Telemedicine programmes in East Africa, like other parts of the developing world, have been attempted for decades. For most African countries, poor communication infrastructure; the prohibitive cost of equipment and the severe and chronic shortage of healthcare workers especially in rural areas where the majority live are just some of the incentives for an effective e-Health strategy.
Telemedicine Programmes in East Africa: Kenya
In May 2016, the Ministry of Health in Kenya, in collaboration with Germany-based multinational Merck Group launched what was viewed as a major Telemedicine initiative. This linked the country’s largest referral hospital, the Kenyatta National Hospital in the capital Nairobi, with Machakos Hospital in Eastern Kenya. Machakos is located around 80 kilometres (50 miles) from Nairobi.
This launch was just the first phase of the telemedicine programme. The ambitious programme’s goal is to get specialist services closer to the rural poor. It focuses on non-communicable diseases. The next phase was to extend the service to the Moi Referral Hospital further east in Eldoret in the Rift Valley region. Eldoret is about 315 kilometres (197 miles) from Nairobi.
Even without more in-depth details about the programme, it is clear that this programme is focused on connecting major healthcare facilities. This is as opposed to individual patients in their places of abode in far-flung places in the country.
Sema-Doc in Kenya
A few months earlier, in August 2015, the Kenyan First Lady Margaret Kenyatta had inaugurated another basic Telemedicine service called Sema-Doc. ‘Sema’ is a Swahili word for ‘say’ or ‘talk’. Sema-Doc is a mobile phone-based service where a patient can have a consultation with a doctor via either a text message or a phone call. The former costs 20 Kenyan shillings (approx. 20 US cents) while the latter costs 60 shillings. To stay in credit, there is a 300 shillings monthly subscription. The service is run by a company called ‘Hello Doctor’. The company runs this service in two other countries.
The service advertisement promises that once a patient has requested a consultation, a doctor will text back or call back within an hour. It is a requirement for the user to have an account with the service. The account must be in credit for one to access it. A prescription service is available for a limited number of conditions. There does not appear to be a medical records component to the service. It is therefore the case that, on the face of it, each consultation would not have the benefit of a past medical history other than what the patient is able to narrate.
Oddly, the Hello Doctor company appears to have struck an exclusive deal with one mobile carrier (Safaricom). It is therefore only accessible to those with a Safaricom mobile line.
For a country like Kenya with a severe shortage of doctors and other healthcare personnel, the ability to access professional help through a mobile phone is certainly a positive for many. This is particularly the case for those in remote rural areas where logistics to access health facilities, mostly located in urban centres, are often difficult.
Telemedicine Programmes in East Africa: Uganda
Uganda has seen numerous telehealth and telemedicine initiatives over the last few years. In fact, Uganda’s first stab at eHealth was in the early 1980s. This was with the help of the Canadian International Development Research Centre funding the East African Telemedicine Project dubbed the ‘HealthNet’. The aims were modest largely focusing on improving distance education among medical students at the country’s then only medical school and to enable resource sharing at the national referral Mulago hospital with other health workers in remote areas.
In 2013, UNICEF set up a telemedicine pilot project at a health centre in a remote part of Karamoja District in Northern Uganda. In an area off the electricity grid, the approach had to be innovative. The set up uses solar energy and satellite internet connection. That meant a substantial initial capital outlay but low running costs.
There are no doctors at the health centre. The nurses who run the health centre use skype video calls to connect with doctors at the nearest hospital. The portable computers are moved to face the patient and the doctor at the call centre in the capital Kampala can carry out a consultation and give the appropriate advice. The call centre is manned by doctors and pharmacists around the clock. Kampala is about 500 kilometres (310 miles). The benefits are that the patient is availed immediate or quick expert input and the nurse on location adds to her knowledge.
The ITU Telemedicine Project in Uganda
The Karamoja pilot project described above was not Uganda’s first stab at telemedicine. 13 years earlier in the year 2000, the government in collaboration with the International Telecommunication Union (ITU) set up the first telemedicine pilot project. ITU provided the telecom technical assistance. The country was facing up to the fact that it had a severe shortage of doctors. There were only 800 doctors in the entire country of 27 million people at that time. Worse still half of all these doctors resided in the capital Kampala.
The ITU telemedicine pilot looked at providing specialist services in specialist areas of surgery, paediatrics, women’s health, and internal medicine. The projection was expansion to other specialties in due course. The strategy was to connect the country’s largest referral hospital Mulago in the capital Kampala with regional hospital. Regional hospitals had a chronic shortage or complete absence of specialist doctors at that time, a problem that persist to this date.
The Uganda Communication Commission (UCC) and MoH eHealth Collaboration
In 2012, the Uganda Ministry of Health in collaboration with the Uganda Communication Commission (UCC) launched a 5-year eHealth project. The focus of the project was on Health Management Information Systems (HMIS) and telemedicine (teleconsultations and videoconferencing) with the aim of covering 53 districts and 103 health facilities made up of 53 hospitals and the rest being Health Centres.
