4 Future Trends and Emerging Technology and Innovation

According to WHO40, future trends in digital education include, but are not limited to:

• virtual, augmented, mixed reality in education for skills development, clinical scenario role playing and facilitation of procedures;

• personalized learning adapted to the health needs of individuals and populations;

• AI and intelligent tutoring systems facilitating the customization of learning experiences;

• SGG for simulation and incentivized learning;

• utilizing social media or communication platforms, such as Facebook, WhatsApp, Skype, LinkedIn or Twitter, for knowledge sharing and interdisciplinary communication;

• big data and learning analytics (including regulatory and security issues) to determine areas needing reinforcement

• MOOCs, virtual learning environments (VLEs) and learning management systems as part of lifelong learning (continued medical development/CPD programmes;

• developing standards for reporting digital health education intervention trials; and validity evidence on measurements of instruments used in digital health education trials

4.1 Virtual reality and augmented reality

Given the finding that training which takes place in a health worker’s workplace setting tends to be more effective, there is a challenge for digital training to capture this “real world” dimension in so far as it can. Some of the newer trends in the training and development of healthcare workers include virtual and augmented reality, which are immersive and interactive technologies that allow the user to explore a digitally generated 3D world in real time. They provide real life simulations and allows for hands on, active learning and skills development experience to be used in clinical practice, far superior to traditional and theoretical learning.

A systematic review and meta-analysis41 on the use of virtual reality for the education of health professionals published by the Digital Health Education Collaboration in 2019, found virtual reality to improve knowledge and skills outcomes of health professionals when compared with traditional education or other types of digital education such as online or offline digital education. The Digital Health Education Collaboration have also published results from a systematic review and meta-analysis that suggested virtual patient simulations can more effectively improve health care workers’ skills development when compared to traditional learning.

40 Digital education for building health workforce capacity. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. 41 Kyaw BM, Posadzki P, Paddock S, Car J, Campbell J, Tudor Car L. Effectiveness of Digital Education on Communication Skills Among Medical Students: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. J Med Internet Res. 2019 Aug 27;21(8):e12967. doi: 10.2196/12967. PMID: 31456579; PMCID: PMC6764329.

Example 23: Life Saving Instruction For Emergencies

Using virtual reality for medical simulation training, a team of researchers based at the University of Oxford and KEMRI - Wellcome Trust Research Programme (KWTRP) - Kenya, developed the Lifesaving Instruction for Emergencies (LIFE) project. This project was tested on healthcare workers in Kenya to establish the potential feasibility and acceptability of low-cost VR for medical simulation training in a low income setting. The technology was well adopted by the cohort however the high cost element due to the hardware needs remained a barrier to wider adoption and scale up.

Trainees work through current best practice guidelines in a ‘real’ environment - they identify and find equipment, demonstrate knowledge of how to assess a newborn baby, and go through the key steps of basic resuscitation in the correct sequence, all under a realistic time pressure. The LIFE app now includes training scenarios that help healthcare workers manage and treat cases of COVID-19. The LIFE app is available on the Google play app store, has received a 4.5 star rating from users and the following review'It feels like a real life situation and helps you think on how best to save life in the shortest time'. The LIFE project has been supported by many global health players including the Médecins Sans Frontières, USAID, DFID and the BMGF.

Interestingly, a University College London start up called ‘Musemio’ are using the virtual reality platform combining virtual reality with gaming to develop innovative mobile virtual reality games for educational purposes for children and aids in the growing remote learning needs that have arisen out of the COVID-19 pandemic. The inventors have found that the immersive experience improves retention of knowledge, helps with attention spans and can help children to understand and relate to a subject better. Although they are active in the education space and not the health sector, the start-up has received a number of small funds and has been named ‘ones to watch in world of virtual reality’.

The WHO Academy is a flagship initiative still in development. The Academy aspires to be a globally accessible school for the future, combining the latest technologies in digital and remote learning (AI, VR etc) with advancements in adult learning science to offer innovative, personalised and multilingual training. The main goal is to ensure training is provided in a more systematic way to achieve scale and impact and reduce the typical 10-year timeframe to implement guidelines. Through a hub and spoke model featuring digital plus on-site training in campuses around the world, the Academy will utilize a train the trainers and leaders/managers approach allowing it to reach other benefactors with multiplier effect.

