Introduction
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Despite substantial improvements in health in recent years, Bangladesh faces several challenges, including limited and inequitable access to health services, lack of adequate resources to meet the demands of the population and an increasing burden of noncommunicable diseases.[@R1]^,^[@R2] Information and communications technologies -- such as health information systems, mobile devices to support health systems (mHealth) and telemedicine services -- can contribute to the improvement of health systems in developing countries.[@R3] Here we describe the implementation of an eHealth policy in Bangladesh.

Approach
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A key aspect of the eHealth policy is the development of an integrated health information system, which includes a health management information system and an integrated human resource information system. A computerized health management information system provides tailored health services to stakeholders[@R4] and a human resource information system integrates health workforce data from a range of sources such as ministries, agencies and health sector organizations. All information is stored in such a way that it can be easily found by users in different locations and in a form that is suited to their needs. The integrated health information system should meet international standards -- such as ISO/TC 215 for health informatics -- and provide access to all digital databases. The completed system combines individual health records of all citizens, registries of organizations, the hospital information system and health workforce data.[@R5]

Relevant changes
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Between 1999 and 2005, several telemedicine initiatives were initiated in Bangladesh, mainly to support rural doctors with expert opinions.[@R6] In 2006 a mobile phone-based call centre was launched for subscribers.[@R4] In 2008, eHealth services were introduced, including computerization of health facilities at sub-district levels, internet connections, internet servers and an mHealth service for communicating with health-care providers. The implementing authority, the Directorate General of Health Services, established a data centre equipped with modern servers, a backup safety system, firewalls, virtual machine software and information security systems to protect the safety of patient records.

The mHealth service is provided by 482 *upazila* health complexes and district hospitals. The *upazila* sub-district health centres have 50--100 bed capacity with an operating theatre and junior specialists. A doctor is available 24 hours a day to provide consultations by mobile phone.[@R5] Subsequently, all community clinics and union health centres had internet connections installed and laptop computers provided by the Directorate General of Health Services. Several training workshops, which included lectures and demonstrations over several days, were organized by the ministry at district level. Selected health workers were given hand-held tablet devices.[@R5]

With recommendations from development partners and the World Health Organization (WHO), the Government of Bangladesh implemented a national eHealth policy in 2011.[@R7]^,^[@R8] In July 2011, the Directorate General of Health Services inaugurated the telemedicine service. By 2014, a total of 43 fully equipped government-operated telemedicine centres were in service.[@R5] These centres provide medical consultations via the internet by qualified physicians to patients visiting rural and remote community clinics and union health centres. The government also introduced a short message service (SMS) complaint--suggestion box to improve the accountability and transparency of public hospitals in Bangladesh. In about 800 public hospitals, a display board is mounted which describes how to send complaints about the quality of services or suggestions for service improvement to a mobile phone number. The government installed remote biometric time attendance machines in all *upazila* and district hospitals and in some tertiary hospitals to improve office attendance of staff. These low-cost machines can track attendance from the central office using locally-developed software.[@R5]

In 2014, 98 million individual electronic health records were generated from rural areas in Bangladesh, which will contribute to the population register for lifetime shared health records. The government has initiated partnership programmes with development and private organizations for implementing different eHealth services. For example, the Mobile Alliance for Maternal Action project by the government and D.Net, a development organization, provides information for pregnant women as well as advice for new mothers on how to care for their newborn infants and children. In collaboration with the Johns Hopkins Bloomberg School of Public Health, the mCare and mTikka projects track antenatal care and childhood immunizations.[@R5]

Lessons learnt
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The integration of information and communications technologies in the health system of Bangladesh faces several challenges and constraints, such as defining the services and standards across different organizations, the financial viability of the initiatives and the availability of technical staff.

There is a lack of common standards on health information and communications technologies and software, leading to difficulties in data management and sharing among different databases. Low internet connection speeds are a limitation in many areas. The high costs of infrastructure and integrated software development are also barriers to adoption of these technologies.

The private sector has fallen behind in the introduction of information and communications technologies and medical records from the private sector are not integrated with the national health database. A few large private hospitals have introduced eHealth and medical record systems. The government has plans to integrate data from the private sector and hopefully the large hospitals will soon join the system. However, organizing national representation of private sector organizations is challenging task. [Box 1](#B1){ref-type="boxed-text"} summarizes the main lessons learnt.

###### Summary of main lessons learnt

-   Despite successful implementation of health information and communications technologies in Bangladesh, challenges still exist -- such as technical problems, definition of services and standards across organizations and financial viability.

-   Common standards for health information and communications technologies are needed to facilitate data management and sharing among different databases.

-   The private sector was not included in implementation of the national eHealth programme and therefore medical records from this sector are not yet integrated with the national health database.

Despite early pilot interventions and successful implementation of several small-scale health projects using information technology, the progress in adopting eHealth strategies in Bangladesh has been rather slow and lacks robust data on effectiveness and cost--effectiveness which can provide evidence for scaling up to the national level. The information gathered in the health information system is starting to be evaluated. A recent study assessing the potential of an mHealth intervention for diabetes[@R9] showed that mobile phone messages could be used to support the management of diabetes.[@R10] The increasing popularity of eHealth services in developing countries can be explained by the rapid increase in mobile phone ownership and limited access to traditional health care and providers. eHealth promises a future where patients are more empowered with respect to their own health, community health workers use health diagnostic devices to monitor patients, to link with medical professionals and to track individuals.

These new methods of information sharing and delivery of services have the potential to improve the health of the population as they are low-cost and are readily accepted by users and service providers.[@R11] However, development of an integrated health information system is a complex and costly process. Clinicians, managers, policy-makers and researchers need to be better informed about eHealth systems, so that the potential of new technology can be realized. Innovative information and communications technologies for health can strengthen health systems by providing services to underserved people in resource-poor settings, helping to achieve universal health coverage in Bangladesh as well as in other developing countries.

We thank Natalie Linton, Oregon State University, United States of America. Shariful Islam is also affiliated with the Cardiovascular Division, The George Institute for Global Health, Sydney, Australia and the Center for International Health, University of Munich (LMU), Germany.

None declared.
