Document(s) 8 de 31

Introduction

It is likely that all aspects of health or health care will be affected by e-health, the broad use of information and communications technology (ICT) in the health sector. No individual, organization, business or government can therefore afford to ignore this development.

The concept of global health has emerged in the past decade. Given that the capabilities of e-health and the health needs of the global and local population are complementary, worldwide provision of the benefits of e-health, i.e. ‘global e-health’, is also an appropriate concept. But, to accomplish this, e-health must be integrated into domestic and global health care systems at both practical and policy levels. The focus to date has been on addressing matters related to the practical implementation of e-health in the local or domestic context, which is proving difficult enough. With rare exceptions, attention to the issues of integration and broader e-health policy development has been fragmented or non-existent.

The rapid development of e-health is causing many changes, the social outcomes of which will be mixed. Winners will be best placed to take advantage of the changes. Losers will not only be left behind technologically, but also be in danger of losing the expanded services capable of being provided through e-health. In order to maximize the number of winners, many challenges must be addressed. Principal among these is a global e-health policy.

Need for a global policy

Does a need exist for a global e-health policy? Consider the following ‘North–South’ scenario.

A 55-year-old man has recently returned home to a remote northern community in a Canadian province after a six-week trip to Tanzania and South Africa, during which he travelled and camped extensively in the bush. Upon his return, he has fallen severely ill and is bedridden with an unknown disease, exhibiting fever, extreme debilitating pain in joints and muscles, and a skin eruption. The patient’s doctor has identified a specialist in rare tropical diseases who works at the Nelson Mandela School of Medicine in Durban, South Africa. An urgent video consultation is desired for diagnosis and treatment, and for guidance for local management. Can we do this? Both locations have access to video-consultation units, good experience with local use of this equipment and adequate bandwidth. From a technical perspective, therefore, we can do it.

Both clinicians are agreeable and local chief information officers are approached to arrange the logistics of the consultation. Having been alerted, senior administrators in the relevant health region in Canada ask questions. Who is this specialist in Durban, and what training or certification does she have? Is her expertise recognized in Canada? Is this within her scope of practice? Will she expect remuneration? Will this open the flood gate to many similar requests? Since diagnosis and treatment are needed, will she be considered to be practising in Canada? What are the licensing issues? Who will have clinical accountability? What about liability to the hospital and health region? Will there be any ethical, confidentiality or privacy complications? For clinical continuity and appropriate care, will the consultant need to review the patient’s electronic health record, or need to enter her opinion in the record after remote patient examination? If so, what about security, and how will access and authorization be achieved since she is not an employee and does not currently have approval? Is any diagnostic equipment licensed and approved for use – and where? How much does this matter?

The health region’s risk manager advises against the teleconsultation, and the Provincial Privacy Commissioner says that he will examine the issue and provide a response – probably next month. The outcome is confusion and uncertainty about what to do or how to do it, since there is simply no clear local, subnational, national or even global policy or legislation to show the way. As an alternative, a specialist in another Canadian province is contacted. But, now sensitized, the administration raises the same issues. The videoconference is cancelled ‘due to technical difficulties’.

And the patient … ?

Global health

Global health has been defined as those ‘health problems, issues and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions’.¹ Global health, similar to its predecessor, international health, maintains a strong focus on the prevention and treatment of infectious diseases such as HIV, malaria and tuberculosis. In addition, however, global health is focused on the identification and eradication of underlying conditions that contribute to the persistence of disease. These include disparities in access to care, cultural and psychosocial factors that impede the prevention and treatment of disease, and issues of extreme poverty, violence and war.¹ The use of e-health, i.e. global e-health, could influence each of these areas.

In most countries, major policy matters include the need for increased access to health care services and health reduction in inequity. Complicating factors include the ageing population, the shortage and maldistribution of health care providers, the growth of chronic disease and poor literacy. Many tools will be needed to address these health care problems, among which must be global e-health.