The WHO Academy launched its first augmented reality course for healthcare workers, on the proper use of personal protective equipment to protect themselves and patients during the COVID-19 pandemic. The course is intended as an immersive, engaging and easily accessible learning experience, which can be downloaded via a smartphone from the Apple App Store or Google Play Store, globally and can be completed in 20 minutes. The WHO Academy hub in Lyon, France will feature a health emergencies simulation centre and collaboration spaces for learning co-design, research and innovation.

4.2 Serious Gaming and Gamification

Serious gaming and gamification (SGG) refers to approaches in which learners engage in a competitive activity with educational goals intended to promote knowledge or skill acquisition. Gamification can be defined as the application of the characteristics and benefits of games to real world processes or problems and serious games can be defined as games designed specifically for the purpose of providing health professional education via a digital device.42

42 Digital education for building health workforce capacity. Geneva: World Health Organization; 2020. Licence: CC BYNC-SA 3.0 IGO.

A systematic review43 was done to evaluate the effectiveness of serious gaming and gamification interventions for delivering pre- and post-registration health professions education which covered 30 studies. From this review, although only one study measured patient outcomes (and reported better scores for doctors controlling blood pressure in some subgroups), all the individually played games with an objective assessment of knowledge suggested serious gaming/gamification was superior to traditional learning.

The review concluded that SGG is an educational strategy that could contribute to transformation of health workforce education in both pre- and in-service training, although there was lack of evidence from low- and middle-income countries (LMICs) which limited the review’s applicability. There was also a lack of studies which assessed patient outcomes or provider behaviour.

The cost of serious gaming devices might be a barrier for use compared with other digital approaches. For example, some use game consoles, which many health care workers in LMICs would not have access to. Other approaches include lower-cost modes of delivery, such as projecting a serious game to a group of students who play together. However, none of the eligible studies provided any information about economic outcomes of education or adverse or unintended effects of the intervention, which limits our understanding of the feasibility of implementing these interventions in practice as a cost-effective solution.

The OpenWHO platform, launched in June 2017, equips frontline responders with knowledge to better contain disease outbreaks and emergencies It is currently exploring possibilities to transform simulation exercises into interactive games, digitizing live role-playing game exercises online for epidemics and health emergency work. The PPE app has a new feature that deploys augmented reality (AR) technology.

Coach2PEV – is an innovative digital solution rolled out in Senegal and Benin by GaneshAID to measure EPI performance. Part of the approach uses gamification, performance reward and gamification, where health workers can see their performance ranking in a mobile phone dashboard.

Technology-focused providers such as Viamo use socalled “Edutainment” to reach health providers and the public. In 2020 Viamo rolled out its Wanji Game about COVID-19 prevention in DRC, in partnership with Peripheral Vision International (PVI) and JHUCCP Breakthrough ACTION. This interactive “listen-thenchoose” audio game is designed to promote positive behaviour and to test players’ knowledge and understanding of prevention techniques.

In high income countries, the use of games is commonplace in management and leadership training as the skill being taught - such as empathy, listeningcan be better taught through experience than imparting theoretical content

Example 24: Project Nigel

An example of a non-digital learning game used by a UK professional performance and coaching company, Lane 4, is a game called “Project Nigel” – in which three tiers of staff (workers, managers and senior executives) are required to complete a task collectively, while being given three different briefs and sets of instructions and working in relative isolation from each other. The point is to bring home the frustrating impact of lack of communication, lack of consultation and failure by leaders and managers to use the inherent knowledge of the “workers” to complete the task. Given many of the issues are management/leadership issues which are common to many sectors, there is scope for adaptation, and possibly digitization, of such illuminating games to local contexts.

The education platform, Moodle, is an open source Learning Management System (LMS) used by universities in the north and the south. Among its varied and versatile functions, the platform allows organization of outdoor/indoor serious-games with learners as its “TreasureHunt” module supports virtual-map treasure-chases using geolocation and QR codes. Medic Mobile’s Community Health Toolkit platform uses Moodle as its back end with offline use and gaming features, integrated with caregiving applications.

4.3 Remote learning and COVID adaptations in other sectors

4.3.1 Education Sector and COVID Adaptations

In the education sector, remote learning has a long and extensive history. The adoption of new technologies has brought many benefits, including automated response software; making accessible authoritative and up-to-date information and learning resources in multiple media; enriched self-access interactive learning activities; increased peer-to-peer interaction and communities of practice; real-time tutorial support; new learning assessment opportunities; and administrative communications and record updating.

