A Snap Shot of ‘Successful’ Telemedicine Implementations in Low and Middle-Income Countries

A Snap Shot of ‘Successful’ Telemedicine Implementations in Low and Middle-Income Countries

What is a successful telemedicine implementation?

A telemedicine implementation can be deemed to be successful when it is fully integrated into healthcare delivery such that it is and no longer viewed as ‘telemedicine’ (Mars and Scott, 2017). This is best exemplified by radiology in many developed countries, where the term ‘teleradiology’ is seldom used and imaging and communication over networks using radiology information systems and picture archiving systems is simply the norm for diagnostic imaging or radiology services. But in order to reach this stage, what characteristics must a telemedicine implementation have that makes it most likely to be successful?

Around the world, many telemedicine projects have been introduced and quickly abandoned (Schwamm et al., 2017; Wade et al., 2016) often due to a lack of continued funding commitment and lack of an overall strategy! Over 20 years ago seven principles were proposed to increase the chances for successful development of telemedicine (Yellowlees, 1997). These, and other principles for success, have evolved to include activities such as strategy development, needs assessment, business cases, and plans, readiness assessment, implementation plans, change management interventions, and ongoing monitoring and evaluation (Mars and Scott, 2017).

The Momentum Thematic Network for the Advancement of Telemedicine Adoption in Europe produced a blueprint of how to move telemedicine interventions from proof of concept to scale-up while making them sustainable. The 18 critical success factors for telemedicine deployment, have been laid out in four subgroups; context (cultural readiness, consensus on advantages of telemedicine); people (good leadership, the involvement of healthcare professionals, patients-centric, and technology-friendly); plan (pull resources, address client needs, business plan, change management plan, legislation, and assure technology can be scaled-up); and run (apply legal and security guidelines, involve legal and security experts, ensure telemedicine users are privacy-aware, availability of technology and e-Health infrastructure, monitoring services in place and procurement process) (Momentum blueprint, 2015). Greenhalgh et al. highlighted an important factor not addressed by Momentum, but noted in earlier literature, that if an innovation or setting under which the innovation has been introduced is complex then it is less likely to be successfully adopted, scaled-up, spread, and sustained (Greenhalgh et al., 2017).

Examples of telemedicine in developing countries

Telemedicine is used globally, but the extent and sophistication in developed countries contrasts with applications in developing countries. In developed countries, there has been continued growth in the use of telemedicine despite a need for heavy investment towards infrastructure. On the other hand, in developing countries telemedicine has mostly been used for tele-education as well as improving adherence to HIV/AIDs treatment using mHealth services (Combi et al., 2016; Hamine et al., 2015).

The RAFT (Réseau en Afrique Francophone pour la Télémédecine) telemedicine network started in Mali in 2001, then extended to other French, English and Portuguese speaking countries in West Africa but has also extended to Bolivia and Nepal. The network uses a very small aperture terminal (VSAT) in some remote areas for e-learning services and videoconferencing at minimal bandwidth to physicians located in the rural and remote areas of developing countries. Among the services under the RAFT network are continuous medical education (CME) courses, access to medical information, and teleconsultation in terms of second opinion from the distant experts (Bediang et al., 2014; Randriambelonoro et al., 2018).

Telemedicine and Telehealth in Latin America and the Caribbean (LAC)

In 1925, the use of telehealth started in LAC when the Maynard Columbus hospital sent a telegram requesting an antitoxin to battle a diphtheria epidemic that was affecting the local community (5G Americas, 2016).  Application of e-health in LAC is growing and has a great potential to address the challenges facing the health sector in this region by providing equitable, efficient, and effective ways to improve access and timely care (Fernández and Oviedo, 2011). Many telemedicine projects exist in LAC to address the severe shortage of HWs (Scott and Mars, 2015).  Therefore, advances in telehealth will improve the health system while speeding diagnosis and treatment and in addition, overcome geographical barriers, facilitate services and improve the quality of healthcare in LAC regions (5G Americas, 2016). Farach et al. examined e-health use for accessing underserved populations in several LAC countries (Colombia, Chile, Peru, Barbados, Haiti, Mexico, and Guatemala), with projects addressing communicable and non-communicable diseases as well as juvenile bullying (Farach et al., 2015). Perhaps the LAC country with the most widespread and sustained telemedicine application is in Brazil.

