The initiative, conducted in partnership with the U.S. Centers for Disease Control and Prevention (CDC) and the Faculty of Medicine and Pharmacy (FMP) of the Université d’État d’Haïti, aims to contribute to the strengthening of human resources in health, increasing the number of qualified clinicians in Haiti. The year-long training comprises theoretical and practical components; this cohort’s practica took place at seven different university hospitals and other health institutions around the country.
“Haiti faces a serious problem of shortage of human resources in health, due in part to the ‘brain drain’ abroad,” says Dr. Jean Guy Honoré, Executive Director of CHARESS. “In some health facilities located in remote parts of the country, there are no physicians, and patients are seen by nurses who sometimes have limited knowledge of the management of infectious pathologies. This training aims to improve the skills of these nurses.”
This aptly fits the vision of CHARESS, which is “to be the reference center, in terms of training, research and technical assistance, allowing populations to receive quality care, with humanity,” says Dr. Honoré. Two other cohorts of nurses have already started this specialized training.
Dr. Bernard Pierre, Dean of the FMP, expressed a wish to strengthen the collaboration between the FMP and CHARESS to extend similar specialized training to doctors — in particular, general practitioners.
I-TECH and its partners have been working in Haiti since 2006, delivering training, clinical mentoring, health information systems, and other health systems strengthening interventions.
Jan Flowers is a Clinical Faculty member and Research Scientist in the University of Washington School of Nursing, and is faculty co-lead of the Digital Initiatives Group at I-TECH (DIGI). Her area of focus is on innovative strategies and technologies for healthcare systems strengthening in resource constrained settings through appropriate electronic collection and use of quality health data for evidence-based decision making.
She has led informatics organizations and teams for over 20 years, focused on technology policy and law, health information systems evaluation and maturity modeling, open source communities of practice building, health technology engineering and implementation, patient centered technologies and mHealth, and standards-based interoperability for improved care at the point of service, surveillance, and program monitoring.
Ms. Flowers serves on the board of directors for both OpenMRS and OpenELIS Foundations, and the founder of the OpenHIE LIS Community of Practice, which develops and shares common standards and best practices amongst the open-source LIS community. She holds an MS in Health Law & Policy from the University of California San Francisco jointly with UC Hastings Law School, and a BS in Psychology from the University of Washington.
The Fifth Annual Global Digital Health Forum was held from 10-11 December in Washington, D.C., attracting more than 300 participants to the FHI 360 Conference Center. At the forum, representatives from the new Digital Initiatives Group at I-TECH (DIGI) and its partner in Haiti, CHARESS, shared knowledge and lessons learned from 15 years of experience implementing digital health solutions worldwide.
“I welcome the messages from donors funding digital health work that they are shepherding a new era through the Digital Investment Principles,” said Joanna Diallo, DIGI Managing Director. “The conference provided DIGI an opportunity to present our contributions to global goods like OpenELIS, OpenMRS, and OpenHIE.”
Diallo moderated a panel titled “Different Labs Need Different Systems: An Exploration of Open Source Laboratory Information Systems Use in Global Health and the Community of Practice that Brings Them Together.” Jan Flowers, DIGI Faculty Co-Lead and Director of Global Health Informatics at the University of Washington Clinical Informatics Research Group, and Casey Iiams-Hauser, Senior Informatics Implementation Specialist with DIGI, were panelists, along with Steven Wanyee of IntelliSOFT, a former member of the I-TECH Kenya team.
The panel highlighted LIS as a critical component of national health information systems (HIS) architecture, exploring a complementary suite of open source LIS that are implemented across low- and middle-income countries, describing the laboratories and use cases each serves.
“The forum is a fantastic opportunity to meet with funders, on-the-ground implementers and technologists to discuss our work and learn about new initiatives and technologies,” said Iiams-Hauser. “We can leverage this knowledge for success both in our existing health information projects and in future partnerships.”
