martes, 27 de noviembre de 2012

Trabajadores comunitarios de la salud, tecnología móvil y Ley de Conway. Parte I


“Un buen sistema de salud debe proveer servicios de calidad a todas las personas, cuando y donde se los necesite. La configuración exacta de dichos servicios varía de un país a otro, pero en todos los casos se requiere un mecanismo financiero sólido; una fuerza de trabajo bien entrenada y adecuadamente remunerada; información confiable sobre la cual basar las decisiones y políticas; instalaciones bien cuidadas y logística que permitan suministrar medicamentos y tecnología sanitaria de calidad”.

Organización Mundial de la Salud, 2012

Lo que leerás a continuación es la traducción del post Mobile Technology & Community Health Workers: A Game Changer for Global Health?, recientemente publicado en el blog de InSTEDD por Dennis Israelski, CEO de la organización.

Dennis Israelski
Para las naciones más pobres del mundo, la escasez de recursos humanos destinados a la salud constituye una crisis alimentada por la inestabilidad social, económica y política, la migración de trabajadores calificados a países más ricos y la inversión insuficiente en los sistemas nacionales de salud. Mientras tanto, nuevas agencias humanitarias globales deben responder ante exigencias cada vez mayores en los ya frágiles sistemas de salud.

En aras de resolver este dilema planteado por una mayor demanda de los financiadores y menos recursos humanos para sostener la prestación de servicios, se verifica un impulso creciente en los círculos de política sanitaria mundial encaminado hacia el fomento del uso de tecnologías móviles por parte de los trabajadores comunitarios de la salud –de aquí en más, “TCS”–.

Los TCS como puentes que acortan brechas

Los TCS funcionan como un puente entre las comunidades y el sistema formal de salud (por ejemplo, puestos sanitarios rurales, centros de salud, policlínicas, hospitales y autoridades centrales como el Ministerio de Salud). Tanto la investigación como nuestra experiencia en InSTEDD nos demuestran que las tecnologías móviles para la capacitación y el empoderamiento de los TCS pueden tener un impacto transformador en la salud pública, a través de abordajes costo-efectivos orientados a mejorar la cobertura de la población, la productividad y la calidad de los servicios de salud en entornos con recursos limitados.

UNICEF Frog Design Project Mwana, 2011
Hay abundante evidencia que demuestra que dispositivos portátiles de telefonía móvil pueden ser utilizados con mucho provecho por los TCS para mejorar una gran variedad de problemas de salud, incluyendo:
  • Determinación de tasas de asistencia prenatal;
  • Cobertura de vacunación;
  • Diagnóstico de enfermedades infantiles;
  • Promoción de medidas que garanticen embarazos y partos seguros;
  • Suministro efectivo de información de riesgos, que permita detener epidemias;
  • Aseguramiento de los mejores resultados posibles para pacientes con enfermedades crónicas.
Los TCS conforman un “reservorio de infraestructura cívica” que puede contribuir a que los sistemas de salud brinden una atención de alta calidad a un costo mucho más bajo, en comparación con los abordajes tradicionales en materia de salud pública. Pero como suele sucede con cualquier oportunidad, ésta viene acompañada de riesgos... En el caso de los TCS, éstos a menudo no son lo suficientemente valorados, entrenados, apoyados ni capacitados, lo que probablemente comprometerá la calidad de la prestación de los servicios sanitarios.

El liderazgo de Ruanda en materia de eHealth y mHealth

Una experiencia llevada a cabo en Musanze, Ruanda, cuya crónica ha sido recientemente publicada, es particularmente destacable. Musanze es el distrito más montañoso de Ruanda, situado a unos 85 km al norte de Kigali. Un ágil sistema de mHealth a través de SMS fue implementado para superar las barreras de acceso a los servicios de salud materno-infantil. Durante el curso del estudio, que duró once meses, los TCS reportaron sentirse mucho más proactivos en la búsqueda de nuevas embarazadas y en el seguimiento de las ya registradas, como resultado de los recordatorios enviados a sus teléfonos móviles. La tasa de error (el número de SMS enviados con errores de formato) cayó de 54% en los primeros cuatro meses al 8% a finales del mes undécimo.

