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Introduction

What is the state of telemedicine in sub-Saharan Africa? There is no single repository of information on telemedicine in Africa, so it is difficult to provide current and accurate information on every country. However, it is apparent that many telemedicine projects in Africa are launched with a fanfare of press releases, but there is little or no information about their subsequent progress.

Demographics

Africa has a land mass of 30 million square kilometres, with a total population of approximately 965 million people, who constitute 14% of the world’s population.¹ Health provision in Africa is poor. The difference between Africa and the industrialized world was highlighted in the WHO World Health Report of 2006:²

The WHO Region of the Americas with 10% of the global burden of disease, has 37% of the world’s health workers spending more than 50% of the world’s health financing, whereas the African Region has 24% of the burden but only 3% of health workers commanding less than 1% of world health expenditure. The exodus of skilled professionals in the midst of so much unmet health need places Africa at the epicentre of the global health workforce crisis.

Sub-Saharan Africa can be defined as that part of Africa lying to the south of the Sahara Desert. This includes five countries whose political boundaries are traversed by the geographical boundary. It is made up of 42 countries and 6 island nations, extending as far east as Mauritius in the Indian Ocean.

Burden of disease and population predictions

The burden of disease is great. Africa has most of the HIV-positive people in the world – approximately 24 million. A million people die annually of malaria, and Africa accounts for over 90% of the half billion new cases of malaria each year. There is a high prevalence of tuberculosis, and poliomyelitis has re-emerged.³ The leading causes of death in the WHO African Region in 2002, in order, were HIV/AIDS, malaria, lower respiratory tract infections, diarrhoeal diseases, perinatal conditions, cerebrovascular vascular disease, tuberculosis, ischaemic heart disease and measles.⁴ While the focus of the industrialized world is on the ageing population and how to keep people out of hospital, average life expectancy is still falling in many African countries. Life expectancy is less than 45 years in 7 countries.³ For the foreseeable future, there will be a large number of people dying in Africa and a substantial birth rate, both of which place heavy demands on health care providers.

Provision of doctors

The WHO recommends that at least 20 doctors per 100 000 population are required to provide minimum basic health care services. Thirty-eight sub-Saharan African countries fail to meet this standard, 31 countries have fewer than 10 doctors per 100 000 population and 13 countries have fewer than 5 doctors per 100 000. It has been estimated that Africa would require an additional one million doctors to meet this minimum requirement. The shortage of health professionals in Africa is a result of underproduction, loss through migration and, surprisingly, in some countries, unemployment. There are 121 medical schools in Africa, with a ratio of 1 per 7.6 million people, compared with the industrialized world’s norm of 1 per 2 million people.⁵ The medical schools are not equally distributed, with 87 medical schools in 47 sub-Saharan African countries and 34 schools in 6 Mediterranean-rim countries. Four sub-Saharan countries do not have a medical school. The brain drain of health professionals from the developing world is the focus of the WHO World Health Report 2006, with rates of migration of health workers from African countries ranging from 8% to 60%.⁴

Health care funding

There is extreme poverty, with 41% of people in sub-Saharan Africa living on less than US$1 per day.⁶ Funding of health care remains difficult. A realistic estimate of the cost of providing basic health care to people in Africa is about US$34 per person per annum. Based on 2004 data, the governments of 34 sub-Saharan African countries allocate less than US$34 per capita per annum to health; 23 countries spend less than US$10 per capita. The average per capita expenditure on health in sub-Saharan Africa is US$22.

In 2001, Member Heads of States of the Organisation of African Unity signed the Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases, in which they pledged to set a target of allocating at least 15% of their annual budgets to the improvement of the health sector. This was re-affirmed by the Ministers of Health in the Gaborone Declaration of 2005. Only two countries have achieved this. By 2004, the average general government expenditure on health was 8.8% in the WHO African Region³ and, by 2005, a third of the countries had reached 10%. There was also a commitment by developed countries to give 0.7% of their annual income in aid. By 2006, only Denmark, Luxembourg, the Netherlands, Norway and Sweden had honoured this pledge.

Telemedicine as a solution?

