To develop and implement self-sustaining telehealth services in Africa and
to increase opportunities for North American health service professionals and
technology companies to participate in this key sector.
Acting within the framework of the African Information Society Initiative,
the United Nations Economic Commission for Africa (UNECA) and the Africa
Telehealth Project, have been promoting the application of information and
communication in various sectors including health. Information and
communication technologies have proven crucial for improved health
administration and connectivity within the health sector; for supporting
decision for curative health; and for improved distribution and reduced cost
of medical supplies. However, the health sector in Africa still lags very
much behind other sectors in application of these new technologies. Basic
applications such as electronic medical records, hospital information
systems, local networks for sharing and distributing information among health
workers, provision of remote diagnostics via Telemedicine, and community
health information systems for local, regional and national services have
not been developed in Africa.
In view of the above, and in collaboration with the Africa Telehealth
Project, the United Nations Economic Commission for Africa held a regional
Telemedicine conference in Nairobi, Kenya, February 19-21, 1999. The
conference, entitled, "The Role of low-cost Technology for Improved Access
to public Health care Programs Throughout Africa," focussed on developing a
strategic plan for identifying and coordinating the use of technology for
improved access to and promoting efficient delivery of cost-effective public
health care programs in Africa.
The conference addressed key issues for designing and implementing a
telehealth system suited to the needs of African health care providers.
This included discussions on securing operating funds, and access to
appropriate technology and medical practices via telemedicine. The
conference concluded that telecommunication technologies would not only help
to improve the delivery of health services, but would also help to deal with
major constraints in uplifting the health standards of African people.
Participants in Africa Telehealth Conference '99 realized the pressing issues
of spreading telecommunication technologies in Africa and passed a number of
resolutions which included calling upon African countries to embrace
Telehealth and spread the use of information and communication technologies
in the health sector; recommending that needs assessment in Telehealth
application be conducted at the national level; calling upon African
Governments for regional cooperation and strengthened South-South and
North-South cooperation in order to share knowledge, resources and networks
that foster health care services teaching and research in Africa; and,
calling upon African Governments, national institutions, universities,
private sector and developing aid agencies to support the principles and
activities outlined above.
Problem and justification:
The fragmeneted nature of health care delivery in Africa; the continent's lack of technological infrastructure over an expansive and varied geography; and its disproportionately high need in relation to available health care services, create problems for health care providers that can be best served by delivering health care supporting services through telecommunication and information technology.
Return to TopThe concept emerged at Telemedicine conference for Arab World, Africa
and
Europe in Tunisia September 28, 1998. It was proposed to establish
four
regional centres of excellence for Telemedicine/Telehealth in Tunisia,
Ethiopia, South Africa and Ghana.
The 25 years since the nations of the world committed themselves to
Health
for All by the year 2000 have been marked by tremendous advances in
the
delivery of health services and the development of personal commitment
to
one's own health and the health of family and community. Among the
most
dramatic achievements have been a longer life expectancy, a reduction
of
infant and child mortality and a marked increase in the enrollment
of
children in schools. In spite of this progress, poverty-linked and
malnutrition-related diseases are still the major killers, and old
enemies
like tuberculosis and malaria have re-emerged along with the pandemic
of
HIV/AIDS. Isolated rural communities have not succeeded in reaching
either
their health or education goals. Much of this inequity is due to
deficiencies in communication, yet the technology to overcome this
is
already available, just as the technology to prevent the killer diseases
is
available. Telehealth can help us go the extra mile and achieve Health
for
All in Africa.
Today health is no longer the sole purview of doctors, and the dissemination
of health information by Telehealth, telecenters, the Internet and
the media
makes health front page news. The health professional's added role
is now
to critically assess this vast array of information available to
practitioners and patients and to ensure the applicability, quality
and
safety of this information.
Telehealth and Telemedicine have been practised for a long time. The
introduction of the telephone brought to the physician and nurse the
capacity to diagnose and manage disease at a distance. At the Montreal
Children's Hospital in the 50's the first Poison Control center in
Canada
were developed, and, as in many other teaching hospitals, patient "help
lines" were established providing a 24 hour telephone response to
emergencies and crises. This was our earliest experience with Telehealth
as
we learned to manage patients effectively over the phone, and teach
these
new skills to students.
The Director general of the African Medical Research and Education (AMREF),
Sir Michael Wood, visited northern Canada and Alaska and was impressed
with
the effective use of 2 way radio as a means of providing consultation
and
help in the management of patients in remote health posts manned by
nurses.