CHARESS HIS Lead Nathaelf Hyppolite participated in a session highlighting the development, implementation, and transition of EMR in developing countries, drawing on I-TECH and CHARESS’s work in Haiti. Participants heard about the benefits of an interoperable EMR: a unified data format, the ability to back up data, and that same data can be used to generate reports via DHIS2 from both the cloud servers and hardware EMR system. Hyppolite also shared the advantages and limitations of transitioning to an OpenMRS and OpenHIE platform, which bring experts together to share knowledge, standards, and best practices, as well as collaborate on technologies.
This focus on community and communication was noted by Diallo and the other participants. “DIGI really appreciated the opportunity to learn more about new standards and technologies, how to best approach digital health governance work, and how a shared language will help us collaborate and work together to ultimately improve health outcomes,” said Diallo.
In spring 2018, the International Training and Education Center for Health (I-TECH) made University of Washington (UW) history when two of its country offices transitioned into independent organizations. I-TECH’s office in India is now the independently run I-TECH India, and its former office in Haiti now operates as CHARESS (Centre Haïtien pour le Renforcement du Système de Santé). Both organizations are sub-contractors on current I-TECH awards.
“With the India and Haiti I-TECH office transition to a local identity, we are applying what we already know about transition to creating new relationships with these independent entities,” says Dr. Ann Downer, I-TECH Executive Director and Professor in the UW Department of Global Health. “To help ensure long-term sustainability, we are working together on business plans and mapping out strategic priorities and mutual interests. This transition has intensified our partnership rather than creating distance.”
A roadmap for the university
I-TECH has worked closely with UW Global Operations Support over the past decade to inform the internal procedures and structures necessary for international office registrations. According to Doug Divine, Director of UW Global Operations Support, this work has promoted operational effectiveness by enabling a safe, compliant, and legal environment for conducting international work.
“I-TECH has been our key partner in the justification and implementation of these registrations, establishing 11 of the 15 entities registered abroad,” says Divine. “It has been so rewarding to have partnered with I-TECH on such an innovative administrative approach. Seeing these registrations become fully functioning independent entities not only fulfills a key mission of I-TECH to help establish sustained capacity where it is needed most, but also reflects the commitment of the UW community toward international engagement.
I-TECH’s close work with Global Operations Support has also prepared I-TECH India and CHARESS for success, helping to create the administrative and policy structures necessary for them to more easily fledge.
The transition of the India and Haiti offices marks new territory in I-TECH’s move toward country ownership, allowing in-country teams to simplify administration and explore funding opportunities that weren’t available to them as UW entities.
The I-TECH India team looks forward to these new opportunities. “This really opens doors to new things,” says Dr. Anwar Parvez Sayed, Clinical Programs Director for I-TECH India. “We were previously looked at as a foreign entity, and we can now apply for local grants.”
I-TECH India has provided technical assistance to 10 Indian Centers of Excellence (CoE) on HIV/AIDS since 2003. In the years ahead, it will continue to support a complete array of educational services and technical assistance to the CoE network in India, plus an additional seven pediatric sites, called pCoE.
“We will now be complying with local Indian regulations, which simplifies things,” says Madhuri Mukherjee, Country Representative of I-TECH India. “Though we no longer have the layer of Washington State and federal compliance, we will remain closely aligned with I-TECH’s and UW’s missions. It’s beneficial from both sides to maintain a close relationship.”
In fact, I-TECH India and CHARESS will each have a memorandum of understanding (MOU) with I-TECH/University of Washington. Each MOU will underscore the organization’s shared history with I-TECH and outline elements of an ongoing commitment — including being preferred partners on new funding opportunities.
In Haiti, CHARESS will continue to maintain, train, and deploy health information systems (HIS) such as iSantéPlus and the Système d’Echange d’Information de Santé d’Haïti (SEDISH), a national health information exchange. It will also ensure that the national sites for both receive on-site and remote technical assistance. In addition, the team will oversee clinical mentoring activities at 20 sites and provide technical assistance to the Ministry of Public Health and Population and other implementing partners in Haiti.