Telemedicine has great potential to solve problems such as the shortage of health-workers and the provision of care to underserved rural populations (Box 22.1).⁷ The World Health Assembly Resolution on e-health (WHA58.28) of 2005 called on member nations to develop long term e-health strategic plans, provide the telecommunications infrastructure necessary for e-health and establish national centres of excellence. Several African countries have started to develop strategies.

It is disheartening to note that neither the WHO African Regional Health Report of 2006 nor the 2007 WHO publication, African Health Monitor, which was devoted to the crises in Human Resources For Health in Africa, mentions telemedicine as a possible solution to the shortage of health workers or the training of health workers in Africa. The World Health Report 2006 mentions telemedicine/telehealth/e-health once: ‘Greater access to education at lower cost can be achieved by regional pooling of resources and expanding the use of information technologies such as telemedicine and distance education.’² Similarly, the Africa Health Strategy: 2007–2015, developed by the African Union Ministers of Health in April of 2007, makes no mention of telemedicine, telehealth or e-health.⁸ The use of information communication technology (ICT) is mentioned twice, in the context of its lack of use to provide evidence to guide action within a health system, and as an ‘ingredient’ that makes up a functional health system. Africa’s commitment to the use of telemedicine is not clear.

The UN Millennium Development Goals (MDGs) include four relating to health: access to clean drinking water, reduced child mortality under the age of 5 years (currently 16.6%), improved maternal health, and combating HIV/AIDS, malaria and other diseases. It is unlikely that any African country will achieve these goals. In 2007, the UN Secretary General found it necessary to form a Millennium Development Goals Africa Steering Group to help African countries improve their performance in meeting the goals.⁹ Forty-one countries have begun developing their national strategies in line with the MDGs, and several have included telemedicine in their plans.

Obstacles to telemedicine

There are many obstacles to the implementation of telemedicine in Africa.

Telecommunication costs

Many barriers to the introduction of telemedicine in Africa centre on telecommunications legislation, infrastructure and costs. Telecommunications are not fully deregulated in Africa, and liberalization of policies is required. In 2003, there were monopolies for local, long-distance and international call services in over 60% of the countries, with 10% of the countries allowing monopolies for mobile and very small-aperture terminal (VSAT) services and Internet service providers (ISPs). This, and the fact that about 70% of Africa’s continental Internet traffic passes out of Africa, pushes up Internet cost.¹⁰ In the USA, the average cost for 20 hours of Internet access (10 hours peak and 10 hours off-peak usage), based on the cheapest available tariff and including telephone usage charges, is US$15.¹¹ The average monthly cost for sub-Saharan African countries is US$55. Twenty hours of Internet access a month, for a year, exceeds the annual gross national income (GNI) per capita, in 26 countries. To put these costs into perspective, the annual GNI per capita is US$41 400 in the USA and the percentage of GNI for 20 hours of Internet access is 0.4%. It is not surprising that fewer than 4% of Africans have Internet access and that broadband access is below 1%.¹⁰

Because of the cost of Internet access, even simple store-and-forward telemedicine is not always an affordable option in Africa. Videoconferencing via ISDN is also expensive. The average cost of a 30-minute videoconference at 128 kbit/s, from Africa to the USA, is US$48.30.¹¹ Satellite connectivity is also expensive. While VSAT access is available to all African countries, its use in telemedicine has been impeded by legislative problems, which have tended to restrict private enterprise and have resulted in high costs. The average annual VSAT licence fee in 83 African universities is US$13 553, compared with US$426 for European Union universities.¹² VSAT communication has been widely used in pilot projects, but the associated high costs are a factor in the lack of sustainability of some projects.

There has been rapid growth in the use of mobile phones in Africa. Mobile penetration has risen from 3% in 2003 to 21% in 2007, and is forecast to reach 30–35% by 2011. Costs are also relatively high, averaging 27% of GNI per capita per annum, compared with 0.3% in the USA.

Other obstacles

Other obstacles to the introduction of telemedicine include:

• a lack of telemedicine policies at national and regional levels and, as a result, a lack of budgets
  
  
• poor connectivity to the rural areas that are most in need of support
  
  
• the shortage of doctors and nurses in almost all countries
  
  
• low levels of computer literacy among health professionals
  
  
• lack of training in telemedicine
  
  
• poor technology support
  
  
• continuing regional conflicts in Africa
  
  
• the absence of administrative and financial models for telemedicine in the African setting.