On returning to Kenya he convinced AMREF that these were indeed the
"tools
of the times" and he established a network of 2 way radio connections
throughout East Africa that are still in use today. This AMREF
communication network was backed by the world famous African flying
Doctor
Service that provided and still provided transport of patients from
remote
areas to appropriate health facilities, and brought physicians and
surgeons
regularly to isolated communities for service and health teaching.
AMREF is
now beginning to use the new "tools of the time" with a computer-based
network. During the early days of the medical school at the University
of
Nairobi we served as paediatric consultants to AMREF and communicated
through the AMREF network about paediatric problems in many of the
rural
sites, and, when necessary, flew in to isolated missions for clinics
or
helped with emergency evacuations. This was an exciting way to utilize
early
Telehealth connectivity and learn about the health care needs of remote
communities...
Telepyschiatry was one of the earliest applications of Telehealth technology
and remains one of the most effective. Interactive video links between
the
Nebraska Psychiatric Hospital and the University provided both psychiatric
care and medical education as early as 1957.
The 1960's were the SPACE AGE and the American Space Program (NASA)
developed telemedical methods to monitor the biological functions of
the
astronauts. They shared, and still share these methods with civilian
authorities and University researchers.
Teleradiology quickly adapted these new techniques and remains the most
widely used Telemedicine service in the world at present. The transmission
of radiographs, video, computed tomography (CT), magnetic resonance
imaging
(MRI), ultrasound, nuclear scans and other images for interpretation,
diagnosis and consultation are all widely accepted and have proved
to be
cost effective and convenient for patients and doctors.
Closed circuit TV and VHF radio connections are still widely used for
consultations and continuing medical education (CME). Audiotapes accompanied
by slide have remained very popular teaching aids since the 60's,
particularly those developed by Dr. David Morley and produced and
distributed by teaching Aids at Low Cost (TALC). These are still used
in
many less developed countries as they are inexpensive, almost
indestructible, and easy to use.
Audio cassettes continue to be a popular form of Telehealth for continuing
education. Many doctors use educational Audio cassettes in their car
tape
decks to maintain their competence while commuting to work or when
stuck in a
traffic jam.
In the 1970's in Canada we recognized the importance of interactive
participation in telelearning. In Newfoundland, at Memorial University,
as
a spin off from the space technology, we acquired the use of the Hermes
satellite and used it extensively for CME. Other Canadian Universities
used
the satellite for northern health services for the native population
of
Canada, while others used it for emergency transport communication.
In the 80's health costs throughout the world increased rapidly and
at the
same time, communication technology costs came down as capacity expanded.
Video and audio teleconferencing were used extensively for consultation,
emergency care, home care, and then specialities developed in Teleradiology,
teledermatology, telepathology, telepsychiatry and telepediatrics.
In 1985 while working at Makerere University in Uganda, we had the
opportunity to establish a teleconference link between the University
of
Nairobi and Makerere, and we expanded this useful linkage with a project
called satellites for Rural health and Education (SHARE) that linked
us to
university centers in USA and Canada for educational programs.
Some colleagues criticised this "high-tech" approach in countries with
so
many basic needs. However, although Uganda was at war and there was
no
running water in the University Hospital and electricity was rarely
available, with our "battery pack" and the dedicated phone lines the
post
and telecommunication Companies of Uganda and Kenya provided, we had
the
capacity for 24 hour teleconferencing and used it extensively for medical
and nursing student education as well as for consultations and postgraduate
seminars.
The 1990's have been a time of rapid expansion for Telehealth in all
its
varied forms. many Canadian Universities have developed Telehealth
initiatives often focussed on CME as recertification and maintenance
of
competence are rapidly becoming requirements for the practice of medicine.
An innovative application of Telehealth has been developed at the University
of Toronto in the project TeenNet which since 1996 has used ICT for
the
provision of information and prevention on adolescent health care programs
by teens as well as health processionals, for adolescents. This project
arose through the recognition that, in North America, young people
have
unlimited access to health information but health risk behaviours in
this
age group have scarcely changed-for example, risk taking, smoking,
unsafe
sex, violence and substance abuse. A TeenClinic on Line was developed
in
which teenagers interact and have fun in a highly participatory youth
in
action adventure in an attempt to engage and interest them in healthy
behaviour change, as they are often turned off by traditional approaches.
The ease and skill with which young people today accept and adopt ICT
make
this an ideal medium for participatory education and behaviour change.
We are currently serving on an advisory committee to the Canadian Network
for the Advancement of Research, Industry and Education, known by the
acronym CANAIRE and based in Ottawa. The purpose of this Committee,
chaired
by Dr. Mo Watanabe of the University of Calgary, is to help create
a virtual
information centre to respond to the health information needs of the
Canadian national health care system and the public, and global health
care
systems. Our initial task is to identify the many Canadian and
International stakeholders in Telehealth, to identify the nature and
type of
their health initiatives, and from this information determine how Canada's
Telehealth strengths and leadership in health care can contribute to
global
health issues.
