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Barkman, C., Weinehall, L. (2017)Policymakers and mHealth: roles and expectations, with observations from Ethiopia,Ghana and Sweden.Global Health Action, 10: 1337356https://doi.org/10.1080/16549716.2017.1337356

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Policymakers and mHealth: roles andexpectations, with observations from Ethiopia,Ghana and Sweden

Catharina Barkman & Lars Weinehall

To cite this article: Catharina Barkman & Lars Weinehall (2017) Policymakers and mHealth: rolesand expectations, with observations from Ethiopia, Ghana and Sweden, Global Health Action,10:sup3, 1337356, DOI: 10.1080/16549716.2017.1337356

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CURRENT DEBATE

Policymakers and mHealth: roles and expectations, with observations fromEthiopia, Ghana and SwedenCatharina Barkmana and Lars Weinehall b

aForum for Health Policy, Stockholm, Sweden; bEpidemiology and Global Health, Department for Public Health and Clinical Medicine,Umeå University, Umeå, Sweden

ABSTRACTThe rapid increase in mobile phone use and other telecommunication technologies inhealth care during the past decade has paved the way for optimism. mHealth (mobilehealth) initiatives need to be integrated into national health systems and priorities andfit into the system that the country has already invested in. Partnership betweengovernment, regional governments, health care systems, Community Health Workers,the private sector and universities is considered as a precondition for success. In turn,this requires strategic and integrative policy decisions on the national/regional level tobe defined in the action plans as concrete steps. Decision makers are calling for scale-upplans to be in place even in the pilot phases. Hope is expressed that the initial joy andcuriosity that new technology generates in the implementation phase will be transferredto routine work. Standards and a common technical architecture that enables interoper-ability and upscaling are key issues. Based on publications on policy and nationalstrategies, this paper highlights some key areas for decision makers’ role and expecta-tions with regard to mHealth. The paper will also report some mHealth experiences fromEthiopia, Ghana and Sweden.

ARTICLE HISTORYReceived 20 October 2016Accepted 26 April 2017

RESPONSIBLE EDITORNawi Ng, Umeå University,Sweden

SPECIAL ISSUEmHealth for ImprovedAccess and Equity in HealthCare

KEYWORDSeHealth; ICT; policymaking;upscaling; implementation

Background

mHealth is:

a service or application that involves voice or datacommunication for health purposes between a cen-tral point and remote locations. It includes telehealth(or eHealth) applications if delivery over a mobilenetwork adds utility to the application. It alsoincludes the use of mobile phones and other devicesas platforms for local health-related purposes as longas there is some use of a network. [1]

In this paper, we do not differentiate betweeneHealth and mHealth since both are used in describ-ing digital health care development.

Creative mHealth applications are able to trans-form health services in low-, medium- and high-income countries by, among other things, bringinghealth care to unserved or underserved populations[2]. A systematic digitalization of the health caresystem could lead to a more sustainable cost trajec-tory and could also improve the quality of care. NewmHealth applications are emerging as ways toaddress contemporary health challenges in a betterway [3,4].

Mobile phones can create entirely new opportunitiesfor health care, especially in many low- and middle-income countries (LMIC) with shortcomings in infra-structure, expertise and human resources in the health

care system. As new studies add further experiences onthe value of mobile information and communicationsolutions globally, awareness is increasing of its poten-tials among practitioners, researchers and decisionmakers. In many LMIC, confidence is growing thatmHealth solutions could alleviate the problems ofhealth systems caused by under-funding, lack of quali-fied staff and inefficient procedures [5].

The rapid increase in mobile phone use and othertelecommunication technologies during the past dec-ade has paved the way for this optimism. It has beenshown that digitalization can drive improvement inhealth care processes and organizations [6].

mHealth studies in LMIC illustrate a burgeoningdevelopment of knowledge in the field. However, theresults of mHealth studies have not yet had a signifi-cant impact on the countries’ policies and invest-ments in mHealth [7].

History shows that the development of eHealth/mHealth infrastructure is not without difficulties [8].Many countries invest heavily in different kinds of ITsystems that prove to be administratively complexand not always successfully deployed. The focus inthese cases is mainly on the technical aspects and noton the patient’s or doctor’s needs. In contrast, privatecompanies (e.g. Apple, Microsoft, Google, Spotify)build their initial digital products and services basedon customer surveys and then develop their offerings.