Global e-health

The term ‘global e-health’ appears to have been used from about 2000. The relationship of its components is shown in Figure 6.1. With recognition of its potential to have a profound effect on the health of the world’s population, it has taken on new meaning and new significance.

A variety of definitions of telemedicine, telehealth and e-health have arisen over time, leading to some confusion and semantic debate. Common to all are the elements of the use of ICT, distance between participants, and health or medical application. Not typically included have been aspects of global application, crossing of existing boundaries and integration into current health care practice. Considering these perspectives, a definition was proffered in 2003 that was consistent with the accepted goals and terms used by the World Health Organization (WHO). Thus global e-health is:²

The sustainable global integration of information and communications technologies into the practice of protecting and promoting health across geo-political, temporal, social, and cultural barriers – including research and education – to facilitate health, public and community health, health systems development and epidemiology.

Global e-health recognizes the interdependence of all nations and the mutual benefit of a flow of health information, knowledge and resources between countries.

Relevance of global e-health

MacPherson and Gushulak³ identified the breakdown of traditional public health barriers to transmissible virulent diseases that has been caused by modern modes of transportation. A potentially contagious person or product can now travel to anywhere in the world within 1–2 days. Kaul and Faust⁴ noted the relevance of this in terms of political boundaries – ‘In today’s world, globalization has brought about interdependencies that blur the distinction between domestic and external affairs’ – and noted that ‘the best way to ensure one’s own well-being is to be concerned about that of others’.

Figure 6.1 The relationship of the major components of e-health (telemedicine and health informatics) to global e-health. Also shown are subcategories of both major components, some examples of applications [square brackets], plus distinct but related elements (e-commerce and e-learning).

Given these perspectives, it is important to recognize the potential for global e-health to affect the health and health care of the world’s population. There are many potential benefits:

• System – improved administration, communication and surveillance capabilities; better patient self-management; lower health system costs.
  
  
• Provider – improved distance education and remote skill development; networks for rural or isolated professionals.
  
  
• Patient – improved education and disease management; reduced patient costs (reduced travel, less time off work, decreased waiting time); positive influence on health outcomes.
  
  
• Public – improved education to maximize independent living and quality of life.

Such benefits have already been demonstrated in many industrialized countries, but usually in small-scale e-health applications. The opportunity exists to achieve benefits on a more widespread basis, but several factors will influence this, particularly in regard to developing countries. Some are health related, some are ICT related, and others touch on socio-political matters, including cultural sensitivities, governance and policy.

Global e-health and developing countries

It is reasonable to speculate that most of the world’s countries have been exposed to e-health in some fashion. Developing countries perhaps have both the most to gain and the most to lose from ‘e’applications, including global e-health (Figure 6.2). They have the most to gain through providing increased access to, and greater equity of, health care to their large, under-served populations. They also have the most to lose, since significant investment in time, effort and funding will be needed to raise their health and e-health infrastructure to the required levels, potentially increasing their debts and potentially diverting funding away from already stressed traditional health care delivery and support.

It will become necessary to build a sound business case for global e-health investment in developing and least developed countries, and for cogent arguments to be developed about the ‘return on investment’ (ROI). With more than 80% of the world’s population living in developing and least developed countries, there is at least a moral argument for investment in e-health adoption and integration. However, given that exotic diseases can now more easily appear in industrialized countries, the North stands to gain from enhanced global e-health exchange with the South, which represents another tangible and valuable ROI. The WHO’s recent macroeconomic study identifies another ROI. That study noted that investing in health in developing countries actually has a profound economic benefit for industrialized and developing countries alike.⁵ The benefit for developing countries includes a fitter, healthier and more productive workforce, and decreased fecundity; the benefits for industrialized countries are – crudely – more participants (and buyers) in the global market place.

