According to some estimates, the world needs more than 4 million additional physicians, nurses, pharmacists, laboratory technicians, midwives, community health workers (CHWs) and other front-line health workers.¹1 The world health report 2006: working together for health. Geneva: World Health Organization; 2006. Available from: http://www.who.int/whr/2006/ en/index.html. [accessed 11 September 2013].
http://www.who.int/whr/2006/en/index.htm... However, there is also a shortage of faculty that can provide high-quality training and mentorship for current training programmes²2 Mullan F, Frehywot S, Omaswa F, Buch E, Chen C, Greysen SR et al. Medical schools in sub-Saharan Africa. Lancet 2011;377:1113–21. doi: http://dx.doi. org/10.1016/S0140-6736(10)61961-7 PMID:21074256
https://doi.org/10.1016/S0140-6736(10)61... and continuing education opportunities for health workers. The use of new information and communication technologies (ICTs) can help to overcome these challenges.³3 GETHealth [Internet]. New York: Global Education and Technology for Health Summit; 2011 [updated 2013]. Available from: http://www. gethealthsummit.org/ [accessed 11 September 2013].
http://www.gethealthsummit.org/... ^,44 Frehywot S, Vovides Y, Talib Z, Mikhail N, Ross H, Wohltjen H et al. E-learning in medical education in resource constrained low- and middle-income countries. Hum Resour Health 2013;11:4–11. doi: http://dx.doi. org/10.1186/1478-4491-11-4 PMID:23379467
https://doi.org/10.1186/1478-4491-11-4...

Recent global investments in fibre and wireless infrastructure, as well as innovations in e-learning, electronic health (eHealth) and mobile health (mHealth) and in the social media, can be leveraged to train, deploy, support and empower health workers.⁴4 Frehywot S, Vovides Y, Talib Z, Mikhail N, Ross H, Wohltjen H et al. E-learning in medical education in resource constrained low- and middle-income countries. Hum Resour Health 2013;11:4–11. doi: http://dx.doi. org/10.1186/1478-4491-11-4 PMID:23379467
https://doi.org/10.1186/1478-4491-11-4... ^–88 Kaplan WA. Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? Global Health 2006;2:9–14. doi: http://dx.doi.org/10.1186/1744-8603-2-9 PMID:16719925
https://doi.org/10.1186/1744-8603-2-9... The International Telecommunication Union estimates that, in only four years (2007–2011), mobile broadband subscriptions in the developing world increased by more than tenfold: from 43 million to 458 million. Mobile devices and internet access are becoming increasingly necessary professional tools for health-care workers at all levels in developing countries. New fibre and wireless infrastructure, as well as the rapid growth of computer processing power, provide an unprecedented opportunity to scale up health worker training and improve its quality, as well as to optimize health service delivery and strengthen health systems.

Over the past 20 years, learning management systems have contributed greatly to the tremendous expansion of e-learning. The past five years have also seen an increase in massive open online courses. eHealth technologies, including electronic medical records, laboratory and pharmacy information systems, along with disease surveillance and supply chain information systems, are transforming health care. Mobile health (mHealth), which is the practice of medicine and public health supported by mobile devices, extends these systems to the most remote and inaccessible parts of the developing world. In addition, the same mobile devices used to optimize communication and support front-line health-care workers can be used to deploy multimedia training programmes and clinical decision support tools. The social media and the development of communities of practice have yet to be fully mobilized to support health workforce capacity building. The use of the social media by health workers has several potential benefits. Some examples are crowdsourcing of educational content, translations and localization (i.e. adaptation of the content to a particular region), peer-to-peer learning, joint problem solving and reflective practice. In addition, ICTs can strengthen communication between providers and patients, increase community support for health worker capacity building and heighten the demand for high-quality clinical services.

E-learning tools can support curriculum development and course scheduling and management in ways that are conducive to blended learning approaches and that take advantage of multiple learning environments. Such tools can also be linked with national health professional registration and licensure systems, as well as with health workforce planning, management and in-service training systems, to provide information and support to the health workforce throughout the health worker lifecycle. Following pre-service training, ICTs can be used to optimize the work of a health-care provider – the use of electronic health records, clinical decision-making, supply chain management and service quality control are examples – and to facilitate mHealth communications, continuing education and the establishment of professional social networks.