CONTACT Lars Weinehall lars.weinehall@umu.se Epidemiology and Global Health, Umeå University, 901 87 Umeå, Sweden

GLOBAL HEALTH ACTION, 2017VOL. 10, 1337356https://doi.org/10.1080/16549716.2017.1337356

© 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permitsunrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Another barrier in some countries is the lack ofcooperation between the public health sector, privatebusiness and research [9].

The aim of this paper is to explore policymakers’roles and expectations with regard to mHealth/eHealth with the main focus being on LMIC-relevant aspects. We illustrate some important topicsby reporting mHealth policies in Ethiopia and Ghana.We also highlight some principal issues from theexperiences in Sweden to illustrate the digital devel-opment in a developed country.

Decision makers’ responsibility

The political responsibility is to create optimal con-ditions for mHealth implementation, in terms of bothinfrastructure and regulatory frameworks. This will inturn support confidentiality and also shape thefinance and reimbursement models. It is essentialthat politicians establish a framework for university–public sector–industry relationships as well as clearrules for participation from the private sector tofacilitate private partners entering the market [10].

A reasonable explanation for why mHealth is notyet given a higher priority on the political agendamight be that the evidence of its scalability and long-term impact on health outcomes and cost benefits isso far insufficient [8]. This could lead to insufficientlevels of financial investments in mHealth and IT.The impact of mHealth projects should be judgedon how the technology influences people’s behaviour(both patients and professional health care workers)to improve the health service [11].

Of particular importance is whether or not themHealth solutions take into account local needs, asmHealth solutions must fit in resource-poor settings.Many times technology solutions designed for ruralneed also to fit urban areas. But it may be difficult toadapt urban solutions to fit rural needs [5,11].

A particular challenge for policymakers is to iden-tify financial/reimbursement models that supportdevelopment of mHealth from pilot tests to the sys-tem level [7].

Credence would be lent to mHealth legitimacy bytransparently monitoring and evaluating contribu-tions of improved work processes, developed serviceefficiency, improved patient safety and improvedhealth outcomes [12].

mHealth solutions

Governments’ and national administrations’ roles areto develop mHealth strategies and coordinate theobjectives of mHealth with defined national policies.Politicians must allow professionals, researchers andprivate operators, who have the necessary creativityand foresight, to find new solutions. How these two

preconditions can connect and work together is whatfosters development in mHealth [10,13].

It is a great advantage with regard to both safetyand cost if new solutions take advantage of, and buildon, an existing technical infrastructure [3]. If thesecriteria are met the solutions will receive growinginterest from decision makers [7].

The development and distribution of generic ser-vice platforms also play a vital role. These provide theprocessing power, storage, security, access controland other services to a broad range of mobile appli-cations, including mHealth. When these services areavailable as platforms everybody can use, in the formof mobile networks or the Internet, the marginal costrequired to develop new applications will be signifi-cantly lower [1].

Another important factor is improved educationand training in the field of eHealth and mHealth formedical personnel. One bottleneck, even with today’stechnical infrastructure, is the lack of knowledgeamong doctors and nurses of how to maximize thepotential of existing systems, not to mention under-standing and learning new mobile applications [5,14].

Coordination and partnerships

Lower costs and better network coverage creategreater opportunities for a wider range of applica-tions based on mobile phones and other telecommu-nication technologies, which in turn increases thepossibilities of using mHealth in health care [14].

In developing countries, mobile infrastructure hashigher penetration than fixed networks. In many places,the only technical possibility for mHealth solutions isdigital infrastructure such as flexible cloud solutionsandmobiles. Data-carrying capacity ofmobile networksis increasing rapidly and can often support programsneeded in the medical field, to transmit high-resolutionimages, videos and large files. Simple mobile phonesare, via text messaging, powerful tools. Smartphones,however, have much greater computing power, poten-tial for data storage, and can also create opportunitiesfor interaction with sensors and an intuitive user inter-face, which in turn can be used as a platform in manykinds of high-tech solutions [1].

mHealth applications are also used for training anddecision support via automated analysis of data or realtime in consultation with specialists. This makes itpossible for local health workers to diagnose and treatconditions remotely without patients needing to travelto specialized hospitals far away from their homes.

