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Introduction

Much has been written about the potential for telemedicine in the developing world. However, after reviewing the literature, it is clear that the evidence base supporting its practical utility is rather slender, and that most of the material published to date has been in the form of comments, letters, discussions, product reports, news items or case reports.¹ None the less, in preparing this book, the implicit thesis was that telemedicine can have a positive effect on health care delivery in developing countries, and that ultimately it can reduce the global burden of disease. The latter could perhaps be regarded as the Holy Grail for workers in the field. How does the experience reported in the book reflect this ideal?

The examples in this book show unequivocally that useful services can be delivered in the developing world using telehealth. None the less, viewed from the perspective of telehealth activity in the world as a whole, it is clear that there has been relatively little use of telehealth in developing countries so far. One obvious reason is the information and communication technology (ICT) environment, where there are evident challenges to the more widespread use of telehealth and to the use of e-health generally. These are, in fact, general problems concerning the use of ICT anywhere, including:

• the cost of IT hardware and software
  
  
• the limited availability of fast broadband and mobile networks
  
  
• the slow development of software in languages other than English.

These and other factors add up to the so-called ‘digital divide’ between the developing world and the industrialized world (see Chapter 2).

ICT barriers

A useful framework for considering access to ICT is provided by the Real Access criteria.² These criteria have been used to analyse the factors concerning access to ICT and its use, including the ‘soft’ aspects that are often overlooked. The criteria are designed to help understand the reasons why ICT development projects fail to achieve their goals, and to identify the reasons why such projects succeed. There are 12 criteria, which are inter-related:

1. physical access to technology
   
   
2. appropriateness of technology
   
   
3. affordability of technology and technology use
   
   
4. human capacity and training
   
   
5. locally relevant content, applications and services
   
   
6. integration into daily routines
   
   
7. socio-cultural factors
   
   
8. trust in technology
   
   
9. local economic environment
   
   
10. macroeconomic environment
    
    
11. legal and regulatory framework
    
    
12. political will and public support.

An understanding of these factors can be used to improve the way that ICT-based development policies and initiatives are planned, monitored and evaluated.

Other barriers

Telehealth, of course, is a complex matter. A satisfactory ICT environment is a necessary, but not sufficient, condition for the successful practice of telehealth. There are other barriers to the use of telehealth, and they apply in the industrialized world as well. The barriers include:

• organizational factors, e.g. changing the way in which hospitals and doctors work
  
  
• human factors, e.g. lack of staff with the appropriate skills
  
  
• medicolegal matters, including ethical concerns.

As the examples in this book show, it is possible to overcome all these obstacles and bring about successful, and in some cases sustainable, telehealth operations.

Telemedicine examples

In summarizing telehealth work, it is usual to categorize the applications under three headings: clinical, educational and administrative. These categories are not mutually exclusive.

Administrative

This book contains only a few examples of telehealth work in the administrative category. This is surprising, since facilitating administrative work – conducting meetings at a distance, providing web-based data collection forms and supplying online reports, for example – are all perfectly proper forms of telehealth, and ones that are likely to provide major benefits in terms of avoided staff travel and improved information flows. Perhaps this is the unglamorous, and therefore under-reported, face of e-health.

Education

Although relatively little mention is made of administrative telehealth work, this book contains more examples of education. One of the most successful educational projects, and one that appears to be sustainable, is led from Geneva by the organization Réseau Afrique Francophone de Télémédecine (RAFT), which provides services in French-speaking African countries. Education is delivered in real time using interactive web-casting.³ A successful example of the opposite modality, asynchronous education, is the Pacific open-learning network of the World Health Organization (WHO).⁴ The open-learning network provides online (web-based) courses, course materials and other resources to health professionals in the Pacific region. In addition, 15 learning centres have been established in 11 Pacific Island countries to increase access to online materials and resources.

Although they are not explicitly identified in this book, there are two other significant educational resources that deserve mention. First, there is the HINARI project (Health Internetwork Access to Research Initiative), which was established in 2002 by the WHO, when it secured agreement from many of the world’s scientific publishers to make their journals available in developing countries at no cost to the reader.⁵

Over 3750 journal titles are now available to health institutions in 113 countries. Second, the US National Library of Medicine made the Medline database freely available to the world via the Internet in the mid-1990s. Using the PubMed search engine, more than 17 million citations and abstracts of biomedical research articles can be searched via the web. The ready availability of the Medline database via PubMed, and free access to several thousand journals via HINARI, are splendid examples of how the industrialized world can assist less fortunate countries. The indirect health gains of these initiatives remain to be quantified, but can confidently be assumed to be substantial.