In 2007, a teleconsultation service within an existing national university and research network was implemented in Brazil linking clinicians (Pessoa et al., 2016). In Brazil teleconsultation is restricted by law to HW – to – HW communication and the patient is not permitted to be involved in the consultation except in an emergency, or for tele-assistance and telemonitoring (Garcia et al., 2015). HWs are able to connect with each other and also many telehealth centers are accredited (Moura, 2016). In addition, the Brazilian HWs have continued to benefit from Technology Enhanced Learning (TEL) through distance education (Oliveira et al., 2016).

Several telehealth systems exist in Brazil, such as HealthNet (teleconsultation); INDU (tele-education); dataNUTES (management); and SMART (monitoring); with a telehealth ontology through the integrated interface (Santana da Silva et al., 2016). Due to the increasing prevalence of the cardiovascular disease, a TeleECG solution was implemented in the city of Belo Horizonte to improve the healthcare services as well as reduce waiting time for cardiovascular services. Reporting on 1,954 consultations over 5 months in 2009, results showed that the use of the teleconsultation system had an important potential to reduce patients’ referral (78%), that the teleconsultation seemed to be adequate to the user’s need, as only 8% of users related that the teleconsultation did not answer their question and that 95% of users were satisfied or very satisfied with the system (Alkmim et al., 2015).  This service has now dealt with over two million cases (Chazard et al., 2015).

Telemedicine in Middle East and Asia

Jaber et al. reviewed telemedicine and telehealth activity and research in Saudi Arabia, Jordan, Kuwait, Syria, and Iraq (Jaber et al., 2014). They concluded that while telemedicine activity existed, barriers to its expansion and adoption were primarily a lack of awareness and knowledge about telehealth implementations, difficulty in application, and lack of time to adopt initiatives. More recently, individual research activity has been highlighted, including telemental health and teleaudiology (Al-Abri et al., 2016; Jefee-Bahloul, 2014).

In India, telemedicine started in 1976 with the satellite instructional television experience that connected several rural villages to provide education on hygiene and adult education (Bhaskaranarayana et al., 2009) and has developed due to the expansion of the ICT industry  (Mishra et al., 2011). The ISRO (Indian Space Research Organization) spearheaded the development of telemedicine and tele-education which has been of social benefit in India. In 2000, ISRO provided the world’s largest VSAT (Very Small Aperture Terminal) network connecting village hospitals. This type of technology has been used extensively in India connecting different hospital centers for teleconsultation and tele-education (Ramkumar and Selvakumar, 2016). Using space technology and satellite communications, ISRO has built and operated modern communication, remote sensing (ETtech, 2018), and meteorological satellites that have been used to connect qualified and specialized health professionals to the rural population in India (Bhaskaranarayana et al., 2009). Telemedicine has been used to offer services like; ophthalmology, retinal screening, tele-emergency, telestroke, telerehabilitation, and epileptology. Other areas that have benefited from telemedicine are teleradiosurgery, teleneuropathology and neurosciences. The Apollo Telemedicine Networking Foundation (ATNF) is the oldest and largest multispecialty telemedicine network in India, and in 2013 alone, 306,170 teleconsultations were done in the Aravind Eye System including 190,878 new and 115,292 review consultations (Ganapathy, 2014). Under the Government of India Pan African e-Network project, ATNF has delivered over 200 CME lectures to doctors in neurosciences and also to villagers in rural Tamilnadu via Internet-enabled village resource centers (Ganapathy and Ravindra, 2008).

