Floris van Dijk THE CITY - April 2018

E-HEALTH: The end of the urban/rural divide?

Photo by Tim Mossholder

Written by Floris van Dijk

In Aesop’s fable “The Town Mouse and the Country Mouse”, a proud town mouse invites his cousin from the countryside to visit the city and get a taste of urban luxury. While sitting down to a feast, the rodents are attacked by a couple of dogs. The rural mouse decides to return home, preferring gnawing on a bean than being gnawed by the fear now synonymous with the city lifestyle.

Historically, living in a city usually meant living a shorter life. The dense population favored the spread of diseases, the concentration of industry lead to more pollution. But since the 20th century and the widespread implementation of sanitary programs, like sewer systems, the life expectancy of the urban population has surpassed that of the rural population. In the US the gap increased fivefold in the last 40 years. Despite the increased risk of pulmonary diseases that accompany air pollution, living in urban areas appears to now lead to a longer life. The cause: the unequal geographic distribution of health facilities.

With an aging rural population and the refusal on the part of the rural elderly to put an end to their current lifestyle, this becomes pressing. In just the last 8 years, the European population older than 80 has grown by one percentage point (from 4.5% to 5.5%). By 2050, the European old-age dependency ratio is set to double. Since a 100% urban population is unlikely, states have to find ways to reduce the costs of healthcare in rural areas. One promising solution for this is e-health.

E-health refers to the use of information and communication technologies to improve health and the healthcare system. E-Health has been utilized for telecare, the installation of sensor-technology, the creation of online self-help courses, education programmes and apps, and other digital tools to reduce the number of health professionals required to take care of the elderly and increasing their ability to live autonomously.

Photo by Samuel Zeller

The Dutch are highly digitalized, with 97% of Dutch households having access to the internet, and internet traffic growing 22% annually. The government clearly has the means to digitize its public services, so it did. In the Netherlands, each and every person is required to have health insurance and the process is made easy. Registration takes place online, along with the application for subsidies for low-income households, and numerous Dutch healthcare apps are available to make things even easier. The Dutch government also has grand plans to cut costs through e-health.

An important step in this reduction of costs is ensuring that each citizen has his/her own personal digital healthcare environment, allowing each to manage to a certain degree a personal health record. Although the sharing of personal data has lost of its attractiveness in the wake of the Facebook data-scandal, this could allow caretakers to know more about their patients and adapt their services accordingly.

Long-term innovation within e-health is also ensured. The Dutch Ministry of Health, Welfare and Sports organize training programs to change the attitudes and behaviors of health professionals in both public and private organizations towards innovative healthcare. One example of this is the foundation of the Health Innovation School in 2017, the first of its kind worldwide. In more practical terms, the Dutch government wants 75% of the highly dependent population – the chronically ill and vulnerable elderly – to be able to independently monitor their own health by 2019, and to ensure quality by making on-screen communication with a care provider available 24/7.

Naturally, e-health is no miracle solution. Numerous sub-problems are yet to be resolved.  The obvious difficulty is training the elderly to use new technology, but a lack of public funding is another issue. The 2017 government coalition agreement stated that a mere €40 million – in a country of 17 million – will be invested in innovative e-Health projects for healthcare over the next 4 years. If the state is supposed to play a role in the innovation of its public services, then this amount is a little disappointing. Finally, and probably most importantly, the previously mentioned problem of data-confidentiality has not received a clear-cut answer when it comes to medical information. It has yet to be decided how exactly a centralized digital platform, which gives access to all medical information of virtually everyone should look like.

Nevertheless, e-health represents an opportunity. With an aging population, e-health offers a way to preserve social achievements of the healthcare systems in Western countries. Furthermore, developing countries will face a similar problem in a couple of decades as well, and with a less financial means. By 2050, China’s GDP per capita is estimated to be roughly half that of the US, yet it will allow its healthcare system to allow equal access to all, over an area of 9.6 million km².

In a word, e-health could contribute to ensuring that healthcare services can be provided to all citizens, not only citadins.

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