Figure 6.2 The potential impact resulting from access to ‘e’ applications, including global e-health. Industrialized countries must integrate e-health into existing (legacy) health and health technology systems, and this may be viewed as a threat to traditional delivery models. Developing countries, which lack legacy systems and can adopt new e-health applications relatively easily, have the greatest opportunities to gain from e-health. Of concern is the potential for the least developed countries to be excluded from the potential gains of e-health, because of the digital divide.

Global e-health policy perspective

Despite various international health-related collaborations, notably the WHO, health policy largely remains the sovereign domain of individual countries. But, to be effective, global e-health must become fully integrated into existing national, international and global health-related structures, in both a process and a policy sense. This will only be achieved through implementing globally accepted strategies, principles and complementary policy options. Such a goal is complicated by several matters, including existing borders and boundaries, the increasing number of stakeholders who influence health care and technology activities (particularly in developing countries), changes in governance, and the breadth and complexity of e-health-related policy matters, each discussed below. Failure to address these matters will create potentially impenetrable barriers that will deny the benefit of global e-health to much of the world’s population.

Borders and boundaries

Some observers consider that national borders are becoming less meaningful.⁶ Certainly, they are becoming more porous to health threats as a result of international mobility.³ Global e-health has the ability – if developed correctly – to transcend existing geopolitical, sociocultural and temporal boundaries. By so doing, it could help to solve some of the health care problems facing the world’s population. This potential also raises concerns, such as the ‘jurisdictional gap’ and fear of loss of control that must be addressed if e-health is to have the desired global benefits.^7–9

Stakeholders

At one time, the WHO dominated international and global health activities. However, the world health system has grown in complexity, as well as in capacity, through an increasing number of stakeholders. These now include development banks, multilateral development agencies, development assistance agencies of industrialized countries, and non-profit private organizations such as non-governmental organizations (NGOs), big international NGOs (BINGOs), international foundations, professional bodies, health and medical assistance groups, consulting agencies, academic institutions, and finally the private sector that produces medical products, health services and ICT components. Each plays a major role in the development and dissemination of ICT and the provision of health services. Collectively, they possess much of the funding and expertise necessary for technology innovation, and are now leading global research and development.

The role of NGOs has been challenged. For many years, they have performed various service and humanitarian functions, acted as intermediaries between citizens and governments, and even tended to fill voids in governance. Now challenging their position are foundations and BINGOs, often created by private companies with access to substantial resources. For example, the Bill and Melinda Gates Foundation has assets in excess of US$36 billion. In 2007, the Foundation granted just over $2 billion for their programmes, which included the Global Health Program and the Grand Challenges in Global Health.¹⁰ Compare this with the total WHO biennial budget of US$2.8 billion.¹¹

Changing ‘governance’

‘Governance’ concerns the actions and means adopted by a society to promote collective action and deliver collective solutions in pursuit of common goals – how to direct, shape or regulate use of something.⁶ It is fairly straightforward to transfer this concept to the health and ‘e’ environments. Despite various international initiatives, ‘health governance’ (and associated health policy) has historically remained largely the sovereign domain of individual countries, and, with the increasing application of ICT and e-networks within countries, the concept of e-governance has arisen. E-governance deals with the whole spectrum of the relationships and networks within government that involve the use and application of ICT. The term ‘e-government’ is sometimes used, incorrectly, in place of e-governance. The former is a narrower concept and deals with the development of specific online services to citizens, such as e-tax, e-transportation and e-health. In a similar way, the advent of global ICT networks and globalization is challenging these recent concepts, and global e-health governance is emerging as a major issue. How does one control activities (health related and otherwise) that increasingly reside in the hands of globally distributed entities?

A notable concern is the fundamental shift in balance and growing influence of all of these entities on local, national and global health-related decisions and policy making. The dominance of the WHO, national governments and NGOs has been superseded by a dominance of private sector conglomerates and private foundations. Each stakeholder has its own priorities and interests. Despite seeking expert input to guide direction and investment, how adequately will the needs of small communities and countries be served? It will be crucial to ensure that local and national needs take precedence over corporate, donor or facilitator needs. But the reality is that global e-health policy development is no longer the sole purview of governments and the WHO. BINGOs and large multinational companies in the health and ICT sectors are extremely influential.