However, the benefits associated with these developments are constrained by limitations in internet connectivity, the familiarity of providers and consumers of teaching and training with technology, the cost of data transfer, electricity supply, ownership of or access to suitable hardware and software. Thus for remote learning, older distance education approaches continue to find a use to reach learners, including the use of television and radio broadcasts. Where internet access allows, there are also options of accessing video or audio files asynchronously, as podcasts or videos to download or stream.

Similarly, audio or video can be loaded onto memory media, such as SD cards, USB flash drives, and provided to learners to install on their phone, tablet or laptop, as relevant. This avoids dependence on internet connectivity and data download costs. Thus the longstanding and evolved model of Interactive Radio Instruction (IRI), emerging from a mathematics teaching programme in Nicaragua in the 1980s and supported in multiple countries, has spawned Interactive Audio Instruction (IAI). An example of a model with installed video clips and other materials is English in Action, in Bangladesh. This programme provided demonstrations of teaching techniques and English language practice for teachers. Its predecessor, of the same name, in South Africa, used radio broadcasts transmitted directly into classrooms, for teachers to use with their pupils, live, in conjunction with pupils’ textbooks.

Whatever communications media and combinations are used, widespread preference is that such remote access to learning resources should be supported by face-to-face or if that is not possible, online chat discussion groups, whether self-supported or led by facilitators. Overall, rather than purely remote learning, the most effective option if possible is widely felt to be a blended approach with some group or individual interaction.

Remote learning under COVID-19

Against this pre-existing background, the COVID-19 pandemic has provoked an accelerated and wholesale ‘pivoting’ (i.e. radical and rapid shift) to remote learning, worldwide, at all levels of education systems. Organisations, teachers, trainers and learners with little or no background experience in remote learning have been forced, or have chosen, to adopt technology-based methods as their existing methods of operating were abruptly made unavailable.

As well as the direct teaching process, this has equally impacted on the essential supporting functions of education programme management, course development and production, administration, assessment, monitoring and certification. It has required new staff training, in areas including materials design and development, online tutoring, counselling, pedagogy, record keeping. Staff and learners have needed to strengthen and learn new ICT skills.

Uses and technologies have proliferated. International bodies have mobilised to collate, share and advocate experience and resources in remote learning. Notable among these have been the World Bank, OECD, EdTech Hub, the INEE, UNESCO and FCDO through Frontier Technology. These have provided platforms for interested parties to identify and contact organisations and programmes with potentially useful and relevant information, experience, expertise or resources.

Different models of remote learning have been adopted in different locations as an emergency response to the closure of schools and colleges arising from the pandemic. To illustrate this range, typical examples are below.

In Ghana, pre-service teacher training shifted from face-to-face model to a distance learning model when the universities and teacher training colleges closed. With the assistance of a project, T-TEL, which was supporting the Ministry of Education to enhance its teacher training, all teacher training went online. Teacher trainers were trained in online teaching and learning, students continued studying, including undertaking and submitting assignments. Training materials were accessed from a micro-site online. Participating teacher training colleges formed WhatsApp and Telegram groups for their students. Assessment and tutor-student interaction continued, entirely using remote methods. The training materials were loaded onto SD cards and provided to students who had limited internet access. For students who did not possess a smart phone to enable them to study this way, suitable handsets were made available on a hired-purchase basis.

In Uganda, all schools closed. With the support of an ongoing education development technical assistance project, SESIL, radio programmes were prepared centrally by the National Curriculum Development Centre, to reflect the school curriculum, and then translated into regional languages and broadcast by regional radio stations, aimed at the school-age children who were out of school. As well as the direct broadcasts to pupils, there were parent radio programmes, to encourage and advise parents and carers to support their children in learning. Based on initial evaluation feedback, radio programmes were revised to include scenarios of a teacher with pupils in a class; and following each broadcast episode, there was a live call-in for questions and clarifications.

In Maldives, when schools closed, the Ministry of Education carried out an emergency review and streamlining of the school curriculum, so that it was reduced in scope to give a better possibility of attending to key essential parts by the reduced means of remote learning. Two approaches for lesson delivery were adopted in parallel.