“As CHARESS, we look forward to continuing the programming that we have been so proud of,” remarks Dr. Jean-Guy Honoré, CHARESS Executive Director. “Our HIS work, in particular, has had a real impact in Haiti, and our new local status will allow CHARESS to pursue even more opportunities to become a global leader.”
An updated vision of sustainability
In its 16 years of operation, I-TECH’s ultimate goal has always been to strengthen local capacity and to help build sustainable health systems. To that end, I-TECH’s direct service and technical assistance programs are tailored from the initial planning stage to produce projects that can be successfully absorbed into national systems. Its main partner in this endeavor is always the local Ministry of Health.
At the International AIDS Society conference this year in Amsterdam, Dr. Downer presented recently completed research on six transitioned I-TECH programs (of more than 350 that have transitioned), exploring the degree to which investments had been sustained by local partners, as well as identifying the key elements of successful transition.
I-TECH’s experience with transition to local ownership and long-term sustainability of interventions aligns with those presented by Vogus and Graff (PEPFAR Transitions to Country Ownership, June 2015), including the need to plan for:
Communication of transition strategies through high level diplomacy;
Stakeholder participation in transition planning;
Government support of the plan, including alignment with local government policies, practices, and salaries;
Use of planning tools (i.e., a roadmap); and
Adapting approaches to the local context during transition.
“In addition to the known characteristics of successful transition of projects to local ownership, I-TECH has found that we also need to identify a champion within local government to advocate long-term for the adopted interventions,” says Dr. Downer. “We also need to plan intentionally for how much and what type of technical assistance or short-term funding will be needed in order to ensure sustainability.”
Doug Divine sees massive benefits at each stage of I-TECH’s country office relationships, from registration to independence. “Without I-TECH and the projects it has spearheaded, I’m not sure UW would have made the advancements it has made on the international front,” he says. “I-TECH had the vision, the infrastructure need, and the boots on the ground — which gave us impetus to set up structures for the rest of the university. Other departments can now leverage those resources, and now the spin-off offices fulfill our commitment to allow these structures to grow in their own context.”
On June 1, 2018, the University of Washington’s International Training and Education Center for Health (I-TECH) country office in Haiti officially became a local non-governmental organization (NGO). The office will be rebranded as the Centre Haïtien pour le Renforcement du Système de Santé (CHARESS) and will continue to implement programs to improve HIV services via a trained health workforce, robust health information systems (HIS), and clinical mentoring.
CHARESS will be responsible for maintaining, training, and deploying HIS such as iSantéPlus and the Système d’Echange d’Information de Santé d’Haïti (SEDISH), a national health information exchange, across Haiti and ensure the sites receive on-site and remote technical assistance. The team will also oversee clinical mentoring activities at 20 sites and provide technical assistance to the Ministry of Public Health and Population (MSPP) and other implementing partners in Haiti.
“I-TECH has a mission to support sustainable development,” says Scott Barnhart, MD, MPH, Professor in the Department of Global Health and an I-TECH Principal Investigator overseeing programs in Haiti. “The conversion of the I-TECH country office and launch of a fully independent NGO to take up those activities is testament to I-TECH’s commitment to fostering locally owned and led development.”
The announcement of the shift to local ownership comes after two years of strategic planning by key stakeholders and partners to successfully transition I-TECH Haiti’s country office into an independently functioning NGO. As such, CHARESS will aim to allocate more of its funding to program activities, as well as pursue local funding opportunities restricted to Haitian organizations.
“The programs that are shifting to CHARESS have already proved to have had a dramatic impact on the health care landscape in Haiti,” remarked Jean-Guy Honoré, MD, I-TECH Haiti’s Country Director. “Transitioning of the key programs, specifically our HIS work, to a local ownership will allow CHARESS to become a leader in sustainability on the global stage. We are proud of the work that we have accomplished and look forward to the future.”
For 16 years, I-TECH has helped develop strong national health systems in low- to middle-resource countries while promoting the importance of local ownership as a way to sustain those effective health systems. I-TECH will continue to be a close partner in supporting CHARESS and looks forward to continued collaboration.