The educational projects described in this book are undoubtedly successful. None the less, they should be viewed in a global health care context. Many countries face critical shortages of health service providers, such as doctors, nurses and midwives (Figure 28.1).⁶ This is important because, unsurprisingly, the number of health workers and their skills are positively correlated with population health outcomes. The WHO has set out a framework for improving the global health workforce, by focusing on strategies related to the stage when people enter the workforce, the period of their lives when they are part of the workforce, and the point at which they make their exit from it. The strategy focuses on:

• entry: preparing the workforce through strategic investments in education and effective and ethical recruitment practices
  
  
• workforce: enhancing worker performance through better management of workers in both the public and private sectors
  
  
• exit: managing migration and attrition to reduce wasteful loss of human resources.

Telemedicine has an obvious role to play in improving access to education, and perhaps in allowing better supervision of a dispersed workforce. One might expect

Figure 28.1 Countries with a critical shortage of health service providers. There is an estimated shortage of almost 4.3 million doctors, midwives, nurses and support workers worldwide. (Reproduced from World Health Report 2006;⁶ data taken from Global Atlas of the Health Workforce¹⁵)

that greater access to education could be achieved at lower cost by pooling of resources and by expanding the use of telemedicine and distance education. Clearly, education represents a fruitful potential area for telehealth in the developing world.

Clinical

In clinical telehealth, there has been little use of videoconferencing in developing countries, for the obvious reasons of the cost of the requisite technology and the restricted availability of suitable telecommunications. The Medical Missions for Children has a videoconferencing network to a number of hospitals in developing countries, although a good deal of the telehealth activity that takes place is educational in nature, for example mentoring of local doctors, rather than direct patient care (see Chapter 10).

In practice, a substantial proportion of clinical telehealth work in developing countries is done by email or by web messaging (Table 28.1). Successful examples of the use of email include the Cambodia work managed from Boston (see Chapter 13) and the global e-referral network operated by the Swinfen Charitable Trust (see Chapter 19). The latter has recently moved from a system based on plain email to one based on a secure web server. Long-running examples of the use of the web for delivering clinical consultations include the US Army’s system in the Pacific⁷ (see Chapter 15) and the highly regarded iPath system for case discussions among groups of pathologists.⁸

Intermediate between the two poles of real-time videoconferencing and store-and-forward messaging lies the VHF radio network installed in the Peruvian jungle to facilitate communications with remote health centres.⁹

Cost-effectiveness

Although the above examples should all be considered to be successful demonstrations of telehealth in the developing world, it has to be admitted that strict evidence for cost-effectiveness remains elusive. Analysis of cost-effectiveness is a health economics tool that enables comparisons to be made between alternative interventions in terms of their costs and consequences. For example, is it preferable to spend resources on a PACS system at the national referral hospital, or to implement a programme of directly observed treatment of tuberculosis? To answer this question requires not only that the costs be known, but also that the consequences – the health gain – can be calculated. The latter may be done in terms of life-years gained, for example; if so, the situation is relatively straightforward. If the health gain includes other advantages – perhaps improved quality of life or reduced incidence of medical complications – then assigning a monetary value to the benefits is likely to be more difficult.

Telehealth research workers know only too well that it is hard enough to obtain evidence for cost-effectiveness in telehealth work in industrialized countries; it is even harder to do so in developing countries. Yet the matter of cost-effectiveness remains a serious question hanging over the potential future use of telehealth. More than a decade ago, the question was posed whether it is ethical to devote significant resources to telehealth in the developing world if the costs and benefits are largely undocumented when there are health measures, such as vaccination, sanitation and clean drinking water, with characteristics that are well understood.¹⁰

The WHO has provided examples of interventions that, if implemented properly, can substantially reduce the burden of disease, especially among the poor, and do so at a reasonable cost (Table 28.2).¹¹ What is striking about this list is how little tele-health has yet been applied in these areas. Telehealth may have a place in directly observed treatment of tuberculosis (DOTS),¹² but little is yet known about its feasibility on a wide scale, never mind its cost-effectiveness. It is true that telehealth has been used successfully to provide HIV/AIDS services (see Chapter 9), but again it remains to be seen how easy it will be to scale up the pilot programmes.

