IMANI Alert: Must the Minister of Health destroy jobs & set the digitisation policy back?

Ghana’s Ministry of Health wants to digitise records in all of Ghana’s public and (religious) mission-owned hospitals and clinics and thus make paper folders for patients a thing of the past.

The idea is good, and the plan itself is very old, but serious attempts to execute date back to 2007, culminating in a detailed national e-health strategy in 2010.

Among other aims is the overall strategy today that encourages the development of an ecosystem of software and ICT innovations to support Health Systems Management across the nation.

Different systems being able to talk to each other (interoperability); local development, deployment and support of solutions; and minimising the financial burden on the state through private participation, are some of the core principles of Ghana’s e-Health policy. Although the policy does not rule out the use of foreign software, it nevertheless impliedly supports the development of local solutions for obvious reasons of job creation, local support, and preservation of local medical records in Ghana.

On 28^th June 2021, the honourable Ministercaused a letter to be written by the Director-General of the Ghana Health Service to the entire senior management corps of Ghana’s frontline health services presenting the Lightwave Health Information Management System (LHIMS) as the only authorised Electronic Medical Records (EMR) solution for all government-run and religious mission-operated hospitals (about 20% of the facilities in the national “public health sector” are managed by religious organisations).

The Minister is genuinely proud of LHIMS and its vendor, Lightwave eHealth Solutions, a small organisation based in Atlanta with mail handling services in the UK and a couple of project managers in Ghana.

So proud that he is fond of reciting the success stories of LHIMS’ deployment in the Central Region, as in a recent testimonial:

“Presently 25 health facilities including the Cape Coast Teaching Hospital are online and active. This covers 345 Doctors and 2,312 clinical staff across the region. Twenty Network Radio Masts have so far been installed. So far 379 computing devices have also been deployed.”

What is left unsaid is that in recent years, a number of major hospitals, such as KomfoAnokyeTeaching Hospital, have been forced to abandon locally developed EMR solutions like HAMSfor LHIMS, thereby increasing the latter’s footprint.

To get LHIMS entrenched in the Central Region, for instance, HAMS, a competing local product, literally had to be ripped out of places its frugal and longsuffering Ghanaian developers had spent years cultivating to even accept the idea of medical records digitisation.

It must be mentioned that local developers in the space built their platforms on their own dime, and had to pay for all the development and testing themselves. They had to prove themselves capable and compete in the market before they could pass due diligence by the public and private hospitals buying their products and services. They have since had to ensure high levels of service to retain these clients. Lightwave has never had to deal with such hurdles. Yet by one fell swoop, the Ministry’s directive, if carried out to the letter, would lose just one of these local EMR vendors as many as 200 clients they have acquired over a period of more than a decade.

It should be reasonable to expect that our government officials will support successful local initiatives and companies more than foreign ones especially when the foreign vendors do not have a superior product or service.

The fact remains that, even with all its touted successes, LHIMS is not a perfect solution. A 2019 study by Princess Gloria Ofori and her colleagues revealed that whilst the LightWave system has indeed reduced waiting time at the Outpatients Department (OPD)of the University of Cape Coast Hospital by 50%, nearly half of the staff (41%) are unable to generate the relevant performance reports from the system.

The main reason why LHIMS is displacing all other solutions in the EMR space like those implemented well before it was brought into the country by the likes of IPMC, Queauji (builders of the well-regarded Carewex health IT platform), Progsoft, Spagad, Sanford, Infotech, MedData, and Africa eHealth Solutions etc is simply Ministerial fiat. When these hardy local technology vendors have scraped and penny-pinched to make some headway in a tough market, a bureaucrat in Accra will step into the fray to fight on behalf of Lightwave, forcing customers to abandon solutions they have built a level of comfort with. This is seriously damaging local ICT companies in droves.

The Sampson Djaba-founded Lightwave is to be commended for having succeeded in obtaining strong buy-in at the Ministry of Health to modernise the country’s medical records system, but the truth is also that it does not have the capacity to replace the large number of ICT companies currently offering health IT solutions, especially in the EMR segment, to public and mission-run facilities.