Nancy Puttkammer, PhD, MPH, presented a poster at the Conference on Retroviruses and Opportunistic Infections (CROI) in Boston on 4-7 March 2018. She was joined by Rose Boulay, a representative from the Haiti Ministry of Health (MSPP) National HIV Program (PNLS). Madame Boulay works on data quality assessment, training for clinical sites, and decision making using data from the iSanté electronic medical record (EMR) system.
The poster, titled “Multi-Month Scripting (MMS) and Retention on HIV Antiretroviral Therapy (ART) in Haiti,” reflected the collaboration between I-TECH and MSPP to analyze national policies using iSanté data from 85 ART clinics. They examined the MSPP-led MMS initiative to prescribe longer intervals of ART for stable patients. The goal of the MMS approach is to improve patient retention on ART by reducing the burden to patients of coming into the clinic monthly to pick up their ART prescription.
“Our analysis showed impressive uptake of MMS across all health facilities, suggesting that longer intervals are welcomed by providers and patients,” explained Dr. Puttkammer. “Patients prescribed ART for two months or more were 18% more likely to be retained, after adjusting for various patient and facility factors, compared to patients on monthly ART regimens. This is a promising result in terms of the goals of the MMS approach.”
Haiti’s national EMR system allows for the MSPP to conduct data analysis to evaluate the success of health interventions across the entire network of clinics and hospitals in a timely manner. “We are very pleased that we have been able use the iSanté data system to measure the progress of our national HIV and AIDS response, and to share our results with an international audience at CROI. It has been a great experience,” stated Madame Boulay.
Representatives from the International Training and Education Center for Health (I-TECH) are headed to New York for the 9th Annual Consortium of Universities for Global Health (CUGH) Conference. The conference—held on March 16-18, with satellite sessions on March 15—will be co-hosted by Columbia University, Stellenbosch University, and the University of Peradeniya.
Featured speakers include Richard Horton, Editor of The Lancet, and Natalie Kanem, Deputy Executive Director of the United Nations Population Fund.
Building on the theme of “Health Disparities: A Time for Action,” staff and faculty from I-TECH will be presenting on the following topics:
King Holmes, MD, PhD, founding chair of the Department of Global Health and a co-Principal Investigator of I-TECH’s IAETC award, will join a morning plenary session and discussion about global health disparities. The discussion will be moderated by Director of the Fogarty International Center Roger Glass. Dr. Holmes will be joined for the discussion by Rose Leke, Gairdner Foundation Global Health Committee member and Emeritus Professor at Universite de Yaounde, and K. Srinath Reddy, President of the Public Health Foundation of India.
Kate Wilson, PhD, Clinical Assistant Professor, is presenting a poster titled “Evaluation of a New Field Epidemiology Training Program (FETP) Intermediate Course to Strengthen Public Health Preparedness in Tanzania.” The locally adapted course significantly improved trainee knowledge and skills in field epidemiology, and the evaluation also showed evidence of improvement in data quality and performance at trainees’ workplaces and districts.
Lindsay Mumm, MPA, Program Manager, is presenting a poster titled “Creating Relevant Change towards Reaching the UNAIDS 90-90-90 Target with High-Impact Leadership Training – Afya Bora Fellowship in Global Health Leadership.”
The mission of CUGH is to build interdisciplinary collaborations and facilitates the sharing of knowledge to address global health challenges while promoting mutually beneficial, long-term partnerships between universities in resource-rich and resource-poor countries, developing human capital and strengthening institutions’ capabilities to address these challenges. Read more about CUGH: https://www.cugh.org/.
Established in 1993, The Conference on Retroviruses and Opportunistic Infections (CROI) was provides a forum for scientists and clinical investigators to present, discuss, and critique their research. The goal of the conference is to provide a forum for researchers to translate their laboratory and clinical findings into tangible progress against the HIV pandemic. Read more about CROI: http://www.croiconference.org/.
