What is the role of free software in healthcare in a developing country, where money is likely to be scarce, where technical and human resources are limited, and where people are forced to improvise more often than in a rich, industrialized country? Is open source only a stopgap solution there, or can it perhaps play to particular strengths? Linux Magazine talked to two practitioners about this. Argentine Fernando Sassetti is an associate professor at the National University of Entre RÌos for the organization of health systems and socioeconomic health policy models. Armand Mpassy-Nzoumba has more than 20 years of experience as an IT manager and IT officer at the World Health Organization (WHO) in Africa and is a research associate at the Technical University of Berlin and a lecturer at the University in Brazzaville (Congo). Both referred to the GNU Health program as a practical example.

What we first wanted to learn about was the work environment of our interviewees: In what size of hospitals do they have GNU Health installed? How many patients are cared for there? How large is the catchment area typically? What is the social situation of the patients? Mpassy-Nzoumba reports that he has already set up GNU Health in hospitals of varying size, specialization, and ownership in Africa, most recently in a private clinic in a suburb of YaoundÈ, the capital of Cameroon. The clinic has 40 beds, employs about 20 medical professionals, and cares for an average of 50 patients per day. It serves a population of about 100,000 people, and patients often come from far away. The patients' social situations vary widely, but most of them are poor and have incomes below the national average of $241. Health care costs can consume up to 30 percent of a family's budget, so patients are sometimes reluctant to seek medical help.

Sassetti also talks about having implemented GNU Health, especially in smaller health centers on the outskirts of the city, where mainly the most vulnerable populations are served. He gained his first experience in a small hospital. Within a year of GNU Health's launch, 6,000 people had registered with the system, many of them from rural areas near the city. One of the most recent projects, he said, was a pilot with a municipality in the province of Entre RÌos that had 18 health care providers spread throughout the area.

What has changed in the work of physicians, nurses, and caregivers as a result of GNU Health? What impact was noted? Before installing GNU Health, Mpassy-Nzoumba tells us, doctors did everything manually. This led to various problems. For example, medical records were poorly maintained, resulting in diagnostic errors. Physicians did not have access to the right information at the right time, resulting in patients undergoing additional testing and incurring unnecessary costs. In addition, there was a lack of control over the supply of medication, and the hospital had high operating costs. Moreover, health statistics were lacking, and where they existed, they were inaccurate.

Since the implementation of GNU Health, all processes in the clinic have been streamlined, improving patient safety and quality of care. Doctors now have access to complete and accurate patient information, can better diagnose diseases, and avoid medical errors. Operating costs decreased due to reduced paper consumption and the elimination of duplicate tests and unnecessary imaging. In addition, revenues increased thanks to the effective billing of various services and the optimized review of bed occupancy. This in turn improved the operational efficiency of the clinic. Updated management information and timely reports and statistics helped. Last but not least, great progress was also made in terms of data security.

Sassetti's experience was very similar: "In a paper medical record, for example, it's difficult to see in a short period of time how many times a patient has visited the health center, whether they've taken medication for a chronic condition, how their blood pressure has been doing in recent weeks, or whether the social worker or health care provider has visited them at home. Professionals often relate that, with the help of the new system, they can follow the path of patients through the services of the health center. In this way, GNU Health improves communication between medical professionals in the same health center, resulting in more comprehensive health care."

And Sassetti reported of another special success (Figure 1): "The software's dental module now has features that are not included in the official GNU Health package. These functions were developed in the scope of a project in our faculty in cooperation with the humanitarian non-profit organization GNU Solidario. This shows that it is possible to work together and on a global scale, not just to use existing code, but to develop new things that meet the needs of professionals on the ground."

Figure 1: Argentine developers contributed special functions for dentists. Thanks to international collaboration, GNU Health is increasingly meeting its users' needs in a better way. Image © asphoto777, 123RF.com

What are the most important features of GNU Health? And what would practitioners like to see in future versions? Mpassy-Nzoumba has a clear opinion on this: "GNU Health's key functions are patient and financial management, ensuring quality and continuity of care and monitoring revenue and expenses to prevent clinic bankruptcy. The most important function to improve at this time is the pharmacy module, which still lacks a point-of-sale function."

Sassetti points out that GNU Health already has most of the features that healthcare needs: electronic medical records, epidemiology, management of medications and supplies, and so on. Of course, there is always the possibility of adding further modules for special cases. Currently, for example, a public health and applied technology study group within the GNU Health academic alliance is working on a project for the JÈrÙme Lejeune Foundation, he said. This foundation is engaged in the research of trisomy 21 and the care and protection of affected people. The project aims to create an adaptation of GNU Health to optimize the registration processes and care of these patients.

One aspect in particular springs to mind in connection with health data: data protection. How does GNU Health handle this? Privacy and security are a major concern for patients in Africa, says Mpassy-Nzoumba, and this is despite the fact that most countries in Africa have not yet enacted privacy regulations in the health care sector. Disclosing a patient's medical condition could lead to discrimination and exclusion in society, he said. GNU Health therefore uses strong encryption and limits access to patient data to authorized personnel with appropriate credentials, he said. The system also includes audit trails that record who accessed which patient data and when. Sassetti confirms this and adds that protecting patient data should not be limited to the computer system, but also needs to include procedures and agreements with employees to comply with data protection.

Earlier on, I mentioned that GNU Health is frequently used where low-income care is needed. How important is it that the software itself is free of charge? Very important, says Mpassy-Nzoumba: "Depending on the size of the healthcare facility, licensing costs for a proprietary solution can be a significant portion of the overall project budget. They typically range from tens of thousands to millions of dollars. This is one of the main obstacles to the introduction of electronic health records in developing countries and a major burden on the achievement of the universal health coverage goal of the United Nations in these areas. Universal Health Coverage (UHC) means that all people have access to the full range of quality health care services without financial hardship and when and where they need them."

Sassetti confirms this, but goes one step further. "It's possible that the lack of a licensing fee was one of the most attractive features initially," he says. But free software is far more than just the fact that you don't have to pay for a license. Free software, he said, allows practitioners in the field to get a handle on the health care system with management procedures without fear of not being able to pay for the license one day, or not being able to continue providing support. GNU Health systems guarantee continuity here and, in his experience, with low-cost resources and low maintenance.

And finally, there is the large and vibrant community. "The GNU Health community is a wonderful team," says Mpassy-Nzoumba. "I've benefited from the collective experience and knowledge of this community. The software is constantly being improved and updated by a large community of developers and users worldwide. In addition, the open source community offers a wealth of resources and support, including forums, mailing lists, and documentation that I can use when troubleshooting and solving problems. This helps me maintain the software effectively and keeps my projects running smoothly."

Sassetti shares this opinion: "Open source allows the community to develop and drive the local and regional customization required by health information systems."