But even if it did, it is clearly against established policy of interoperability and resilience from having multiple vendors and a diverse ecosystem, as against a single vendor and a single point of failure across the entire health technology landscape. Monopolies are out of fashion everywhere and no good policy allows the creation of single providers who the whole system will soon be entirely reliant on, and thereby create negative dynamics for performance and efficiency as happens with all monopiles.

It is clearly more desirable to allow for competition and diversity and ensure standards which create seamless interoperability. An interoperable model will lead to a virtuous cycle of vendors improving their systems in order to be more preferred, and those who slack are likely to be replaced. In the end, users and ultimately patients are the beneficiaries of operationally effective and cost-effective systems and services. This also leads to the development of local capacity and the creation of high-quality jobs in ICT.

A credit check report we have seen shows that Lightwave’sreported annual revenues have been under $300,000 in recent years for its Atlanta-based holding entity and also that its full-time employees number less than ten. Compared to their Ghanaian counterparts who together employ hundreds of employees, it is a stretch to find good enough reason to throw out all the local entities and install LightWave everywhere.

There are indications that LightWave itself depends on others for its systems. It is not surprising that much of the deployment work seems to have fallen on India-based Plus91, which has been white-labelling its Medixel solution for the bulk of the implementation. Plus91 is itself a very small operation in Pune and cannot be expected to pre-finance any part of the rollout. Our checks reveal an engineering team of fewer than ten individuals.

Some analysts suggest that Lightwave is a one-trick pony that cannot survive without Ghana’s contract; it is worrying to dump everything in Health ICT at its feet. The evidence has been clear for a while that LightWave has since 2016, when “nationwide implementation” of its system started, completely relied on the government’s sclerotic budget cycle to be able to function. The obvious outcome is a slow deployment of the LHIMS across the country, raising questions about whether Lightwave will be capable of surviving any serious financial or operational shock. In such an event, it is likely that the entire health system in Ghana will be at risk.

Recently, during a transition from one ICT system to another in a major health district, many nurses had issues charting patients because of persistent downtime. Patients may die if their records and charts cannot be accessed or sorted out properly in time for their critical medication. Transitions are delicate and must be managed with tact. The brute force approach of replacing local health ICT platforms with Lightwave could well be endangering lives across the country.

In such circumstances, it is completely unacceptable for the Minister of Health to command the agencies under his office to tell the dozens of Ghanaian EMR vendors with hundreds of active deployments across the country, employing over 2000 skilled personnel, directly and indirectly, to abandon the solutions they have already installed in clinics across the public and mission-run health system so that Government can use scarce tax cedis to start all over again.

This is not a prudent use of national resources. The continued hectoring of facility directors across the country to stop using existing solutions and embrace only LHIMS is indeed a statement to the industry to abandon the public health ecosystem.

The Minister’s approach is particularly problematic and reckless considering what it will take to sustain all the current investments being made with government money once all the other vendors have been pushed out of the market to safeguard Lightwave’s monopoly.

Rigorous studies show that considerable resources are needed to boost the uptake of modern technologies in the Ghanaian health sector. Resources that the government and its darling, Lightwave, alone cannot mobilise.

The national e-health backbone for electronic medical records alone, ignoring numerous other e-Health requirements, was said to require $15 million in investment as far back as 2010. With the dramatic increase in service points, that number has more than tripled. A more competitive EMR landscape should ensure that we have a deeper pool of entrepreneurial talent to help mobilise some of these investments from the private sector.

Some of that money, skills, methods, inventions and ideas from a more diverse field will also find their way into neglected aspects of health innovation left unattended to because government ministers and top bureaucrats only focus on juicy software and hardware procurements. These neglected aspects include organisational transformation and behavioural change, as outlined in the National e-Health Strategy of 2010.