At a more practical level, the intensification of flows of people and goods are generating trans-border health risks that are different from those of previous eras. These new risks require novel approaches to health governance, and there is widespread belief that the current system of ‘international’ health governance does not sufficiently address them. E-health applications might assist. As a result, the concept of ‘global e-health governance’ must become a subject of greater interest, debate and development. This perhaps represents an opportunity for the WHO to remould its own policy, reclaim its confidence and influence, and take on a central role in the global e-health governance agenda.

The breadth of policy issues

E-health has been practised in some countries for several decades, and comprises health informatics and telehealth (see Figure 6.1). E-commerce and e-learning are distinct but related elements. Although originally quite localized in application, e-health solutions have became more national (crossing domestic borders) and even global (crossing national borders) – referred to as inter-jurisdictional e-health activity.¹² Such activity is often performed on the basis of ‘good Samaritan’, intra-professional consulting, or specific and limited inter-agency agreements. However, the need for broad policy to facilitate unfettered inter-jurisdictional activity has been recognized for many years.^13–15

There are several commonly identified policy problems. For health informatics, they are privacy, confidentiality and security (and, more recently, patient safety) and, for telehealth, they are licensure, liability and reimbursement.¹⁶ These have, to a large extent, usurped the limited policy debate, and the fact that they have remained unchanged for over a decade demonstrates the glacial pace of debate and action. Assuming that inter-jurisdictional e-health is a desirable goal, attention must be paid to much more than these limited matters. In earlier (unpublished) work, I identified 34 key e-health policy-related issues, and a recent paper identified almost 100 issues.¹⁷ A three-dimensional ‘global e-health policy matrix model’ is being developed as a tool to assist in understanding this complex setting¹⁸ (Figure 6.3). This tool highlights specific policy issues at the intersection of different policy levels, under specific policy themes, for specific policy stakeholders.

Figure 6.3 The three-dimensional e-health policy matrix model that highlights specific policy issues at the intersection of different policy levels, under specific policy themes, for specific policy stakeholders.

Definitive e-health policy is limited in scope, sparse in quantity and located primarily in a handful of industrialized countries. In other words, there is a global e-health policy void. Nascent e-health policy development can be identified in some countries, but is often indirectly related (information privacy policy) or focused on ICT rather than specifically e-health. Tools for e-health policy research^{18, 19} and development^20,21 have been reported. In reality, it will be too much to expect rigid global e-health policy, and a format encompassing global e-health principles and ‘complementary’ e-health policy²⁰ is much more likely. This might be structured in the form of a global e-health convention, as originally suggested by Schwarz and adopted at the Rockefeller conference on e-health policy.²²

Earlier expectations that global e-health might revolutionize the way in which we perform health care, and maximize our well-being, have not been realized. The recent resolution by the WHO may be a turning point, drawing the attention of domestic governments of member countries to the potential of, and need for, e-health in each of their countries. The next logical step is to focus that individual effort into the larger concept of global e-health. Each jurisdiction must accept that internal e-health policy cannot be independent of the international environment. This current policy fragmentation is as much a concern as the previously described policy void. An accepted strategy is needed that attends to global as well as local needs within a responsive policy environment, giving rise to the idea of ‘glocal’ e-health policy.

‘Glocal’ e-health policy development: cautionary examples

In any policy development, it is possible that ‘domestic’ (i.e. local) policy decisions may prevent e-health from functioning on a worldwide scale (i.e. global) by putting in place – inadvertently or deliberately – administrative and policy barriers.²⁰ When preparing their 1998 directive on protection of personal information, the EU commented that: ‘If each Member State had its own set of rules on data protection, for example on how data subjects could verify the information held on them, cross-border provision of services, notably over the information superhighways, would be virtually impossible.’ This perspective exemplifies the need for ‘glocal’ e-health policy development.

