PERSPECTIVES
Rebuilding the ship as we sail: knowledge management in antiretroviral treatment scale-up
Christopher Bailey
Knowledge Management Adviser, Department of Knowledge Management and Sharing, Evidence and Information for Policy, World Health Organization, 1211 Geneva 27, Switzerland (email: baileyc@who.int)
In a recent film about the Napoleonic wars, a frigate suffers heavy damage and loss of life after a withering canon barrage from a faster and more heavily armed privateer. Listing with a damaged hull and broken mast, the crew assumes they will return to port to rebuild. In the captain's mind, however, his duty is clear and their options are singular: they must rebuild as they sail.
In meeting the challenge of providing equitable care to the 40 million people in the world living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), the course of the disease makes the goal doubly demanding, as it has become increasingly clear that the future path of this pandemic will run through the poorest and most densely populated areas of the world areas that are the least well equipped to respond. Africa is home to 10% of the world's population but accounts for almost two-thirds of global HIV infections, so the greatest burden will be borne by countries with already weakened and in some cases failed health systems. Without proper health systems in place, is an effective strategy for scaling-up antiretroviral treatment (ART) possible? There is only one answer to this question: we must rebuild health systems as we confront the epidemic.
From an information science perspective, this is a two-fold problem. First, we do not have the information base and infrastructure to manage treatment and prevention and measure their impact. Second, which is more important, we have no mechanisms to recognize effective practice and disseminate this knowledge on a continent-wide scale. Simply put, expansion of treatment delivery has never before been accomplished on such a scale in such limited resource settings, and we do not know how to do it.
The maxim "learning by doing" has been adopted by WHO to capture the essence of the challenge ahead. It is clear that traditional approaches to operational research, though still necessary and vital, are not sufficient to respond with the speed and urgency that the global crisis demands. Classic double-blind peer-reviewed trials are, in many cases, too expensive and time consuming and may or may not have relevance or exposure to caregivers in clinics and hospitals in the developing world. In addition, information systems that have been proposed for Africa are often driven and owned by donor governments and international organizations and offered without local control or ownership of the information. This could have the unintended effect of undermining already weakened health systems in the countries most severely in need of assistance.
A new approach is needed
The world health report 2004 focused on the global challenge of HIV/AIDS and called for the application of knowledge management principles and techniques that can accelerate expansion of ART delivery as one way of meeting the historic challenge of delivering care to millions of patients in the most resource-challenged settings (1). WHO believes that effective delivery of care reduces stigma and offers individuals hope and incentives for prevention as well. But how can this be accomplished in practice?
WHO is advocating a new and ambitious holistic knowledge strategy to the historic challenge of ART scale-up in Africa. Combining the structures and techniques of knowledge sharing and management with information technology appropriately adapted to existing infrastructure and information-gathering practices, a vision of a system integrated throughout Africa is emerging that will capture, test and disseminate effective practice and innovation in HIV/AIDS treatment. The knowledge within this system will be locally generated, owned and applied but also shared across boundaries, with multiple benefits.
HIV treatment centres will have instant access to patient information within their clinic or hospital as well as immediate, preformatted reports of area treatment information, from catchment area to district level and countrywide analysis.
District-level analysis and resource allocation will be based on real patient care needs and data directly impacting on every aspect of care, from making available diagnostic tools to preventing stocks of ARVs from running out.
Country-level policy-making will be based on locally generated information, thus adding a broad and relevant evidence base as a supplement to information gathered from guidelines supplied by international organizations.
International organizations and research institutes will be able to identify evidence-based patterns and trends that could form the basis for better constructed hypotheses to help ensure relevance and success of classic research studies and trials, making them more problem-solving in focus and more cost-efficient.
All these aims will be accomplished with two basic tools used in an integrated way. The first is quantitative, with an electronic medical records (EMR) system designed specifically for low bandwidth settings with core data fields essential to monitoring and evaluation across borders, but flexible enough to add data fields to test out information that is of local urgency and relevance. The second tool is qualitative, a collaborative web space serving local networks of people through which knowledge can be shared across clinical settings; as new observations on treatment are made, testing strategies will be formulated to evaluate quickly and efficiently the promise of the emerging practices.
Although the driving urgency is the HIV/AIDS epidemic and the challenge of scaling-up ART, this system will be applicable to all of primary care from the first level of treatment to the making and implementation of effective policies. The end result will not only accelerate the pace and effectiveness of the expansion of ART in Africa, but will also strengthen health systems from the clinic to the global research community.
Is this approach realistic in Africa?
Four major categories of criticism have been levelled at this approach: information and computer technologies and human resource infrastructure are weak; there are cultural obstacles; nothing similar has been accomplished in Africa; and international organizations are unable to coordinate with each other let alone with local governments and organizations. These points are dealt with below.
Technology and infrastructure. It is true that general statistics on Internet connectivity have not improved much in Africa, rising from 1% to 2% of the general population in the last five years. In terms of total numbers, however, it is a dramatic increase, with 1 in 160 Africans now using the Internet (2). Regarding the weak human resources infrastructure, it is also true that the situation is bleak, often with no doctor present in the treatment centre. Paper information systems do seem to be in place, however, and are followed appropriately. As long as the electronic system is based on what is already being done effectively at the local level by the caregiver, professional or not, it should be easily learnt and will have an impact on the efficiency of workflow and will improve treatment.
Culture. Africa has been described as an information "gatekeeping" culture, with few traditions of information sharing or collaboration across organizations or communities. However, Africa also possesses an equally strong indigenous tradition of storytelling and knowledge sharing "under the palaver tree" (3). Capturing knowledge through informal networks, better to inform decision-making in more formal administrative structures, is at the heart of knowledge management. From this perspective, Africa may prove to be a more effective setting than others for this form of knowledge transfer.
Previous experience. An effective EMR system is in place in western Kenya and has already had a positive impact on health care in rural clinics (4). The argument that nothing like this has been accomplished in Africa and therefore cannot be expected to work is no longer valid.
Coordination. Given the ever shifting political landscape experienced by many organizations working in Africa, either foreign or indigenous, effective coordination is always a challenge. WHO's special relationship with ministries of health, its convening power, and its reputation as an "honest broker" will be crucial in aligning the locally operating partners that are essential to this strategy's success.
The proposed integrated information strategy is practical, scalable, locally relevant and realistically achievable. Within its framework, all members of the HIV/AIDS treatment community from the nonprofessional clinical caregiver to district-level resource managers, health ministers and researchers in medical institutes will do their part in rebuilding the ship as we sail. 
Conflicts of interest: none declared.
1. Sharing research and knowledge. In: The world health report 2004 Changing history. Geneva: World Health Organization; 2004. Chapter 5.
2. Jensen M. African Internet: a status report, July 2002. Available from: http://www3.sn.apc.org/africa/afstat.htm
3. Sopova J. In the shade of the palaver tree. UNESCO Courier, May 1999. Available from: http://www.unesco.org/courier/1999_05/uk/signes/txt2.htm
4. Rotich JK, Hannan TJ, Smith FE, Bii J, Odero WW, Nguyen Vu, et al. Installing and implementing a computer-based patient record system in sub-Saharan Africa: the Mosoriot Medical Record System. Journal of the American Medical Informatics Association 2003;10:259303.