A study by Abdul-FatawuAbdulai, Fuseini Adam and KwasiTorpey last year on the health readiness of personnel at the two main hospitals in Tamale, for instance, found that only 54.9% of personnel were ready to use any type of EHR at all. Worse, no digital transformation plan is in effect at these two vital hospitals serving as the main referral facilities for more than 5 million people in the Northern part of Ghana. This is the case, even though the Ministry of Health is engaged in a fierce contest to rip out existing software solutions so that LHIMS from Lightwave can commence its unchallenged reign.

Likewise, a 2018 study by Henry Ogoe and his colleagues found that even in Accra, the country’s most advanced (by far) health market, some tertiary facilities, such as the University of Ghana Hospital, are operating at just 10% of the required IT staff capacity.

There are many such problems impeding the full and sustainable uptake of technology that can bridge the frightening inequities in healthcare delivery in Ghana. Nowhere in the draft enterprise architecture for the health sector or the even older EMR policy is the rationale for the incorporation of ICT framed as needing a single vendor. Lightwave’s imposition is thus completely at variance with all the norms of decision-making in the health sector.

The National e-Health Strategy (“e-Health Strategy”) was prophetic in observing that:

“One of the key risks is therefore the ability of vendors to deliver robust solutions in a timely manner. This limits the health sector in many ways to implement very small basic solutions and pass them on as solutions that must be adopted.” (Page 32).

The Strategy is moreover emphatic about the need for an intersectoral approach:

“The health sector will depend on the Ministry of Communication to deploy a national infrastructure that will deliver the core elements of the national e-health infrastructure. The rollout of the e-health plan will depend on the coverage of the National Information and Communication Technology infrastructure.” (Page 37).

This “open ecosystem” approach is further reinforced by enforcing interoperability:

“To ensure interoperability and integration the Ministry of Health will work within the e-Government Interoperability Framework for Ghana.” (Page 43).

Yet, the Ministry of Health adamantly refuses to allow NITA to play its proper role of standardisation and capacity development, even though its own e-Health Strategy acknowledges the need for the Ministry of Communications approval of plans (page 70). Nor has the Health Ministry consented to NITA’s established status as the e-Health Regulator.

In our research for this brief report, we sighted documents showing considerable disquiet at NITA for its complete marginalisation in these matters, contrary to national policy and regulations. In fact, its advice in this whole EMR controversy has been routinely ignored. Though, of course, it can be argued that it has also become complicit by its silence.

The lack of dynamism at the Ministry of Communications is no doubt allowing these completely irrational procurement binges and the use of public money to enforce private monopolies to proceed across government. The Ministers of Communications and Finance better sit up.

When we say that the Ministry of Health’s Lightwave policy contravenes settled national policy, we are talking about norms and prescriptions in black and white, not our own interpretations.

The e-Health Strategy document makes ample provision for local e-health projects to align with, but not to be displaced, by any national framework:

“The strategy will seek to align all e-health solutions to the standards outlined but will not limit the development of local e-health initiatives.” (Page 38).

By what regulatory authority and under what policy cover then is the Honourable Minister and his assigns at the Ghana Health Agency doggedly pursuing actions that border on tortious interference with the contracts of Ghanaian EMR vendors? Actions which may well be actionable at law. These directives are clearly going to cause disruptions in contractual arrangements between the local software vendors and the hospitals using their software. If care is not taken this will lead to another series of Judgment Debts.

Why is the wider government looking on unconcerned as Ministerial power is being deployed, clearly contrary to stated policy, in a way that will decimate the efforts and investments of several Ghanaian enterprises, with reckless disregard for the jobs and livelihoods being destroyed?

This brief note, aside from shining the spotlight on a matter long ignored by powers that be, despite multiple petitions to the highest offices of the land by industry players, is also to serve as an open letter to the Ministry of Health, Ministry of Communications, the Ministry of Finance, and the Chief of Staff at the Presidency. We shall be following up separately with these bodies.

IMANI would, of course, welcome any engagement with the authorities to find a workable model of amicable co-existence among the legacy EMR vendors and Lightwave in a rich, fertile, and interoperable health innovation ecosystem where healthy competition and creative collaboration, rather than Ministerial fiat, become the sources of value for Ghana, patients and the Government treasury.