1. Is Anybody Out There? Assessing the Global Audience for Health Care Web Sites Elizabeth Gummerson, Center for International Development at Harvard University

2. The Debate “Information is the fuel of medicine, and we have none. Year by year we are falling behind.” - Doctor in Timbuktu “Our priorities are hygiene, sanitation and safe drinking water. How is the internet going to help with that?” - Nurse in Kathmandu

3. Study Design Development Health Site- A web site that addresses health issues that are widely or over represented in under developed Countries. The site should provide tools or information regarding medical care, donors, epidemiology, health care policy and economics, or other information expressly relevant to health care and development.

4. 200 Health Web Sites 100 Non-development Health Sites (General) 100 Development Health Sites Sites Hosted in Europe US or Canada (Development-Global) Sites Hosted Locally in Developing Nations (Development-Local) Study Design Cont..

5. Study Questions  IS IT USED? Are development health web sites actually being accessed by users in developing nations ?  IS IT USEABLE? Are development health sites designed in a way that is accessible to users in developing nations?

6. Are development health sites designed in a way that is accessible to users in developing nations? –Size in Bytes? –Uptime? –Java and Plug-ins? –Browser requirements? –Text-only versions? –Multiple languages? Criteria Evaluated: Question #1: ________________________________________________

7. No differences in website uptime, But locally hosted sites larger Percent Uptime (n=185) 97.3 98.5 95.8 Average Size of Home Page in Bytes (n=185) 57,000 52,000 86,000

8. Development sites support lower version web browsers Minimum Browsers Supported (n=45)

9. Both development and general health sites offer simplified versions Percent offering simplified version (No Java, No Plug-ins) (n=45)

10. Development sites better tailored to low resource and multiple language environments Percent of Sites with a Text-only Option (n=185) Percent of Sites with Multiple Language Options (n=185)

11. Answers to question 1: Are development health sites designed in a way that is accessible to users in developing nations? -Uptime is comparable across all categories -Local sites home pages slightly larger in bytes -All three categories offer java and plug-in free versions -Development sites offer more for low resource and multiple language users CONCLUSION : development sites do not suffer major drawbacks in accessibility ____________________________________________

12. Question #2: Are development health web sites actually being accessed by users in developing nations ? Surveyed webmasters of health sites asking for user session data: - Total user sessions -Top countries by user session -Percentage distribution by developing nations, industrial nations, LDCs and unknown origin ____________________________________________

13. Total User Sessions- March 2001 (n=45)

14. 25 Top Visitor Countries

15. Developing Nations 2% Unknown 40% Industrial Nations 58% General Health Sites (n=11) Where are User Sessions Originating?

16. Developing Nations 2% Unknown 40% Industrial Nations 58% General Health Sites (n=11) Where are User Sessions Originating? Developing Nations 3% Industrial Nations 57% Unknown 40% Global Development Sites (n=12)

17. Developing Nations 2% Unknown 40% Industrial Nations 58% General Health Sites (n=11) Where are User Sessions Originating? Global Development Sites (n=12) Developing Nations 3% Industrial Nations 57% Unknown 40% Developing Nations 10% Unknown 12% Industrial Nations 78% Local Development Sites (n=4)

18. Answer to Question #2: ________________________________________________ Are development health web sites actually being accessed by users in developing nations ? CONCLUSION: Development health sites do not to appear to be any more successful than their non-development counterparts at reaching audiences in the developing world. Locally managed health sites may be an exception.

19. Further Thoughts/Questions E-health encompasses much more than health web sites Why is usage of apparently useable sites so poor in developing countries? –Is content irrelevant? Would it help to “focus group” content for developing country consumers? –Is connectivity poor? How would the data look if normalized to total national bandwidth? –Is there simply less demand than we imagined?

20. Thanks Thanks to Dr. Amir Attaran and Tariq Mohammed for their contributions to this research.