To mark the 10th year of the iSanté electronic medical record (EMR) system, the International Training and Education for Health (I-TECH) team in Haiti embarked on an analysis of the EMR’s implementation, the results of which were published as a case study last month in Health Policy and Planning.
The study focuses on factors of success, contributing to the industry’s understanding of what it takes to sustain and transition an EMR system in a low- and middle-income country (LMIC) like Haiti. The team found that while functionality and technical factors continue to be relevant as EMR implementations mature, other factors also become significant over time, including governance and leadership, ongoing user capacity, data quality, integration within a larger eHealth framework and financing.
The team assessed factors for success in eight categories: functionality, technical, organizational, training, political, ethical, financial, and sustainability. Seven of these were determined by the work of Fritz et al. in a review of factors contributing to EMR system success in low-resource settings. However, one of the main findings was the eighth category the Haiti team added to the list of factors: sustainability.
Why sustainability is critical
When a system like iSanté is implemented at scale for so many years, the definition of success shifts from design, planning, and rollout to financing, governance, maintenance, and long-term ownership of the system by Haitian stakeholders. Transition planning, including long-term financial sustainability of the system, needs to begin at the start of any implementation.
“iSanté is a part of the legacy of the HIV information system, a model that will be used from generation to generation especially in terms of sustainable HIV/AIDS interventions,” said Nirva Duval, M&E Lead at the National AIDS Control Programme of the Ministry of Public Health and Population (MSPP) in Haiti, a case study author who has been involved in the iSanté implementation since its beginning in 2005. She went on to add, “Use of iSanté data is a major asset and an opportunity to better understand issues and contribute to decision-making at all levels.”
Ultimately, the goal is for iSanté to be fully owned, managed, and maintained in Haiti and wholly integrate into clinical practice. In 2016, I-TECH, the U.S. Centers for Disease Control and Prevention (CDC), and the MSPP undertook an overhaul of iSanté, including moving all servers and the majority of software development to Haiti.
Lessons learned pave the way for integration
The rebuild, known as iSantéPlus, uses an OpenMRS platform, which is supported by a growing global community. The phased national rollout of iSantéPlus is under way and will continue during 2018. I-TECH is also supporting the creation of a new national health information exchange known as “SEDISH” (Système d’Echange d’Information de Santé d’Haïti in French).
SEDISH will ensure a seamless flow of data between the community level to sites to the national level and back, improve clinicians’ ability to see patient history from other sites, and maintain a continuity of care document for patients who move between care sites. SEDISH uses international data standards and a Master Person Index to facilitate harmonization and information sharing between the EMR and other health data systems like lab and supply chain systems, transitioning the Haiti HIS landscape from multiple disparate systems to an interconnected network. Both iSantéPlus and SEDISH will promote collaboration between MSPP and CDC- and USAID-funded partners to improve how health care providers serve individual patients and populations across these systems.
Many of the lessons learned during the implementation of iSanté were applied in the design and execution of iSantéPlus and SEDISH. “iSanté has kept Haiti on the leading edge of HIS implementation in resource-constrained countries,” said Dr. Scott Barnhart, Principal Investigator and Professor in the University of Washington’s Departments of Medicine and Global Health. “The changes under way will have broad global applicability — integrating across direct patient care, lab, pharmacy, as well as supply chain. We have an exciting opportunity to come together and build on our success to respond to the challenges of local ownership, financing, cost-effectiveness, and governance so that these important tools are sustainable.”
Once the team completes and assesses the results of the iSantéPlus and SEDISH pilot, the new systems will be deployed throughout Haiti. It will be critical that the MSPP, CDC, and I-TECH’s partners in Haiti come together to assess the sustainability of iSantéPlus and SEDISH and their impact on the HIS landscape in Haiti.
 Fritz F, Tilahun B, Dugas M. 2015. Success criteria for electronic medical record implementations in low-resource settings: a systematic review. Journal of the American Medical Informatics Association 22: 479–88.