The shortage of doctors is a particular problem. Telemedicine requires additional effort and, while its potential benefits are acknowledged by most doctors, many will not participate in telemedicine because of the extra work involved and/or the disruption to their work routine.

International telemedicine services may be a method of addressing the shortage of doctors in Africa. However, in the absence of adequate funding, service providers outside Africa are unlikely to be remunerated at the rates to which they are accustomed, if at all. Also, diagnostic and treatment algorithms used in the industrialized world may not be appropriate in Africa, and pharmacopoeias are likely to differ from country to country. The question of liability is yet to be formally resolved.

What has proved to be effective in South Africa is videoconferenced education, and there is a growing demand from African medical schools to participate in shared education. The provision of education may prove to be the catalyst for developing tele-medicine services.

Telemedicine initiatives in sub-Saharan Africa

Telemedicine in Africa is not new. In 1984, doctors in London made a diagnosis of Crouzon’s syndrome in a patient in Swaziland, using satellite communication.¹³ In 1987, there was clinical case-conferencing between Canada, Kenya and Uganda. This consisted of twice-weekly satellite audio-conferences, with EEGs transmitted from Mulago in Kampala to the Health Science Centre at St John’s in Canada.¹⁴ Satellite-based store-and-forward telemedicine was used by the US Army in Ethiopia in 1993.¹⁵

Pan-African telemedicine initiatives

The African Union is an international organization of 53 member states. The New Partnership for Africa’s Development (NEPAD) is a special programme of the African Union. NEPAD has developed a health strategy for the African Union, which does not refer to telemedicine or e-health but does refer to ‘the appropriate use of technology’.¹⁶ The NEPAD e-school project makes provision for the incorporation of an ‘e-health point’. The first NEPAD e-school was launched in mid-2005 at the Bugulumbya Secondary School in Busobya Village in Uganda, and a consortium of private companies has agreed to sponsor the demonstration project of 6 schools in each of the 16 participating countries.

The former President of India announced the launch of the Pan African Network, which aims to connect 53 African countries by satellite and fibre-optic links, to provide tele-education, telemedicine, Internet access, videoconferencing and voice-over-Internet protocol (VOIP) services. For telemedicine, one remote hospital in each country will have access to 10 specialist hospitals (7 in Africa and 3 in India). The remote hospitals will be provided with email and videoconferencing facilities, and facilities for transmission of ultrasound scans, echocardiographs and ECGs. The project has financial backing for five years, and will be coordinated by the African Union. While this will not provide a solution to Africa’s medical problems, it might serve as a starting point for further development and cooperation.

A workshop sponsored by the European Commission and the European Space Agency was held in Brussels in 2006. It established a Telemedicine Task Team, which has subsequently reviewed telemedicine opportunities in Africa. It will make recommendations for future telemedicine actions in Africa and in particular sub-Saharan Africa, with an emphasis on the use of satellite communications.¹⁷

International telemedicine initiatives

Some international store-and-forward projects, in which African doctors have participated, have been in operation for several years. However, use of these services in Africa has been limited. Why is this? The obvious reasons include the lack of infrastructure, the shortage of health professionals and the cost of bandwidth. What is often overlooked is the lack of training of African health professionals in simple store-and-forward telemedicine. The assumption is made that everyone knows how to take a photograph and send an email message. Many of the obstacles listed previously are relevant.

The Moorfields Eye Hospital ophthalmology projects have linked three regional hospitals in South Africa to England for second opinion services by videoconference and email,¹⁸ and their web-based second-opinion service is used by doctors in South Africa, Gambia, Tanzania and Ghana. The Orbis Cybersight programme also offers store-and-forward services to ophthalmologists in Ethiopia and Tanzania. The Swinfen Charitable Trust’s store-and-forward telemedicine service has been used by doctors in Sierra Leone, Ethiopia, Malawi, Uganda and Zambia,¹⁹ as has iPath, which commenced as a telepathology service and evolved into dermatology and radiology services. Private and multinational companies have also set up telemedicine services, both for their employees and for private patients who are able to afford international service.

