Inclusive Healthcare: How telemedicine facilitates rural access to basic healthcare.

Inadequate quality of care claims between 5.7 million and 8.4 million lives each year in low- and middle-income countries. In August of 2020, the independent Africa Regional Certification Commission certified the World Health Organization (WHO) African Region as wild polio-free, after four years without a reported case.  Cases due to wild poliovirus have decreased by over 99% since 1988, from an estimated 350 000 cases to 33 reported cases in 2018. While we applaud the commitments of the African Governments and accomplishments of the World Health Organization (WHO), discussions on resolving inequalities in accessing quality healthcare products and services remain a global subject. In Africa, government expenditure (% GDP) on healthcare services remains inadequate despite international aids leading to a low Human Development Index (HDI).  According to the National Institutes of Health, amongst indissociable contributing factors such as inadequate healthcare services,  challenges identified were inadequate human resources, inadequate budgetary allocation to health and poor leadership and management, challenges related to logistics, cost minimization and service delivery are cogent, particularly in developing nations.

The Fourth Industrial revolution which is characterized by the advancement and domestication of technology and innovation has opened the world to new possibilities. Industries are being disrupted with optimized service delivery options, and to a large extent, fostering the achievement of the United Nations Sustainable Development Goals. In recent times, the term “Telemedicine”, or Telehealth, is referenced by development practitioners and technologists. Telemedicine systems allow health care professionals to evaluate, diagnose and treat patients remotely using telecommunications technology. This groundbreaking possibility is further propagated by growing internet access and mobile phone penetration in Africa, breaking distance barriers to accessing quality healthcare, particularly in rural communities.  Organizations such as Health eVillages and eHealth Africa are leading the way in Africa’s emerging telehealth industry. eHealth Africa has developed electronic health (eHealth) solutions that can be rapidly deployed to manage patient information, streamline clinical procedures, and provide data and analysis on health program outcomes. This organization provides health management information systems to hospitals and private health clinics in both urban and rural parts of Nigeria. They implement an electronic medical records system using the OpenMRS platform. This system provides access to the first patient-based health indicators in Nigeria (as opposed to previously error-prone aggregate data).

However, while telehealth or telemedicine promises utopia, its implementation in the global south still faces systemic, and often infrastructural impediments. Telemedicine is cost-intensive. The primary operational requirements for the system include available labor, adequate communication hardware, electricity, and efficient broadband infrastructure. Apparently, these systemic issues are yet to be addressed in rural parts of Africa, and the global south. According to a report by the National Library of Medicine, Sub-saharan Africa suffers a deficit of 2.4 million doctors and nurses. This acute shortage translates to a merger 2 doctors and 11 nursing/midwifery personnel per 10000 population, compared to 19-49:10000 in the Americas and 32-78:10000 in Europe. Globalization is ruthlessly exerting tremendous impact on brain drain—the osmosis of skilled labor from Africa, thus wasting the government’s investments in education. Furthermore, Africa’s population is the fastest-growing in the world. It is estimated at 1.8 billion by 2035, up from 1.34 billion in 2020. Subsequently, the dearth of healthcare workers in the region is expected to worsen.

According to the International Energy Agency (IEA), although access to electricity has doubled in the past two decades, 71% of the 578 million people in Sub-Saharan Africa without access to electricity live in rural communities. This has hindered the provision and adequacy of basic services in schools and hospitals. In the region, only 34% of hospitals and 28% of health clinics have reliable, 24-hour access. In South Africa, 95% of rural dwellers have access to electricity with less than 3 million people, whereas compared to 20% in other southern African countries combined. A number of resilient non-profits have emerged in the past decade such as Rees Africa in Nigeria and Solar Sisters in Tanzania to foster rural access to renewable electricity.  Since its launch in 2010, Solar Sisters has supported over 5,000 entrepreneurs, distributed over 400,000 clean energy products, and reached nearly 2 million people in a mission to eradicate energy poverty by empowering women with economic opportunities. In addition, Power Africa—a USAID initiative— set a goal to add more than 30,000 megawatts (MW) of cleaner, more efficient electricity generation capacity and 60 million new home connections. In September 2020, grants worth $2.6 million were awarded to 9 companies to install off-grid electric power systems in 288 healthcare facilities in Nigeria, Togo, Zambia, Madagascar, Rwanda, Lesotho, Ghana, Mozambique, and Malawi. 

While cellular connectivity has increased exponentially in Africa, rural access to reliable broadband internet services is a daunting task challenge and this connectivity gap remains an impediment to the scalability of telemedicine and telehealth in rural Africa. In 2019, the World Bank Group estimated the set-up cost for broadband infrastructure for all of Africa at $100 billion. These developmental issues can be addressed with adequate private capital with fiscal supports by the government due to its capital intensiveness. Telemedicine though still in its developing phase due to systemic and infrastructural barriers is potentially very useful as a conduit to quality health care. Even if pervasive barriers prevent its wide-scale use and application, the benefits of telemedicine are real and significant. Governments must also develop the policies needed to guide the implementation and adoption of telemedicine across Africa. Regulation of the scope of care, as well as minimum criteria for practitioners and facilities, are much needed. Effective measures to reduce the per-unit cost of care should be explored. Finally, guidance for assessing the quality of care should be implemented to avoid abuse of the system. 

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