Around the world, some policies have been developed that affect global e-health. These include:

• the policy environment in Africa, which illustrates coincidental policy development;
  
  
• the European Union’s directive, and Canada’s response (the Personal Information Protection and Electronic Documents Act, PIPEDA), which illustrate reactive policy development;
  
  
• the e-health policy implemented by Malaysia in the 1990s, which is an example of potentially restrictive policy development;
  
  
• the Legally eHealth initiative of the EU, which is an example of a potentially autocratic approach.

The African policy environment

Kirigia et al²³ provided an optimistic view of the e-health policy environment in Africa, and concluded that the policy environment for e-health growth internationally was very encouraging. This was based on observations of a number of international policies that encourage sustainable e-health usage, such as the World Health Assembly e-Health Resolution²⁴ and the health-for-all policy for the 21st century.²⁵

In addition, Kirigia et al²³ pointed to ‘regional development and political forums such as the New Partnership for Africa’s Development (NEPAD), sub-regional economic communities, regional development banks and the United Nations Economic Commission for Africa’, each of which have ‘elements in their policies and/or strategies encompassing ICT development’. Finally, they noted the Blair Commission for Africa, which advocated massive investment in ICT and Internet connectivity and a ‘growing realization among bilateral and multilateral donor agencies of the need for supporting investments in ICT infrastructure and Internet connectivity in developing countries as an essential strategy for economic growth’. In addition, the African Union’s strategy for health in Africa lays out the planned development of health initiatives until 2015.²⁶

With the exception of the WHO resolution for e-health, all of the other documents refer to ‘ICT’ and not specifically to e-health. While a supportive ICT environment is needed, such policy is coincidental to, and not focused on, e-health. Developing a clear, supportive, e-health-specific policy environment is necessary too.

EU directive on protection of personal information

Ironically, as the EU prepared its 1998 directive on protection of personal information, they also contributed to the creation of potentially restrictive policy. OECD guidelines for privacy protection existed, but the European Commission decided to promulgate their own directive. This directive compelled countries wanting to do business with EU countries to have a regulatory system in place to protect personal information, and required businesses to adhere to ‘fair information practices’.

Lacking such legislation, Canada quickly introduced its own PIPEDA legislation in 2001 – a reactive response. But this also affected cross-border activities with Canada’s largest trading partner, the USA, since they had to meet the specified requirements in order to do business with Canada and the EU. This form of reactive, snowball, and ad hoc policy development is inappropriate. Furthermore, it may well cause difficulties for developing countries, effectively setting the policy bar too high. If ‘glocal’ e-health policy is permitted to develop in this fashion, those countries that could benefit most may be excluded from the outset.

Malaysia’s e-health policy

Malaysia was very proactive in developing both legislation (e.g. the Telemedicine Act²⁷) and guidelines (e.g. for teleconsultation) for domestic telemedicine. These were intended to broaden access to health care in a borderless fashion. They achieved this for domestic purposes, but may be viewed as restrictive for global e-health activities. For example, the section ‘Teleconsultation Beyond National Borders’ states that ‘Patients and health care professionals should be provided the opportunity to seek an expert opinion and treatment from overseas through teleconsultation’. But then two subclauses state ‘Foreign experts can provide teleconsultation to health care professionals and/or patients in Malaysia only at the invitation of the local health care personnel’ and ‘All overseas experts who are invited to provide opinion or who are referred cases must be registered with the appropriate regulatory authorities in Malaysia’. Processes for invitation and/or registration are not provided, and penalties for transgression are severe, including fines and imprisonment.²⁷ Such legislation raises potential administrative barriers to borderless global e-health initiatives.