It is an urgent task to develop generic mHealthmodels that support mHealth solutions and fit differ-ent health conditions or primary care needs. Even if aresearch program based on mHealth applicationsfocuses on a particular disease, such as HIV/AIDS, itis necessary that the mHealth application also be useful

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for health interventions in general. Electronic medicalrecords software or a specific mobile application mustbe able to communicate with other systems [13].

Investments in publicly available services have thepotential to contribute to several programs. The moreprograms that are involved, the more profitable theinvestment. One advantage is that operators do notneed to go into the health sector, as they only need toactivate the application to be used. This can in turnfacilitate sector-driven innovation, and makes it possibleto develop applications even if the user base is small [1].

Standardization

Reports from both ministries and international agen-cies state that standardization is a key issue. TheWorld Health Organization (WHO) is by manyseen as the ‘technical agency’, which can help todeliver the best buys/best practices for mHealth.There is a strong need for a common technical archi-tecture that permits interoperability and upgrading,while at the same time, standards are also needed thatclarify national ownership, control of business rulesand information flow [13].

In consultation with market participants, the roleof governments and national administrations must beto find a balance between the individual solutionsversus standardization. Without standardizationcomes the risk of chaos and inefficiency. On theother hand, excessive standardization could paralyzedevelopment by removing business incentives.

It is imperative that mHealth solutions are sustain-able. A partnership between the government, localauthorities, health care systems, universities, privatesector (e.g. digital platforms) and donors is essentialin the planning phase in order to identify commongoals. mHealth requires strategic, integrated nationalefforts based on (if possible) common goals. Thesemust be adopted by the parties concerned and outlinethe main mission and policies, including concretesteps and follow-up plans. The private sector shouldbe involved from the start, represented by both largeand small companies and also start-ups [5,10].

Coordination between ministries/national authori-ties, academia, health care providers and private busi-ness is seen as a prerequisite for success. Forums,both digital and physical, promote dialogue withinpartnerships and new ideas.

Within the national authorities, it is particularlyimportant for mHealth development to occur withina consensus between the Ministry of Health andMinistry of IT and Telecoms [5]. This must includecommon policies, effective utilization of commonresources, partnerships with the private sector andupgrading mHealth competence within the healthservice [14]. Solutions must be designed in conjunc-tion with Community Health Workers, who

constitute the backbone of the health care systemand guarantee acceptance among patients and thegeneral public [14].

Expectations of potential benefits have causedmore than 100 countries to explore mHealth as ameans of achieving better health. At the same time,there is widespread recognition that there are alsomany obstacles and challenges to be addressed inorder to achieve success, such as limitations of access,as well as health and technological illiteracy.

At an mHealth symposium, ‘Evidence from low-and middle-income countries’, organized in 2015by UCL Institute for Global Health, BBC MediaAction and Umeå Centre for Global HealthResearch, Sweden, a number of challenges formHealth interventions were summarized. Theseincluded:

a lack of national policies to inform decision making,a lack of mHealth initiatives at a national scale,limited integrated partnerships between nationalgovernments and commercial organizations, limitedattention on how to tackle ethical issues aroundconsent, privacy and data protection and the separa-tion of mHealth interventions from existing healthsystems. [15]

Examples from three countries

Ethiopia, Ghana and Sweden have different experi-ences with the introduction of mHealth in their healthsystems. Without claiming completeness, we summar-ize the efforts and experiences of each country.

Ethiopia

Ethiopia currently has over 90 million inhabitants,80% of whom live in rural areas. The country has adecentralized three-level system of primary, second-ary and tertiary care where the regional and districtlevels have great influence.

The lowest level in Ethiopia’s health system is theprimary health care unit, which usually consists offive ‘health posts’, one health centre and one primaryhospital. In total there are 17,000 health posts. Eachhealth post has two Health Extension Workers(HEW) who provide preventive and basic curativeservices. These HEW represent the backbone of thehealth system. A HEW has one year of health train-ing, and is employed and paid by the state. A HEW isalso part of a career system which can provide oppor-tunities for training and advancement. HEWs notonly provide skills and knowledge of health, butmust also be agents for social transformation. Forexample, they work with the Model Family TrainingPrograms which train families on issues of impor-tance to individuals’ health, and, according to themodel of diffusion, allow these families to serve asmodels in the local community.