Training methods based on video conferencing, webcasting, recording, localization and playback of training can enable global access to the very best educators and are more cost-effective than standard face-to-face educational programmes. Interactive content programmes that incorporate gaming and adaptive learning tools can also be used.⁹9 Erhel S, Jamet E. Digital game-based learning: impact of instructions and feedback on motivation and learning effectiveness. Comput Educ 2013;67:156–67. doi: http://dx.doi.org/10.1016/j.compedu.2013.02.019
https://doi.org/10.1016/j.compedu.2013.0... By enabling the development of virtual networks of learners, e-learning makes learning a community effort and facilitates the sharing of training content. Furthermore, since e-learning can take place in the community, at the point of care or at other convenient points, training costs are reduced and health-care providers can remain in their clinics and communities, where they are most needed, without disruption of health-care delivery.¹⁰10 Funes R, Hausman V, Rastegar A. Preparing the next generation of community health workers: the power of technology for training. New York: Dalberg Global Development Advisors; 2012. Available from: http://hetv.org/pdf/ power-of-technology-for-training.pdf [accessed 11 September 2013].
http://hetv.org/pdf/power-of-technology-...

E-learning is not a second-rate alternative to traditional health worker education. It adds value and makes it possible to overcome the limitations of existing educational strategies. The goal of any health education strategy or curriculum should be to present the educational content and conduct the training in a manner that will enable all learners to acquire the clinical competencies they need. A blended learning strategy based on the use of ICTs, e-learning and other educational methods can achieve this objective.

Despite the potential and opportunities described herein, several challenges must be addressed before ITCs and e-learning can be fully employed to build health-care worker capacity globally. Some of them have to do with the limitations of the ICT infrastructure and of the ICT and e-learning technologies themselves; others are cultural, societal and regulatory barriers.

Despite recent investments in fibre and wireless network infrastructure, two thirds of the world's population still lacks internet access and, even in communities with new network architecture, the cost of connectivity remains prohibitively high.¹¹11 Farhan H, D’Agostino D, Worthington H. WebIndex 2012. Geneva: World Wide Web Foundation & Oxford Economics; 2012. Available from: http:// thewebindex.org/2012/10/2012-Web-Index-Key-Findings.pdf [accessed 11 September 2013].
http://thewebindex.org/2012/10/2012-Web-... The number of highly trained ICT experts is also insufficient for health programmes and institutions to adequately staff their own network support teams. In addition, in many communities a lack of electric power is the main obstacle to the use of ICTs and mHealth tools. The use and scale up of ICTs in health programmes are also hindered by the absence of appropriate and enabling strategies, policies and standards, the lack of harmonization across communication systems and the poor interoperability of technologies and platforms.

Many medical faculty members and health programme staff are reluctant to modify or abandon traditional teaching and learning methods that have been essentially unchanged for decades. Incentives may be required to promote the uptake of e-learning strategies among these professionals, in addition to training in computers and e-learning tools. Furthermore, since women represent the majority of health-care providers, efforts to leverage ICTs to train health workers will have little impact unless computer literacy and access to ICTs are promoted among women.¹²12 Tella A, Mutula SM. Gender differences in computer literacy among undergraduate students at the University of Botswana: implications for library use. Malays J Libr Inf Sci 2008;13:59–76. Various ministries, especially the ministries of information technologies, education, finance and health, will need to better coordinate and synergize their missions in connection with the use of ICTs among health workers. In addition, several issues need to be addressed with respect to regulation on content sharing and the use of e-learning platforms for the certification and accreditation of health professionals. Use of the internet to share content, faculty members, lessons and best practices, as well as to build social networks of learners, could bring down the regulatory silos that limit cross-border collaboration in health education.

Governments and donors will need to be shown evidence that investments in ICTs and e-learning for health workers lead to programmatic cost savings, increased productivity and improved health outcomes. New models of public–private partnership are needed to ensure the scalability and sustainability of investments in ICTs for the support of health-care workers. Governments and donors will need to recognize that corporate partners expect public–private partnerships to lead to new business and new markets. Similarly, private sector partners will need to recognize that governments, donors, health programmes, institutions and communities will expect public–private partnerships to lead to sustainable improvements in programmatic efficiency, productivity and improved health outcomes.

We recommend several measures to train, empower and support health workers in resource-limited settings in Africa, Asia and Latin America through the use of ICTs (Box 1). ICTs are a global transformative force. E-learning and other ICT tools offer ways of bridging the global health workforce gap, but several challenges must be overcome. The ICT “train” has left the station. It remains to be seen whether the global health workforce will ride along or remain behind.

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