Encontramos este ejemplo particularmente interesante, ya que es representativo de la fuerte política de incentivos en Ruanda en torno a la implementación de prácticas de atención médica con soporte en procesos electrónicos y proyectos de comunicación. Un abordaje estandarizado de la prestación de servicios de salud en todos los distritos y una aplicación coherente de la política sanitaria aseguran la armonización a nivel nacional de todos los proyectos de salud móvil –en contraste con las prácticas generales de mHealth observadas en otros lugares–.

El excelente liderazgo del Dr. Richard Gakuba, Director de eHealth del Ministerio de Salud de Ruanda, ha hecho de esta nación un lugar en el que otros países interesados en la escalabilidad de soluciones integradas sostenibles de mHealth para empoderar a los TCS deberían estar extrayendo protocolos de mejores prácticas

Richard Gakuba
En este video –en inglés– el Dr. Richard Gakuba describe cómo ve a las TICs como herramientas valiosas que ayudan a superar los obstáculos que aquejan a los sistemas de salud: http://youtu.be/O2k1l7sIo00.

La relevancia de la Ley de Conway

Tal como lo expresó Melvin Conway en 1968, “Las organizaciones que diseñan sistemas... están constreñidas a producir diseños que son copias de las estructuras de comunicación de estas organizaciones”. Esta observación, a menudo citada como “Ley de Conway”, se basa en el razonamiento de que para que dos sistemas separados puedan ser integrados eficientemente, los diseñadores e implementadores de cada sistema necesariamente deberán comunicarse entre ellos. Por consiguiente, la estructura de la interfaz de un sistema de software reflejará qué tan bien se han comunicado entre sí sus creadores...

Para ejemplificar qué tan crucial es el alineamiento de las estructuras de comunicación en la implementación eficiente de las tecnologías, recordemos el tristemente célebre accidente sufrido por la sonda de la NASA Mars Climate Orbiter (MCO). Dos equipos habían trabajado en colaboración, pero con base en dos sistemas de medidas diferentes: mientras que uno de ellos había utilizado el sistema anglosajón de unidades (pulgadas, pies y libras), el otro había recurrido al sistema métrico decimal (centímetros, metros y kilos). Asegurarse de que estas medidas se unificaran devenía crítico para la correcta ubicación de la sonda en la órbita de Marte... 

La sonda MCO (Mars Climate Orbiter)
“La gente a veces comete errores”, dijo el Dr. Edward Weiler, administrador asociado de la NASA para la Ciencia Aeroespacial. “El problema aquí no fue el error en sí, fue el fracaso de la ingeniería de sistemas de la NASA, y de los controles y ajustes en nuestros procesos para detectar el error”. El fracaso al no haber podido reconocer y corregir el error en la transferencia de información entre los dos equipos de la sonda MCO condujo a la pérdida de la nave espacial, destruida por la fricción con la atmósfera del planeta.

Como reflejo de la importancia de la Ley de Conway, el Ministerio de Salud de Ruanda es un claro ejemplo de una brillante política de eHealth, que garantiza la armonización de las estructuras de comunicación, lo que permite priorizar el despliegue de sistemas de información de salud interoperables, flexibles e innovadores.

Aplicando una arquitectura de diseño centrada en los beneficiarios

En InSTEDD aplicamos una arquitectura centrada en los beneficiarios para diseñar y desarrollar nuestras plataformas tecnológicas. Con el fin de crear y aplicar tecnologías que sean a la vez útiles y usables, trabajamos directamente con los usuarios en el diseño de aplicaciones móviles. Mediante la combinación de una comprensión de los requisitos de las diversas estructuras de comunicación involucradas en el suministro de servicios con métodos ágiles, producimos herramientas de código abierto escalables, de gran relevancia en los contextos en los que son empleadas.

En una próxima entrega presentaremos ejemplos concretos de cómo las herramientas de InSTEDD son utilizadas específicamente para empoderar a los TCS en entornos de muy bajos recursos.

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