A few of the Telehealth projects at the University of Ottawa where we
now
direct the Centre for International Health and Development (CIHAD)
include
the following:
The University of Ottawa School of Nursing is particularly active in
an
international educational partnership program in two provinces in China
where nurse clinicians are being taught using Telehealth methods. The
University of Ottawa School of Nursing also participates in
a distance-learning computer-based degree course for nurses working
in remote
sites. Through this program over 300 nurses have achieved competency
as
nurse practitioners while remaining at their work-site. This program
uses
expensive teletutoring and infrequent but essential face-to-face sessions.
At the University of Ottawa two-way video CME sessions for family physicians
in remote rural and northern sites are provided on a regular basis
with
patient problems described and discussed interactively by ten doctors
in 3
remote sites. The information exchange was excellent and useful but
after
our experiences in Newfoundland, we are not convinced that the costly
video
component added much to the exchange and at times was distracting.
In our initial involvement in Telehealth in Newfoundland 25 years ago
we
participated in weekly rounds sharing paediatric problems with a dozen
colleagues who were scattered over the province which is the same as
Kenya.
Controlled studies showed us the much more expensive video conferencing
added
little to information sharing and most of our colleagues preferred
the
simple audio-conferencing for consultations and sharing of new information.
In Uganda in 1985 we continued with voice-only teleconferencing as
part of
project SHARE described above, linking Uganda and Kenya to North America
by
satellite for a continuos 12 month period. We added some diagnostic
services including electroencephalograms as the EEG machines in Mulago
hospital were non functional. By sending out slides and printed handouts
we
shared courses on a variety of topics from Dermatology to critical
Appraisal
of the literature. In 1986 the Primary Health care East Africa network
was
established between Kenya, Uganda, Tanzania and Zambia. Junior Faculty
leaders from each of the four countries attended training workshops
on
Telehealth, computer skills and the development of health materials
through
desk top printing technology. Computers with modems were provided in
each of
the four sites and faculty exchanges were carried out. The Computer
network
was difficult to operate due to a combination of poor maintenance and
repair, major security problems and unreliable power and telephones.
using
desktop publishing skills, the Fellows produced a PHC Manual for medical
Students which is now in its third edition and is used in several African
medical schools.
Our current Telehealth involvement is a project developed by a partnership
between the University of Cape Town in South Africa and the University
of
British Columbia and the British Columbia Institute of Technology (BCIT)
in
Canada to provide a distant flexible Masters level program in Maternal
and
Child Health for senior rural health workers, both nurses and doctors,
in
Southern Africa. This program began in July 1998 with a 2 week face
to
face session where the learners were introduced to each other, their
computers and their tutors. At their home workstations the learners
are now
completing seven modules and developing their theses. They maintain
close
email contact with their tutors and fellow learners. In March we joined
all
the members of this program for a second 2 week session and a participatory
mid-term evaluation in other African countries...
In Telehealth the scope and varieties of the technical processes have
expanded beyond our imagination but the major value of telelearning
is not
the novel process but the content of knowledge, skills and attitudes
that
can be shared. This is the vital role we all have as medical scientists
and
educators who must rethink the way we provide information and services
to
meet the needs of the communities we serve. In all Telehealth applications
we must focus on accurate, relevant content, and on making the learning
interactive. We must not be carried away by the technology.
With proper recognition of such limitations, the Internet, a superb
communication facility, can serve health professionals as a dynamic
source
of health information while providing the public with information needed
to
assume a personal responsibility for their own health.
The degree to which the Internet becomes a positive force for health
depends
on how much it costs to access, and how well health professionals and
communities are trained in its use, and how relevant, information is
on the
Internet.
The Internet has the potential to be a great equaliser around the world,
but
in these still early days it may widen the gap unless equity of access
can
be assured, and the Internet made less expensive and more available
in
developing countries. We must make sure there is equity of access world
wide.
Interactive participation is an essential difference between teleteaching
and traditional lecturing. Considering a teleconference as an expanded
lecture room is inappropriate.
All stakeholders of a Telehealth project should be involved from the
beginning. This includes not only the learners and the faculty but
also
the computer experts, hospital administrative personnel, department
of
ministry of health directors and offices of the post and telecommunication
companies in the region.
The system should be flexible, using many modalities of information
communication technology. Careful evaluation should be included from
the
beginning.
Based on personal experience and a review of relevant literature we
are
convinced that Telehealth/Telemedicine has the potential to improve
the
access to health care needed to achieve the goal of Health for All.
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