The current pandemic has shown that there is a need to re-examine what lies at the heart of healthcare, which is the health and wellbeing of people, in Africa and the world as a whole. It has shown that quality health has to return to its place as a fundamental human right and that the attainment of the highest possible level of healthcare is an important global goal to be pursued till quality health can be provided across every community in the world.
The Alma-Ata Declaration of 1978 is arguably the most important milestone of the twentieth century in the pursuit of universal healthcare delivery. It highlighted primary healthcare as a fundamental means to achieving the goal of health for all. But few decades after this declaration, health for all remains one of the challenges facing the twenty-first-century world, especially in Africa. The fulfilment of this vision will be a herculean task in Africa, if not impossible, because of the exponential rate at which the population of Africa is increasing. This is concomitant with growing burdens of endemic and new infections, brain drain in the health system, depressing socioeconomic factors, inadequate financing and increased divide in healthcare delivery in the urban and rural areas.
One of the fundamental challenges hindering quality healthcare delivery in remote areas in Africa has been the inability of both healthcare providers and the recipients to be available at the same location and at the same time. Any measure that can reduce this gap in time and location beckons a great hope in the realization of quality health for the dwellers of the remote places in Africa. With the level of commitment to universal healthcare delivery, information and telecommunication offer possibilities beyond bounds to improve healthcare delivery to remote areas.
Information and telecommunication have shown the potentials to address the challenges of location and time in healthcare delivery especially in underserved and remote communities which constantly suffer from a lack of quality healthcare if any at all. The importance of telemedicine cannot be overstated though much of its impact has not been seen and felt. The key issues – access, equity, and quality – that face the twenty-first-century African health system can be addressed by taking advantage of information and telecommunication.
The World Health Organization (WHO)recommends that the WHO and its member states should “integrate the appropriate use of health telematics in the overall policy and strategy for the attainment of health for all in the 21st century, thus fulﬁlling the vision of a world in which the beneﬁts of science, technology, and public health development are made equitably available to all people everywhere” (World Health Organization, 2008).
While the definition of telemedicine continues to be debated in medical literature, it must be noted that telemedicine is not a technology or branch of medicine that offers a cure for all without the involvement of health care providers. Any attempt taken to describe or define the term must have at its base four fundamental elements (World Health Organization, 2010):
1. Its purpose is to provide clinical support.
2. It is intended to overcome geographical barriers, connecting users who are not in the same physical location.
3. It involves the use of various types of ICT.
4. Its goal is to improve health outcomes.
If telemedicine is to be considered in the simplest term, as any medical activity performed at a distance, its history dates back to the Middle Ages. However, the development of modern telemedicine has been hinged on the advances in the electronic means of disseminating information. The introduction of digital methods of communication as a replacement for the analog methods sandwiched between the rapid drop in the cost of access to information and communication technology (ICT) has kindled the fire of telemedicine among healthcare providers.
This improvement among others is leading the implementation of telemedical services across Africa, especially in remote areas.
In Africa, the first reported use of modern telemedicine was in 1984 when a diagnosis of Crouzon’s syndrome was made via a satellite link through a slow-scan television transmission between Swaziland and London. By 1987, clinical case conferencing started between Canada, Kenya, and Uganda with EEGs being transmitted from Mulago Hospital in Uganda to the Health Science Centre at St. John’s Hospital in Canada.
Over 60% of Africans reside in remote areas, with up to 80% facing socioeconomic and geographical barriers in accessing quality healthcare (Amzat & Razum, 2018). The health condition of remote dwellers is generally below that of those living in areas with accessible healthcare. Millions of residents of rural, remotes areas in Africa travel a long distance, at an enormous cost, just to access healthcare especially in cases where a specialist is needed. In fact, in almost all cases, when a general physician refers a patient in a rural area to a hospital at a distant place for specialist attention, the response on the part of the patient is usually delayed due to long waiting list at urban hospitals, fear of hospital admission and cost of accessing health care.