The Pan-African e-Network (PAeN) project is an Indian Government contribution in collaboration with the African Union to provide tele-education, telemedicine, e-commerce, e-governance, resource-mapping, and metrological services to the people in Africa. The aim of this project was to create significant linkages for tele-education and tele-medicine, Internet, video-conferencing, and VoIP services, making available the facilities and expertise of some of the best universities and super-specialty hospitals in India to the people of Africa. Although aimed at all African countries, tele-Education learning centers have been set-up in 5 Regional University Centres in Africa, namely, Kwame Nkrumah University of Science and Technology, Ghana; Makerere University, Uganda; Yaounde University, Cameroon; Alexandria Faculty of Commerce, Egypt; and Chancellor College, Zomba, Malawi (Pan African e-Network Project, 2013). During the permanent executive committee meeting in Addis Ababa (African Union, 2018), the PAeN’s infrastructure and management of the project was transferred from the Indian Government to the African Union Commission which has already has identified ways of making use of the PAeN infrastructure for further add-on services which will be beneficial for Internet infrastructural development on the continent.

Skandarajah et al. evaluated an automated tablet-based mobile microscope as an adjunct for telehealth-based oral cancer screening (Skandarajah et al., 2017).  The tablets successfully collected images of sufficient quality to enable remote diagnoses in concordance with existing techniques. India has also implemented a toll-free helpline connecting HWs in the rural areas to access specialized medical care and professional services (Hegde et al., 2018) in management of hypertension and diabetes (Jindal et al., 2017) and a tele-diagnostic community-based hearing screening for children (Ramkumar et al., 2018).

In Bangladesh, a study that explored the knowledge, attitude and practices on eHealth of doctors in Dhaka hospital found that, of the 112 respondents, 50% had average knowledge and only 26%  had good knowledge of eHealth,  90% had a favorable attitude while patient follow-up and diagnosis were identified as the common eHealth practices (Parvin and Shahjahan, 2016). An advanced telehealth model was implemented to provide healthcare services for the rural people of Bangladesh. The model was successfully tested with patients of Marie Stopes hospital in Dhaka and demonstrated visualization of real-time data with the expert doctors (Prodhan et al., 2018). Another study conducted among university students in Bangladesh about the impact of Web 2.0 such as Facebook and Twitter on health information-seeking behaviors indicated that web-based health information seeking and sharing behaviors influence health-related decision making (Islam et al., 2017). Whilst for Sri-Lanka, a dengue surveillance system called Mo-BUZZ was developed and launched. An assessment of the usage and impact of the system showed a slow but positive uptake of the system (Lwin et al., 2017).

Hussain (2015) documented the history of eHealth initiatives (telehealth, telemedicine, and mHealth ) in Pakistan, that have evolved since 1990 and which started as small projects under public-private partnerships and donor funding. According to Khoja (2017), Roshan Telecommunication setup a telehealth link connecting hospitals in three Afghanistan provinces, Kandahar, Bamiyan, and Badakhshan to Aga Khan University Hospital in Karachi, Pakistan. The author reported that close to 20,000 patients have received treatment and nearly 6,000 teleconsultations and teleradiology sessions conducted. A telehealth solution for mental health was also implemented and this enabled primary care workers in rural areas to consult with those in urban communities to provide better access to healthcare (Khoja et al., 2016). In addition, Zahid et al. (2017) showed that those in those in the rehabilitation field had knowledge of ICT, which presents an opportunity for Pakistan to implement telehealth like telerehabilitation services for consultation, assessment, and therapy. In The Philippines, an Asian e-Health Information Network (AeHIN) was formed as a way of building capacity in the public and private health sector in support of patient care and public health (Marcelo and Marcelo, 2016).

Telemedicine in sub-Saharan Africa

Although countries in sub-Saharan Africa have benefited from telemedicine and telehealth projects with non-government organizations, government, and private entities providing financial, logistical and clinical support (Sundin et al., 2016),  few have scaled to full potential often remaining at the pilot level or proof of concept (Kiberu et al., 2017). mHealth has been implemented to serve multiple purposes as follows: (1) communication tool for behavior change, (2) clinic appointment or medication reminders, (3) monitoring and management of diseases and pandemic, (4) data collection and tracking, (5) enhanced communication among health professionals or between patients and providers, (6) education for health professionals or patients (Kallander et al., 2013), as well as for management of chronic diseases (Watkins et al., 2018) and telemedicine (Mars and Scott, 2017). mHealth interventions using short messaging services have improved adherence to antiretroviral therapy and tuberculosis (TB) treatment completion (Hermans et al., 2017). Likewise, technology support for TB treatment adherence using a smart pillbox improved TB treatment outcomes and lowered costs per patient and the burden on the limited resources (Broomhead and Mars, 2012).