The Masaka Referral Hospital Mulago Hospital eHealth tie-up
Masaka is a city in the south-western part of Uganda. It is located approximately 130 kilometres (80 miles) from the national referral hospital Mulago in the capital Kampala. That is an almost 3-hour drive in normal traffic conditions. This combined with the shortage of specialists in the country mean a telemedicine tie-up between the Masaka Hospital and Mulago made sense. A fully-equipped complex for this purpose has been constructed at the Masaka Hospital. Mulago already had one.
Africa Tele-dermatology Project
Uganda is one of the 6 African countries involved in the Africa Teledermatology Project launched in 2007. This is in collaboration with partners in Austria and the United States. It is funded by the Commission for Development Studies, Austrian Academy of Sciences and the American Academy of Dermatology. The project was set up in recognition of poor dermatology services, not least because of a severe and enduring shortage of dermatology specialists in these countries. The visual nature of skin conditions makes it perfectly suited to telemedicine services. The service is provided at no cost to the patient. Utilised are digital cameras, laptop computers and mobile phones. Countries in the project are Botswana, Burkina Faso, Lesotho, Malawi, Swaziland, and Uganda
The Ugandan arm of the project known as the Uganda–Austria Tele-Dermatology Web Consultation and E-Learning Project was successfully launched. However, it has had a turbulent existence with a whole host of challenges including poor internet reliability, shortage of dermatologists and poor buy-in by local specialists.
eHealth success in Uganda
The examples mentioned above are not the whole eHealth picture in Uganda. The multiplicity is arguably an indictment of the state of strategic planning at the national level. Almost all these projects have either withered or, at best, stagnated; never advanced beyond the pilot stage. This is despite the noble intentions and the obvious need. Dependence on donor funding, lack of local ownership, poor accountability, communication and/or coordination and poor eHealth frameworks are some of the problems that have bedevilled these projects. Nor is Uganda unique in this. It is seen in many developing countries trying to implement these projects.
Telemedicine Programmes in East Africa: Tanzania
Tanzania has had a remarkable internet growth. The government has invested heavily on getting the high-speed internet infrastructure across the country. This has reached every district in the countyr. Providing the perfect template for eHealth services. Up to now, implementation of eHealth services in Tanzania appears to have lagged behind the neighbours in the region. However, this may be changing in the last few years.
Like its neighbours, Tanzania has a severe shortage of doctors. The problem is much worse when it comes to specialists. Its road infrastructure, though better than years gone by, is also challenging. Telemedicine therefore holds great potential especially for the rural poor who form the majority.
Tanzania Telemedicine Network
In 2007, the Evangelical Lutheran Church in Tanzania (ELCT) launched the Tanzania Telemedicine Network. The ELCT runs numerous hospitals spread throughout the country. Many of these hospitals are located in rural areas. It also runs one of the largest referral hospitals in the country, the Kilimanjaro Christian Medical Centre (KCMC) located in the north-east of the country in Moshi. Also involved in the network are the Aga Khan Hospital in the commercial capital Dar es Salaam and the Swinfen Charitable Trust. The latter has actively championed telemedicine throughout the world since the turn of the 21st century
The network utilises the iPath web-based portal and, at the start was connecting 43 hospitals across the country. The portal was chosen mainly because of its user-friendliness with low-bandwidth setting. The telecommunication situation has of course transformed since with more efficient internet services available.
Consultants in the network are volunteers and some of the consultants make peer reviews as a way of securing quality control. The consultants are based in several countries. However, almost all of them would have had some experience in Tanzania at some point. One study specifically looking at the children services within the network showed median consultation response time to be 6 hours. The range was 2–24 hours.
Whilst it appears to have had ‘steady as she goes’ look in the first decade of its existence, the project is now seeking to expand its reach. It has also been exploring ways of formally working with health insurers. It is already in discussion with the largest insurer, the National Health Insurance Fund (NHIF). To begin with, they are looking at two specialties namely, dermatology and radiology.
Regional Communications Infrastructure and eGovernment Project (RCIP) for Tanzania
The Regional Communications Infrastructure and eGovernment Project (RCIP) for Tanzania was launched in 2009. The main purpose of the project was to improve health services in the country through ICT. The objectives were to extend the geographic reach of broadband networks, lower their international costs, and improve government efficiency and transparency through various eGovernment applications including telemedicine. The project was funded by the World Bank’s International Development Association (IDA).
As part of the RCIP, a telemedicine pilot project was launched. This involved the Muhimbili National Hospital in Dar es Salaam connected by broadband to eight district and regional hospitals in the eastern part of the country. These included Mafia District Hospital. Mafia is an island in the Indian Ocean. The specialists based at the National Hospital were able to carry out consultations with patients in those hospitals. Videoconferencing with doctors and other healthcare workers were also facilitated. This meant practical training for those in remote locations could take place with immediate and future benefits. The RCIP alongside the telemedicine pilot concluded at the end of 2017. Initial assessment was very positive especially in reducing costly referrals.