EU initiative

In support of the European eHealth Action Plan, a report called Legally eHealth²⁸ was intended to place e-health in a European legal and regulatory context. The report focused on how EU legislation on data protection, product and services liability, and trade and competition law applies. The report correctly noted that ‘until these issues are tackled head-on in real cases, we will not begin to change the legal landscape in order to provide fertile ground for new developments’. However, if the resulting EU e-health policy is implemented then once more the EU will be forcing their requirements on the practice of global e-health. At the very least, such an approach will result in many years of retrospective policy realignment with other jurisdictions, maintaining rather than removing inter-jurisdictional barriers to global e-health practice. At the worst, it may ostracize developing countries from the global e-health community. Such approaches are not appropriate in the context of global e-health.

The way forward: a strategy

There are two basic policy options for global e-health:

1. Continued ad hoc development followed by policy realignment. This is the status quo. It maintains the confusion and prevents streamlined global e-health, and will require years of retrospective policy realignment to bring the many disparate approaches together. In the interim, many potential benefits of global e-health may be denied to the world’s population.
   
   
2. Progressive and collaborative complementary policy development. A better approach, likely to permit the benefits of global e-health to be realized sooner, would be to initiate a process to guide global e-health policy development. The goal would be to identify common principles that can be agreed with relative ease, and then to use these to encourage development of domestic policy that is in line with global e-health principles, and is thereby complementary. The outcome would be removal of administrative and political barriers to global e-health.

Collaborative policy development would necessitate the creation of an inclusive and ‘glocal’ process whereby policy implemented at each level permits meaningful access to ICT in a country and therefore in the health sector. To guide this process, the Glocal E-health Policy Development Framework has been proposed.²¹

Conclusion

Global e-health has the ability to cross all geopolitical, socioeconomic, cultural and temporal barriers – to provide health and health care to anyone, anytime, anywhere. But how do we facilitate, yet also manage, this new paradigm? Any future activities have the potential to create functional or policy barriers. To avoid this, and to allow the benefits of global e-health to be equitably distributed, a coherent strategy is required that is based on both global and local (i.e. ‘glocal’) thinking.

The potential impact of global e-health is huge. However, awareness must be raised of the improvements in health care that could be achieved through global e-health. There is a need for consistency in approach to complex inter-jurisdictional issues. There is also a need for concerted development of ‘glocal’ e-health principles and complementary domestic policy. The current global e-health policy void is a serious concern. Inappropriate policy developed in one jurisdiction could hamper the ability of e-health to fulfil its potential.

Global e-health is no different from any other tool. To use this tool for global good requires a common vision and collective determination to achieve that vision. At present, e-health is struggling to establish itself even on a local or national basis in many countries, particularly developing countries. Policy can determine the pace and direction of change. If the potential of global e-health is to be realized, a strategy is required that will identify globally acceptable principles and thereby allow complementary domestic policy to be developed.

Further reading

Commonwealth Secretariat. Commonwealth Health Ministers Book 2008 – E-health. London: Henley Media Group, 2008.

eHealth ERA. Database of European eHealth Priorities and Strategies. Available at: www.ehealth-era.org/database/database.html.

World Health Organization. Building Foundations for eHealth. Progress of Member States. Geneva: WHO, 2006.

References

¹ Institute of Medicine. America’s Vital Interest in Global Health. Washington, DC: National Academy Press, 1997.

² Scott RE, Palacios MF. E-health – challenges of going global. In: Scott CM, Thurston WE, eds. Collaboration in Context. Calgary: Institute for Gender Research and Health Promotion Research Group, University of Calgary, 2003.

³ MacPherson DW, Gushulak BD. Human mobility and population health: new approaches in a globalizing world. Perspect Biol Med 2001; 44: 390–401.

⁴ Kaul I, Faust M. Global public goods and health: taking the agenda forward. Bull World Health Organ 2001; 79: 869–74.

⁵ World Health Organization. Macroeconomics and Health: Investing in Health for Economic Development. Available at: whqlibdoc.who.int/publications/2001/924154550X.pdf.