In 1999, South Africa (SA) launched a National Telemedicine System (Jack and Mars, 2013). This has led to several telehealth initiatives in SA, for instance; dermatology, pathology, radiology, and ophthalmology, etc. (Mars, 2013). Several mHealth interventions have been used to improve HIV/AIDs and TB treatment adherence exists in SA (Maraba et al., 2018; Nachega et al., 2016). Guidelines have been developed to facilitate the practice of telepsychiatry. These were based on research and international evidence delivery of psychiatric services (Chipps et al., 2012a). After several years and some difficulty (Kekana et al., 2010), the Health Professionals Council of South Africa (HPCSA) has recently published General Ethical Guidelines for the Good Practice in Telemedicine in SA (HPCSA, 2016; Kekana et al., 2010; Mars and Jack, 2010)

The University of KwaZulu-Natal has been broadcasting lectures by videoconference and sending recorded videos of lectures to different African countries since 2001, with over 40 h of interactive sessions broadcast per week by 2010. These have covered postgraduate and more recently undergraduate training in over thirty medical specialties, nursing, medical informatics, and telemedicine (Mars, 2012). This has been shown to meet the academic needs of rural-based and African students with minimum impact on service delivery and substantial time and cost savings (Chipps et al., 2012b). For instance, an evaluation of the evidence on telepsychiatry and video conference-based education revealed that implementation of the telepsychiatry outreach model improved access to mental healthcare (Chipps et al., 2012a).

Social media platforms have also gained use in healthcare. WhatsApp technology has been reported in developing countries in the form of chat groups at hospital departments to provide updates on patient admissions, telehealth second opinion, changes in treatment plans and theatre scheduling, etc. (Mars and Scott, 2016). WhatsApp use has reduced unnecessary referrals, optimized use of scarce resource allocation, aided pre-hospital communication and facilitated CME (Martinez et al., 2018). A mHealth technology in Kenya has been used to remotely monitor malaria rapid diagnostic testing by community health workers for purposes of quality improvement (Laktabai et al., 2018) while in Ghana such technology has done well for hypertension control (Nichols et al., 2017) and access to sexual and reproductive health (SRH) services among the adolescents (Rokicki and Fink, 2017).

Although Botswana is classified as an upper-middle income country, the country still has a struggling healthcare system (World Bank Botswana, 2018). Despite continued scarcity of human and technology resources, the Botswana – University of Pennsylvania Partnership (BUP) piloted four mobile telehealth projects for cervical cancer screening, radiology, oral medicine and dermatology. The pilot projects were a success, and the m-Learning platform at BUP (through the University of Botswana, School of Medicine) enabled patients and healthcare workers to gain access to healthcare resources (Littman-Quinn et al., 2013). In another study Witt et al. (2016) demonstrated use of smart devices (tablets) in rural Botswana where there was only intermittent Internet access. The findings showed that the tablets are relevant in providing access to current medical information resources. An implementation evaluation on the use of television white space (TVWS) to provide bandwidth and connectivity to clinics in the rural areas of Botswana showed that TVWS has the potential to strengthen healthcare delivery in resource poor settings by providing reliable Internet connectivity (Chavez et al., 2016).

In Uganda, telehealth initiatives started in 1984 when clinical case conferencing was broadcast between Canada, Uganda, and Kenya by audio conferencing (House et al., 1987). In Tanzania, an SMS reporting tool was used to rapidly collate and monitor data (location, sex, age, and clinical condition) on Lymphatic filariasis (LF) in real-time. The approach of identifying, recording, and mapping patients’ data was reported to be feasible with the potential for scale-up in LF endemic urban settings (Mwingira et al., 2017). In 2012, Rwanda implemented an SMS-based system to improve maternal and child health (MCH) using RapidSMS. The pilot, which lasted for a year in Musanze district, indicated that the use of mobile phone could improve emergency care but requires a well-organized community structure in a low resource setting (Ngabo et al., 2012).

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Article by: Dr. Vincent Micheal Kiberu, PhD,
Health Informatician,
Makerere University School of Public Health.
https://sph.mak.ac.ug/