, DC earlier this year. Participants left Bali knowing that there was a thriving community of practice that they could draw on for advice and support, and ADB is proudly part of that.

 

 

 

 

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Blogs posted for Asian Development Bank (ADB)

Malaria elimination – a public health best buy

 

Published on ADB website on Monday, 12 October 2015

Written by Susann Roth and Jane Parry

Despite the many successes across Asia and the Pacific in reducing the incidence of malaria, the disease continues to be a heavy burden for many countries, with an estimated 2.2 billion people at risk in the region. Growing resistance to simple-to-use, effective malaria drugs and sub-optimal delivery of malaria treatment, in particular for mobile and migrant populations, are both widespread throughout the Greater Mekong Subregion (GMS). Lack of timely and comprehensive disease surveillance and inadequate cross-border and multi-sectoral cooperation are also serious obstacles to malaria elimination. Together, they threaten to undo all the progress to date toward elimination of this public health menace. Any serious effort to tackle malaria and other communicable diseases must thus start from this understanding: these diseases thrive in the face of weak health systems, and they do not respect national boundaries. Malaria has long been on ADB’s radar as a threat to regional prosperity and security, and our efforts to support countries striving to eliminate malaria received a significant boost when the Regional Malaria and Other Communicable Diseases Threats Trust Fund (RMTF) was set up in December 2013 to support developing member countries create multi-country, cross-border and multi-sector responses. To date, the RMTF has pooled over $28 million in resources from multiple donors, among them Australia, Canada, and the United Kingdom. Over $19.5 million in technical assistance has already been approved, including support to countries to reduce the risk of drug-resistant malaria and work toward elimination of the disease; malaria and dengue risk mapping in the GMS; and support for the Asia-Pacific Leaders Malaria Alliance. Expectations of solid results by the end of 2017—when the first round of financing expires—are high, with ambitious targets set for each of its six components: strengthened regional leadership; increased financing for malaria; better access to drugs and commodities; better use of surveillance technologies; improved capacity to detect drug resistant malaria and other disease threats; and inclusion of malaria and communicable disease prevention in large commercial and development projects. The focus of the RMTF tells us that five changes to the business-as-usual approach are needed if we are to get serious about malaria control and elimination:

  1. More sustainable financing.
  2. Cooperation to ensure supplies of affordable and effective malaria drugs and commodities.
  3. Improved data for evidence-based decision-making.
  4. Stronger national malaria programs.
  5. Expansion of leadership that looks beyond the health sector.

Under the RMTF, ADB is busy leveraging financing by mobilizing co-financing from other donors, and linking with ADB’s ongoing and planned loan and grant portfolio on communicable diseases control in the GMS. We are acting as both a catalyst and financing body for innovation, bringing together centers of excellence such as the the Harvard School of Public Health, Oxford University, the Mahidol Oxford Tropical Medicine Research Unit and the University of Tokyo to help GMS countries better manage their malaria and dengue surveillance and response planning through call data record and geographical information systems. The benefits of the RMTF stretch beyond malaria and will feed into broader health systems strengthening,  so we are working with the World Health Organization and the Asia eHealth Information Network to improve the regional evidence base for elimination of malaria and control of other communicable disease threats through better data collection, and analysis including accurate data on the costs involved. And since accurate surveillance of malaria relies on being able to identify, track and treat people with the disease, ADB and UNICEF are supporting national efforts on civil registration and vital statistics systems, based on unique identifiers for every member of the population. Finally, we are also teaming up with Singapore’s Center of Regulatory Excellence and other partners to improve regulatory convergence of pharmaceuticals to improve availability of high-quality communicable disease and anti-malaria pharmaceuticals and commodities. For ADB, malaria elimination is an obvious public-health best buy, not just because of the reduction in human suffering that it offers, but also because it can bring substantial economic gains: annual per capita GDP growth in malaria-affected countries is 0.25–1.3% lower than in countries without the disease. Investments in malaria now will yield savings in the longer term through reduced health care costs, more robust and sustainable health systems, increased worker productivity, improved educational outcomes, and a more vibrant tourism sector. Success depends on countries, agencies and sectors working together, being as innovative as possible, and putting our developing member countries in the driving seat.

 

 

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Blogs posted for Asian Development Bank (ADB)

ICT helping countries move toward universal health coverage

 

Published on ADB website on Friday, 12 December 2014

Written by Susann Roth and Jane Parry

When the Conference on Measuring and Achieving Universal Health Coverage with ICT in Asia Pacific wrapped up earlier this month, the 290 participants could head home knowing that it had been time well spent. Not only did they share their experiences as health systems administrators and managers, they also left with a bigger network, and a commitment to taking concrete steps to use information and communications technology (ICT) to help their countries move closer to universal health coverage

It was gratifying, as one of the co-organizers together with colleagues from World Health Organization and the Asian e-Health Information Network to see this process unfold. The conference was designed to get people talking in small groups, actively learning from each other, consulting together to hammer out what needs to happen for health systems to fully harness the benefits of ICT, and it culminated in a vote on what the 10 most important next steps are.

ADB is committed to increasing health investments in the coming five years and those investments have to go where the organization can have the biggest impact. One of ADB’s key strengths is its ability to convene disparate organizations and foster partnerships.

This conference was a prime example of effective collaboration among partners to capitalize on each other’s strengths. The knowledge that was gained in the conference room will not just travel back home with the participants. ADB’s health team learns from this process too.

The 10 next steps agreed to at the meeting will also inform a forthcoming joint ADB/WHO policy brief on using ICT to promote and measure progress towards universal health coverage.

ICT can bridge the gap between existing health systems and universal health coverage, but it’s a complex process and every country has its own challenges. We need to know from the people who are closest to the respective health systems to ensure that ADB’s commitment to supporting the goal of universal health insurance continues to hit the mark.

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