In the Francophone African countries, the RAFT (Résau en Afrique Francophone pour la Télémédicine) project, based at the Hôpitaux Universitaires de Genève, has been running at eight sites in Mali since 2001, with additional sites in Mauritania, Morocco, Burkina-Faso, Senegal, Tunisia, Cameroon, Côte d’Ivoire, Madagascar, Djibouti and Niger coming on line in 2005. Over the first 5 years, this project ran 98 webcast teaching sessions (50 from Geneva and 48 from Bamako in Mali). The infrastructure was also used for teleconsultations using the web-based iPath platform and IP-based videoconferencing for remote consultations. Only 14 international teleconsultations, for neurosurgery, radiology and dermatology, were reported by 2005. This project has noted that the ‘high expectations of satellite technology are still unmet, as the cost of connectivity remains unaffordable for rural communities’.²⁰

The African Medical and Research Foundation (AMREF), based in East Africa, was founded in 1957, and has a long history as a flying doctor and radio doctor service. It is currently involved in developing four store-and-forward telemedicine sites in Kenya and Tanzania.

Projects within countries

As well as the international store-and-forward services, there are several examples of telemedicine projects in sub-Saharan Africa. As stated previously, this summary of activity in sub-Saharan African countries is likely to be incomplete, and may refer to some projects that are no longer active, as failure is not often reported.

In Angola and the Democratic Republic of the Congo, a non-governmental organization (NGO) called Promoting Social Development in Africa ran a trial store-and-forward project in collaboration with Partners Telemedicine. The project was not sustainable, and ended in 2005. Botswana has identified the need to set up telemedicine services, and the Botswana–Baylor Children’s Clinical Centre of Excellence has established the first telemedicine site in the country. Benin has a histopathology store-and-forward service with Paris, for the management of Buruli ulcers. Burkina-Faso is part of a tele-epidemiology network with France, and also participates in the RAFT project. Burundi participates in the iPath programme. Chad participates in the RAFT programme.

Anesthesia Overseas is assisting in training nurse anaesthetists in Eritrea, and is setting up a telemedicine distance education resource centre in one of the hospitals. Ethiopia is relatively active, although the country’s five-year health sector development plan does not include the use of digital technology to improve rural health. In 2006, an ICT for Health workshop attended by 300 people agreed to set up a working group to formulate an e-health strategy for Ethiopia. Telemedicine activity has been supported by a recent grant of US$2 million from India to fund a telemedicine project between Ethiopia and India for 3 years. There is also a report of 10 local hospitals being linked for telemedicine. Doctors have participated in both the Swinfen and iPath programmes and Johns Hopkins runs biweekly HIV clinical case presentations at the distance learning centre in Addis Ababa.

Gabon has participated in iPath. The Gambia has used the Swinfen Charitable Trust service and has participated in the Moorfields project. Ghana too has participated in the Moorfields and iPath programmes, and Satellife has been very active in the evaluation of personal digital assistants (PDAs) for clinical data capture. Ghana is in the process of expanding its fibre-optic connections throughout the country, which will improve its capacity to offer real-time telemedicine. At the same time, two projects are being piloted in a collaborative programme between the University of California at Berkeley and Intel Research. These are the REACH (Remote Asynchronous Communication for Healthcare) and TIER (Technology and Infrastructure for Emerging Regions) projects. In the latter, 5 WiFi networks covering distances of up to 58 km have been installed in Ghana, for use in education.

Guinea, which had early support from the International Telecommunication Union for telemedicine development, does not appear to have made further advances. Guinea-Bissau is participating in the Spacedream project funded by the European Space Agency, which is investigating how Earth observation, navigation and telecommunication systems can be used to improve access to antiretroviral therapy and health care. Telecommunications will be used to connect health workers in rural areas with a central hospital.

Kenya is working on an e-health initiative. The AMREF group has set up telemedicine pilot projects, and the Agah Khan Hospital group has telemedicine links with North America. They are also investigating the use of videoconferenced education between their centres. The Regenstrief Institute at the University of Indiana has a long association with Moi University in Eldoret and helped to found the Open MRS project, which is developing a framework for electronic patient records in resource-poor areas.