In this connection, it is worth noting the Peruvian telemedicine network that is based on email transmission by VHF radio link. A recent study has documented fewer urgent patient transfers from health posts and health centres,⁹ and there is emerging evidence of cost-effectiveness.¹³

A strategy for telemedicine

Given the above, and the need to obtain quantitative evidence of cost-effectiveness, what is the right strategy for telehealth in the developing world? The key aspects appear to be:

1. Concentrate on areas identified by the WHO as being likely to affect the disease burden.
   
   
2. Work with local staff.
   
   
3. Try and establish within-country telehealth networks.
   
   
4. Evaluate the costs and consequences, to provide evidence of cost-effectiveness.

In 2006, Lord Crisp examined how the UK experience and expertise in health could best be used to help improve health in developing countries.¹⁴ He made a number of detailed recommendations, but pointed out that it was necessary for developing countries to take the lead and to ‘own’ the solutions, which could be supported by international, national and local partnerships based on mutual respect.¹⁴ This surely epitomizes any potential use of telehealth.

Conclusion

What then is the future for telehealth in the developing world? Clearly, telemedicine does not represent ‘the answer’ to all public health challenges in developing countries. However, it can provide value, particularly when it is employed to strengthen and support a local team, rather than simply being used to import expertise from outside to supplement or supplant local efforts. One important role for telemedicine is in the training of local health professionals. The place of telemedicine in direct patient care delivery remains to be established, although there are promising indications of its success in certain circumstances. Consultations via email and the web should form an essential part of health partnerships.

The long-term goal of telehealth work must remain the demonstration of its efficacy in comparison with well-understood measures such as the provision of safe drinking water and immunization (Figures 28.2 and 28.3). One unanswered question is the future design of telehealth networks. Whether resources should be concentrated into a single network or into several, it is clear that the long-term aim should be to establish within-country telemedicine networks (supported from out of country where appropriate) that:

• demonstrably alter health outcomes
  
  
• can be shown to be cost-effective and sustainable
  
  
• will act as a model for other countries to copy.

Figure 28.2 People forced to use one water source for all daily chores – like this girl in Pakistan – face increasing risks of gastrointestinal infections and other waterborne diseases. Together, these diseases kill around 2.2 million people globally each year, mostly children in developing countries. (Photograph courtesy of WHO/Christopher Black)

Figure 28.3 Child immunization at the Malipur Maternity Home in Delhi, India. Immunization is considered to be one of the most cost-effective health interventions. There is a well-defined target group; contact with the health system is only needed at the time of delivery; and vaccination does not require any major changes of lifestyle. (Photograph courtest of WHO/P Virot)

This will enable the success of the telemedicine second-opinion work that has been performed to date to be exploited on a global scale.¹ Telemedicine is a small but significant component of ICT in health care delivery. In the future, it is to be hoped that telemedicine will develop into a proven tool for facilitating learning and for capacity building, in addition to its role in direct clinical care.

References

¹ Wootton R. Telemedicine support for the developing world. J Telemed Telecare 2008; 14: 109–14.

² Bridges.org. Real Access/Real Impact Criteria. Available at: www.bridges.org/Real_Access.

³ Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: 5 years of distance continuing medical education and tele-consultations over the Internet in French-speaking Africa. Int J Med Inform 2007; 76: 351–6.

⁴ POLHN. Pacific Open Learning Health Net. Available at: www.polhn.com.

⁵ World Health Organization. HINARI Access to Research Initiative. Available at: www.who.int/hinari/en.

⁶ World Health Organization. The World Health Report 2006 – Working Together for Health. Available at: www.who.int/whr/2006/en.

⁷ Callahan CW, Malone F, Estroff D, Person DA. Effectiveness of an Internet-based store-and-forward telemedicine system for pediatric subspecialty consultation. Arch Pediatr Adolesc Med 2005; 159: 389–93.

⁸ Brauchli K, Oberli H, Hurwitz N et al. Diagnostic telepathology: long-term experience of a single institution. Virchows Arch 2004; 444: 403–9.

⁹ Martínez A, Villarroel V, Seoane J, del Pozo F. A study of a rural telemedicine system in the Amazon region of Peru. J Telemed Telecare 2004; 10: 219–25.

¹⁰ Wootton R. The possible use of telemedicine in developing countries. J Telemed Telecare 1997; 3: 23–6.

¹¹ World Health Organization. The World Health Report 2000 – Health Systems: Improving Performance. Available at: www.who.int/whr/2000/en.

¹² DeMaio J, Schwartz L, Cooley P, Tice A. The application of telemedicine technology to a directly observed therapy program for tuberculosis: a pilot project. Clin Infect Dis 2001; 33: 2082–4.

¹³ Martínez A, Villarroel V, Puig-Junoy J et al. An economic analysis of the EHAS telemedicine system in Alto Amazonas. J Telemed Telecare 2007; 13: 7–14.

¹⁴ Crisp N. Global Health Partnerships: The UK Contribution to Health in Developing Countries (‘The Crisp Report’). Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065374.

¹⁵ World Health Organization. Global Atlas of the Health Workforce. Available at: www.who.int/globalatlas/default.asp.

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