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Health centres have around 20 health professionalsand are responsible for the preventive, curative, inpa-tient and ambulatory services, treatment of commonpsychiatric disorders, and dental services. A primaryhospital provides approximately 60,000–100,000 peo-ple with preventive, curative, inpatient, ambulatoryand emergency surgical services, including caesareansection and blood transfusion. They serve as referralcentres for the health centres and as training centresfor nurses and paramedical health professionals. Thenext level above the primary hospital, called aGeneral Hospital, serves about 1–1.5 million people,while each of the 28 Specialized Hospitals has acatchment area of 3–5 million people.

For Ethiopia, the development of mHealth is con-sidered to be of particular importance within fiveareas:

● Data exchange to assess whether HEWs reachtheir community

● Supply chain so that the pharmaceutical supplyis guaranteed

● Real-time referral to the next higher level of care● Consultations between hospitals and remote

area services● Training and health education, for acquiring

skills locally.

mHealth solutions are regarded by the Ministryof Health to be important resources at the healthcentre level, which is why staff at this level shouldhave specialized expertise in information andcommunication technology (ICT). Therefore,priority is given to employment of HealthInformation Technicians (who undertake threeyears of education after high school) at everyhealth centre in Ethiopia. These technicians havea mandate to (a) improve the computer skills ofthe staff in the unit, (b) report health dataupwards in the system and (c) extract health datafor local use to improve the quality of care. BothPrimary and General Hospitals are also staffedwith Health Information Technicians. Thenational goal is to have 10,000 technicians withthis needed competence by 2020.

Parallel to this, a Public Health EmergencyManagement System has been developed to reportdaily or weekly on 23 severe diseases. In addition, aDrug Supply Management System has been imple-mented, with 26 regional hubs, that is responsible forkeeping track of drug availability at all health centres.

Ethiopia has more than 33 million mobile phones,mainly basic models. However, progress towardssmartphones has been rapid. Thus, mHealth solu-tions must take into account both the need for appro-priate technology and also adherence to countrystandards, while at the same time promoting thedesired health service outcomes [15,16].

Ghana

Ghana currently has about 26 million inhabitants, ofwhom almost 50% live in rural areas. In 2007, Ghanaadopted a new National Health Policy. Subsequently,however, it became increasingly evident that thehealth sector needed new and innovative ways ofreaching more people with information and resourcesto help them make informed decisions. This led theMinistry of Health (MoH) to adopt a Nationale-Health Strategy in 2010, with four strategies:

(1) Streamlining the regulatory framework for healthdata and information management, (2) Building sec-tor capacity for wider application of e-health solu-tions in the health sector, (3) Increasing access andbridging equity gap in the health sector through theuse of Information and Communication Technology,and (4) Towards a paperless records and reportingsystem. [17]

mHealth represents a key future component of thisnational strategy, which has the following goals:

● Mobile phone service to provide engagement tomeet overall health sector objectives.

● Appointment of an interagency team to assesshow specific services to support treatment andfollow-up, adherence to medication and patientsupport could be developed with mobile phones.

● Establishment of disease surveillance and epi-demic tracking systems within the GhanaHealth Service which use mobile telephonesand involve the private sector.

● Provision of real-time information for selecteddiseases [17].

This national strategy proposes action areas aspilot stages as well as a mechanism for scaling upwhere necessary. The strategy expects the govern-ment and private actors to work together to developand implement new solutions and to share the addedvalue of what they jointly achieve. The governmentwill define standards and rules on data protection,and introduce mechanisms for implementation andenforcement. Special attention will be given to inno-vative solutions that in the near future can contributeto improved public health [17].