• Firstly, television programmes were made, of teachers delivering the lessons in a classroom (later, in their home, in lock-down). The recorded classes were then broadcast to a published timetable, live on TV, and also uploaded to a website for download or streaming on demand. A similar approach was adopted in several other countries.

• Secondly, Google Suite was adopted and teachers switched to holding live classes with their usual class of students, to a fixed timetable, by Google Classroom. Homework was set and received back, and marks recorded. Additionally, through the same system, attendance records were kept, teacher timetabling and absence and substitutions arranged. Teachers sought out and used teaching resources – materials and Apps, such as Pear Tree interactive presentation software, at their own discretion. Teachers were trained and certified as Google trainers, to support teachers in their locality. This approach was made feasible due to students from P3 upwards having been provided access to a tablet computer.

While there has been this wholesale shift to digital delivery, some analysts have described this as more digital “conversion” than digital “transformation” particularly in higher education establishments In the dawn of the digital explosion last year, many were caught off guard and reverted to simpler tools, for example delivering lectures through live, on-line sessions. However digital delivery also brings its own pedagogy and new ways to do things, extending boundaries of time for pre-class and post-class. For example, a “flipped classroom” is where students can listen to a pre-recorded lecture first on their own, then might be asked to take a test to gain entry to a live classroom, to demonstrate sufficient understanding of the subject matter. The class can then focus on the more interesting, discussion and analysis, after students have absorbed the factual part. This is a very good way of maximising the potential that digital has to offer.

Though it is too early to see how matters will change following the present COVID-19 situation, there is a widely expressed view that there has been a permanent change and that ‘building back better’ in the education system will include the incorporation to some extent of remote learning, alongside restoration and strengthening of face-to-face learning. For some training purposes, which are not logically tied to a locality in the way that school-based learning is, there may be less requirement to return to face-to-face mode. However, this would only be so if remote means were found to be sufficiently effective.

4.3.2 Agriculture sector

COVID-19 is impacting most sectors due to the mitigations, such as social distancing and lockdown measures, implemented to reduce further spread of the virus. The food and agricultural sector and its workers have been exposed to the impacts of the pandemic and like many other sectors have applied innovative and digital technology to respond to challenges

The agriculture sector has several online information sharing platforms, predating COVID-19, to enhance the knowledge base of agriculture workers. In addition to online learning platforms, agricultural workers have also benefited from innovative technology that helps improve worker performance and efficiency, especially during COVID-19. An example is the Water Efficiency Pilot based on Smart Agro technology that are being implemented in some Latin American countries. The project consists of a combination of remote sensors in the crops to detect agronomic variables, matched with an artificial intelligence algorithm to predict optimisation factors. The workers then receive recommendations via a smart device and can plan when to be in the field to irrigate their crops.

Taroworks44 is another example of a tool used to remotely manage agricultural field work operations. Through an offline platform and mobile app, Taroworks enables the creation of feedback loop between the extension office and field agents on farm data, crop yields and training materials. During the pandemic, the mobile app has been used to conduct field worker training and keep remote team members updated on important developments, via videos, documents or spreadsheets. Similarly, the Olam Farmer Information System45 works as a monitoring and evaluation tool for small agricultural companies, and the newer apps built in the system provide agri-training and development for workers, which has been used by over 300,000 farmers across 60 countries.

The technology solution providers Viamo have developed IVR messages for both teachers and agricultural extension workers in DRC, in addition to their work in the health sector. Viamo has produced IVR messages through its 3-2-1 service. Farmers can listen to sequenced recordings on topics such as improved seed varieties, how to purchase, how to plant, cultivate, and can hear impact stories. There are also early warning messages related to shocks, pests, weather etc., messages on climate mitigation and on market prices.

In Nepal, in response to an issue caused by high yields and insufficient storage capacity, Viamo launched an app to connect agricultural buyers and sellers. Users could register, select whether they had access to transport or not, and be connected to the best available option that matched their needs.

Viamo’s 3-2-1 service is sustainable as it is funded through partnership with mobile network operators (MNOs) – this PPP is not donor dependent. Viamo has found that putting a small price on messages can increase their perceived value. There can be different ways to do this –in Malawi, messages were free but users had to have a certain balance of credit on their phone to access them.