⁶ Dodgson R, Lee K, Drager N. Global Health Governance: A Conceptual Review. Available at: whqlibdoc.who.int/publications/2002/a85727_eng.pdf.

⁷ Bettcher D, Lee K. Globalisation and public health. J. Epidemiol Community Health 2002; 56; 8–17.

⁸ Rigby M. The management and policy challenges of the globalisation effect of informatics and telemedicine. Health Policy 1999; 46: 97–103.

⁹ Scott RE, Lee A. E-health and the Universitas 21 organization: 3. Global policy. J Telemed Telecare 2005; 11: 225–9.

¹⁰ Bill and Melinda Gates Foundation. Foundation Fact Sheet. Available at: www.gatesfoundation.org/MediaCenter/FactSheet/.

¹¹ World Health Organization. Policy and Budgets for One WHO. Available at: ftp.who.int/gb/archive/e/e_ppb2003.html.

¹² Scott RE, Jennett P, Yeo M. Access and authorisation in a glocal e-health policy context. Int J Med Inform 2004; 73: 259–66

¹³ Bashshur RL. Health policy and telemedicine. Telemed J 1995; 1: 81–3.

¹⁴ Gobis LJ. Licensing and liability: crossing borders with telemedicine. Caring 1997; 16: 18–24.

¹⁵ White AW, Wager KA, Lee FW. The impact of technology on the confidentiality of health information. Top Health Inf Manage 1996: 16; 13–21.

¹⁶ Stanberry B. Legal and ethical aspects of telemedicine. J Telemed Telecare 2006; 12: 166–75.

¹⁷ Khoja S, Durrani H, Fahim A. Scope of Policy Issues for eHealth: Results from a Structured Review. Available at: ehealth-connection.org/files/conf-materials/ScopeofPolicyIssuesforeHealth_0.pdf

¹⁸ Scott RE. Investigating e-health policy – tools for the trade. J Telemed Telecare 2004; 10: 246–8.

¹⁹ Varghese S, Scott RE. Categorising the telemedicine policy response of countries and their implications for complementarity of telemedicine policy. Telemed J E Health 2004; 10: 61–9.

²⁰ Scott RE, Chowdhury MFU, Varghese S. Telemedicine policy – looking for global complementarity. J Telemed Telecare 2002; 8(Suppl 3): 55–7.

21. Scott RE. ‘Glocal’ e-Health – A Conceptual Policy Development Framework. Available at: www.mrc.ac.za/conference/satelemedicine/Scott3.pdf.

22. Rockefeller Foundation. National eHealth Policies – an Overview. Available at: ehealth-connection.org/content/national-ehealth-policies-an-overview.

23. Kirigia JM, Seddoh A, Gatwiri D et al. E-health: determinants, opportunities, challenges and the way forward for countries in the WHO African Region. BMC Public Health 2005; 5: 137.

24. World Health Organization. WHA58.28 e-Health. Available at: www.who.int/gb/ebwha/pdf_files/WHA58/WHA58_28-en.pdf.

25. World Health Organization. Health-for-All Policy for the Twenty-First Century (Resolution WHA51.7). Available at: www.paho.org/English/GOV/CSP/csp25_27.pdf.

26. African Union. Africa Health Strategy 2007–2015. Available at: www.africa-union.org/root/UA/Conferences/2007/avril/SA/9-13%20avr/doc/en/SA/AFRICA_HEALTH_STRATEGY_FINAL.doc.

27. Malaysian Government. Laws of Malaysia, Act 564, Telemedicine Act, 1997. Available at: www.parlimen.gov.my/actindexbi/pdf/ACT-564.pdf.

28. European Commission. Legally eHealth. Putting eHealth in its European Legal Context. Available at: ec.europa.eu/information_society/activities/health/docs/studies/legally-ehealth-report.pdf.

Document(s) 8 de 31