Specific eHealth solutions will predominantly bedriven by the MoH in collaboration with stakeholdersand solution vendors which will enable the develop-ment of eHealth solutions that meet specific healthsector needs. Through the MoH, the government hasthe overall responsibility for setting the nationaleHealth agenda and is directly responsible for fund-ing, implementing and operating eHealth infrastruc-ture. It is hoped that this will stimulate andencourage the market to develop quality eHealthsolutions that are scalable, standards compliant andaligned with national priorities. To help keep the

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implementation on track, the strategy identified sev-eral critical building blocks for the first four years,including eHealth coordinating, regulatoryframeworks, mHealth pilots, broadband connectivity,an eHealth human resource capacity developmentprogramme, a functional Telemedicine pilot, initia-tion of electronic public interaction with the healthsector, an electronic patient records system piloted inselected health facilities and a Web-based DistrictHealth Information System [17].

Since 2010, several pilot mHealth projects, includ-ing Internet-based consultancy, have been initiated inGhana. In a published review which illustrates themHealth development in Ghana from 2010 to 2013,22 pilot projects were identified at various stages ofimplementation [18]. However, in the most recentlypresented Health Sector Medio-Term DevelopmentPlan 2014–2017 from the Ghana MoH, the eHealthStrategy was not specifically mentioned in the text.This could possibly indicate that the landmarks iden-tified as critical building blocks for the success of theeHealth strategy for the first four years are not yetfully in place [19]. Another possible explanationcould be that the field studies currently are financedby donations, which is why these efforts have not yetbecome visible in the MoH’s budget.

Sweden

Health care in Sweden is largely tax-funded, withresponsibility for health and medical care shared bythe central government, county councils and munici-palities. The role of the central government is toestablish principles and guidelines and implementlaws and ordinances. The counties are responsiblefor providing health care and the municipalities forproviding elderly care. Challenges include futurefunding (demographic development), quality (largevariations in the country) and efficiency (resultsclearly indicate potential for improvement).

The central government and the SwedishAssociation of Local Authorities and Regionshave endorsed a shared vision [20]. Many activ-ities related to digitization of mHealth/eHealth atvarious levels are already under way. More than90% of pharmaceutical prescriptions are e-pre-scriptions (electronically transmitted prescriptions)which are generated in the doctors’ electronic pre-scription system and transmitted through a securenetwork to the national e-prescription database.Patients can pick up their medication when theychoose at any pharmacy throughout the country.Through the platform My Health Contacts (MinaVårdKontakter: https://www.1177.se/Vasterbotten/Other-languages/Engelska/), a patient can usetheir mobile phones to request, reschedule or

cancel appointments, request prescriptions andask to be contacted by a health care centre.

Even though Sweden has long experience in digitaldevelopment in general, the development inmHealth/eHealth is relatively slow. A number of bot-tlenecks constrain how fast new technologies areimplemented and what benefits they yield. Thus,there are some lessons to be learned on what keyelements are necessary for success:

● Adoption of necessary legal changes to makedigital documents equally valid with paper docu-ments and to ensure security and privacy rulesetc. (In Sweden the patient has the right to seetheir own medical records, decide on informationsharing and block access to information.)Transparency of health data for the patients isalso essential from a democratic aspect.

● Agreement among key parties in the health caresector about common use of terminologies andcodes to ensure standardized data for researchand development.

● Focus on changing processes in health carewhen implementing new technology. Whenmedical records were first computerized inSweden, the administrative burden for doctorsincreased. The main reason for this was thatroutines for writing medical journals did notchange. Demands increased on doctors andnurses to report more data. Today there is toomuch documentation in health care which jeo-pardizes patient security. Swedish doctors spend60% of their working hours with patients [21].

● Infrastructure for mHealth/eHealth. Use what isalready working and available. One example ofthis is mobile ID in Sweden which was introducedby banks and is now applicable in health care.

● Develop reimbursement systems/financing systemsthat enhance mHealth/eHealth development. Forexample, in some areas in Sweden, doctors onlyget paid if they see the patient in person, not online.

● Set up clear governance to ensure possibilitiesfor private entrepreneurs. Governance shouldfocus on infrastructure and standardization,and free up private business to develop IT appli-cations through an authorization process.

● Prioritize financial investments in mHealth/eHealth. In Sweden the IT share of the healthcare budget has been constant at a level of 2.83%since 2003, while eHealth/mHealth developmentand IT users have increased by 90% [22].