It is clear-cut that there is an overwhelming need for the provision of quality health services in areas outside the urban terrains. And if quality healthcare is a basic human right, quality healthcare must reach those in remote areas. The shortage of health professionals especially specialists in remote areas of Africa is none to be compared across the world. The current health workforce in Africa would need considerable upscaling to serve the increasingly growing population of Africa which leaves the residents of remote areas to an unfortunate fate as a greater percentage of the small workforce are concentrated in the urban areas. Health professionals who work in remotes areas are often isolated from specialized input due to geographic barriers.
Can telecommunication offer provable and adaptable solutions? Yes, telemedical links between distant hospitals offer hope to centralize and coordinate the limited healthcare services and resources. Africa, especially in remote areas, is in dire need of many of the services telemedicine provides:
– Maximization of a small number of physicians for the populations
– Communication with specialists at a distant location
– The different location of patients and healthcare provider in time and space
– Improved education of healthcare professionals in remote areas
Telemedicine offers hope in the improvement of healthcare delivery in remote areas for several reasons.
1. Telemedicine is one of the new health models that could help address the rural health needs and narrow the urban-rural health divide
Several types of telemedicine such as real-time consultation, store, and forward telemedicine and mobile communication can help alleviate the various challenges of rural health such as healthcare professional shortage, geographical barriers, lack of good transportation network, etc. Also, remote monitoring can be used to track vital signs of patients who require constant follow-up or patients who are on post-discharge care which allows healthcare professionals at a distant location to intervene swiftly in case of emergencies.
2. Telemedicine provides help in overcoming the stigma associated with certain health conditions
In small remotes areas, patients are often reluctant in seeking in-patient help at their local hospitals because of privacy and confidentiality concerns and important because of the stigma associated with some health conditions. The provision and access to healthcare from a healthcare provider outside their immediate environs may motivate individuals to seek help.
When there is a shortage of healthcare professionals there is also a shortage of healthcare professionals to teach. However, telemedicine offers a great solution. This is an area where telemedicine has thrived most in Africa. The Institute of Tropical Medicine in Antwerp uses a hybrid email web support system with a discussion forum for continuing education in HIV (Maurice, 2013). Also, the Africa Medical and Research Foundation uses a virtual training school to reskill nurses in remote areas of East and Central Africa. With telemedicine health professionals in remotes, areas can be updated about the recent development in medicine which helps in increasing the quality of healthcare delivered to patients (Maurice, 2013).
There are several telemedicine services already providing healthcare services to remote areas in Africa:
1. Mashavu Networked Healthcare Solutions in Kenya and Tanzania. The service uploads basic medical information collected at different locations by trained personnel after which the doctors provide recommendations and indicate whether there is a need for the patients to travel for expert management.
2. Merck in Uganda, Kenya, and Ghana. Merck provides e-diagnostic and consultation clinics that grant access to a specialist at Kenyatta Hospital via video conferencing.
3. Telemedicine Africa in South Africa. The company offers telemedicine solutions to healthcare challenges.
Telemedicine will increase the reach of healthcare by increasing the number of accessible health end-users. In places with good infrastructure, adequate awareness, and considerate affordability telemedicine offers hope of breaching the healthcare divide between urban and rural dwellers.
Telemedicine has great potentials in improving healthcare delivery to remotes areas but faces fundamental barriers in its progression in Africa for several reasons:
1. Inadequate infrastructure: Telemedicine depends largely on advanced technological facilities which are lacking in most remote areas of Africa
2. Negative public perception of telemedicine: Resistance to new technology on the part of patients, especially older patients, with many believing that telemedicine is more expensive than the traditional way of healthcare delivery.
3. Legal and ethical concerns on the part of health professionals: Health professionals who serve rural areas may be reluctant to take on the new way due to fear of legal litigation amidst other ethical issues.
4. Lack of governmental regulations and legislation: Lack of proper governance framework and policies may hinder the entrance of government especially for financing.
4. Poverty and illiteracy: These are socioeconomic factors that must be tackled efficiently if Africa will maximize the benefits of telemedicine in the nearest future.
Telemedicine offers a new model of tackling the various challenges of healthcare delivery in remote areas of Africa. In a context with limited options of healthcare delivery like Africa telemedicine should be a welcomed development. However, a transition to an African healthcare system that will maximize the benefits of telemedicine would be slow if proper frameworks are not put in place especially by the government. There is a need to provide adequate funding and development of a feasible implementation plan to see the realization of this transition.
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