The Malawi Polytechnic is developing a wireless network to be used for telemedicine, and the Baobab Health Partnership has developed a touch-screen clinical workstation in open source software, which captures data in real time at the point of patient contact. The patient management system allows poorly qualified health care workers to provide high-quality HIV treatment.

Mali was an early partner in the RAFT programme and, with the ongoing assistance of the Hôpitaux Universitaires de Genève, has implemented the e-well project, which supplies stable power supplies and Internet connections to six sites to enable telemedicine, primary school education, adult literacy and the development of small business enterprises. In 2005, a store-and-forward teleradiology service was established between four hospitals using open source software via switched telephone links. After a slow start due to technical problems, 338 cases were sent in the first 4 months, a case load of approximately 30 X-rays per hospital per month, or about 1 case per day per hospital.

Mauritania has participated in the Raft and iPath programmes, and a strategy for community access to ICT has been proposed. In 1997, Mauritius – which is classified as part of sub-Saharan Africa – launched its first telemedicine project. The project failed, and a new store-and-forward service for radiology and ECGs between a private hospital and a hospital in India was set up in 2005, with a supplementary videoconference link.

Mozambique had a teleradiology service operating in 1998 between two hospitals, but this project was not sustainable. Namibia is a large country with a small population and no medical school. A nuclear medicine telemedicine link between Namibia, South Africa and the UK was established in 2003. Niger is part of a tele-epidemiology network with France, which monitors infectious disease. Doctors in the country have also made use of the RAFT and iPath programmes. Nigeria has Africa’s first and only national telemedicine association. In 2006, the first telemedicine centre was launched with a videoconference-based service between a private hospital and a hospital in India.

Rwanda formally launched its national telemedicine programme in 2007. Videoconference links have been established between three hospitals. An active distance education programme in public health has been running between the National School of Public Health and Tulane University. Sao Tome has sent cases to iPath. Sites in Senegal have participated in the RAFT programme, with reports of videoconferenced consultations with Toulouse and three hospitals with store-and-forward facilities for teleradiology and teledermatology. Sierra Leone and Sudan have sent cases to the Swinfen Charitable Trust.

South Africa has several new and established projects and services, which are described in Chapter 21. Tanzania has a store-and-forward project with the Rikshopitalet in Oslo and the Aga Khan Board of Volunteers in North America. AMREF has linked two sites in Tanzania as part of its four-site pilot project. Healthspan International, an NGO, has been active in setting up telemedicine projects using telephone lines, video cameras and television monitors for both store-and-forward and real-time telemedicine.

Uganda has connected three hospitals, and has been very active in a PDA project to gather health data, using Healthnet and Satellife. Through the International Telecommunication Union, there are several projects providing ICT access to rural communities. Cases have been sent to the Swinfen Charitable Trust service from Uganda and Zambia. In Zambia, two hospitals were recently linked to the University Teaching Hospital through a Swedish International Development agency grant.

Conclusion

While there is an upsurge in telemedicine activity in sub-Saharan Africa, it remains to be seen whether sustainable programmes will emerge. There is a need for telemedicine training throughout Africa, as, without it, telemedicine practice will remain the domain of a few enlightened enthusiasts. The use of international projects such as the Swinfen Charitable Trust, iPath, RAFT and the new Pan African Telemedicine Project will assist the introduction of telemedicine, but, unless substantial use is made of these services, they will not make a major contribution to improved health care in Africa. Problems such as international cross-border practice of telemedicine have not yet been adequately addressed, nor have questions of international and ethical standards for the practice of telemedicine. Africa needs to solve these problems so that they do not impede further progress.

For telemedicine to be of assistance in Africa, there needs to be greater government will to embrace telemedicine, changes in telecommunication policies, provision of affordable bandwidth, and the development of sustainable and affordable rural tele-medicine solutions. This will require substantial external assistance, goodwill and perseverance.

Further reading

Heinzelmann PJ, Lugn NE, Kvedar JC. Telemedicine in the future. J Telemed Tele-care 2005; 11: 384–90.

Kaplan WA. Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? Global Health 2006; 2: 9.

Kirigia JM, Seddoh A, Gatwiri D et al. E-health: determinants, opportunities, challenges and the way forward for countries in the WHO African Region. BMC Public Health 2005; 5: 137.

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