● Focus on evaluation when installing or testingnew mHealth applications.

Digitalization of health care in Sweden faces manychallenges, including integration of health data col-lected by individuals using either remote monitoringsystems or mobile devices, use of digital decision

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support to develop personalized medicine, and imple-mentation of new e-services (specially to integratesocial care and health care services).

Summary

Digitalization in health care drives patient-centredimprovement and may increase efficiency andimprove quality of care. As previously presented,Ethiopia has focused on mHealth development,predominantly in rural areas. The country’s planis to staff every health centre, primary hospitaland General Hospital with trained HealthInformation Technicians. As Ethiopia already has33 million mobile phone holders, there is greatpotential to strengthen mHealth development.Ghana adopted a National e-Health Strategy in2010 with a priority to serve rural areas. Sincethen a large number of pilot mHealth projects,including Internet-based consultancy, have beeninitiated in the country. Sweden has a high levelof digitalization, but the road has been rocky. Manylessons have been learned as to the importance ofintroducing reimbursement models that supportinnovation and mHealth development, setting upclear governance to facilitate cooperation withboth research and private business, and finding abalance between standardization of terminologyand codes on the one hand and innovation anddevelopment on the other.

Successful development of mHealth requires clear-cut roles for key parties. Governments’ and nationaladministrations’ main role should be to create pre-requisites in a proper way for professionals, research-ers and private operators with creativity and foresightto find new solutions.

Conclusions

To achieve good results, mHealth applicationsmust interact with established health systems(and be regulated to fit these systems), which inturn is significantly influenced by how well thehealth care system can adapt to, and interactwith, new technology. Research is essential to pro-vide evidence-based findings on the results ofgovernmental decisions. Private business plays animportant role in creating new techniques, treat-ments and pharmaceuticals. The government’sresponsibility is to create optimal conditions formHealth to succeed, in terms of infrastructure,regulatory frameworks and reimbursement mod-els. The government’s role is also to evaluate andtransform successful pilot programs into full-scaleimplementation. The challenge is to balance thesefactors optimally.

In recent years, ministries, national authorities andinternational agencies of various countries have pre-sented their assessments and expectations formHealth implementation. There are numerous chal-lenges, and it is always easier to formulate a policythan to implement it. However, by learning fromother countries’ mistakes and successes, it is possibleto speed up mHealth development.

Acknowledgments

This article is one of the bases for the Round Table onmHealth organized by The Stellenbosch Institute forAdvanced Study (STIAS) in February 2017. The articlewas published thanks to financial support from theWallenberg Foundation and Umeå University.

Author contributions

Both authors are jointly responsible for the design of thisCurrent Debate paper and have together identified scien-tific articles and reports to be included. Both authors readand approved the final manuscript.

Disclosure statement

No potential conflict of interest was reported by theauthors.

Ethics and consent

None.

Funding information

None.

Paper context

To be sustainable, mHealth (mobile health) initiatives needto be integrated into national health systems and prioritiesand fit into the system that the country has alreadyinvested in. Strategic and integrative policy decisions onthe national/regional level are required in the concretesteps of action plans. Partnership between government,health care providers, Community Health Workers, theprivate sector and universities is considered a preconditionfor success.

ORCID

Lars Weinehall http://orcid.org/0000-0003-3025-2690

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[20] Government Offices of Sweden. Vision for eHealth2025 – common starting points for digitisation ofsocial services and health care. Stockholm. 2016.[cited 2016 Oct 19]. Available from: http://www.government.se/contentassets/b0fd09051c6c4af59c8e33a3e71fff24/vision-for-ehealth-2025.pdf

[21] The Swedish Agency for Health and Care ServicesAnalysis. Healthcare from the perspective of primarycare physicians – a comparison between Sweden andnine other countries. Stockholm; 2015. (Report 2015:9).

[22] Jerlvall L, Pehrsson T. [Inventory of eHealth in thecounty councils in 2014]. Stockholm. 2014. [cited 2016Oct 19]. Available from: http://www.inera.se/Documents/OM_OSS/Styrdokument_o_rapporter/SLIT-rapporter/eHlsa_i_landstingen_SLIT_2015.pdf

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