The digitalization of all spheres of life had begun in earnest when the Covid-19 pandemic catapulted the health sector into digital age. Telemedicine can bridge the gap between health systems and people in remote areas with limited resources. Cost might be a constraint for LMICs, nevertheless, the benefits are multiple.
As of 2021, more than 40% of the world population are living in rural areas1. Of them, the majority (~80%) belong to the low- and middle-income countries (LMIC) of South and East Asia and Sub-Saharan Africa1. Although rural domicile is not the sole determinant of the remoteness of healthcare, but rural areas in these countries often lack proper healthcare facilities, transport facilities and diagnostic or therapeutic services. For example, Darjeeling, a hilly town of almost 170,000 people in West Bengal, India got its first and only MRI facility only in 20172. Thus, compared to urban infrastructure, these areas may be still considered “remote” from availability and access point of view.
The Covid-19 pandemic has made the shortcomings in global health system painfully clear. One of the main shortcomings that has been accentuated in recent times is the lack of coverage in remote areas. For example, Arunachal Pradesh, a remote hilly state of north-East India with an area of 83700 sq. km, has only about 1000 registered doctors3. While overcoming these shortcomings physically (that is, suddenly increasing the number of specialists) will remain a challenge in the near future, new technologies are offering opportunities for alternative ways to provide healthcare in these locations. Telemedicine, which was considered just a promising field earlier, has become mainstream post-Covid and is a means of ensuring universal healthcare.
Healthcare in Remote places: Present scenario
The Alma-Ata declaration of 1978, establishing the need for universal healthcare, was further affirmed in 2019 when the 83-point “Universal Health Coverage” pledge was taken by UN member states4. However, all countries have realized the fact that although such goals can easily be fulfilled in well-equipped urban centres, the remote areas still remain a challenge. Let’s look at a few examples.
Very recently, a family in a village in North Bengal were forced to take their infant twins to a hospital 200 kilometres away when local treatment facilities were deemed inadequate5. Last year in Sitamahri, Bihar a pregnant woman gave birth on the roadside while being referred to higher centre6. In Liberia, the overall number of health workers, including doctors, have remained very low post civil war and this was one of the reasons why the country fared so badly during the Ebola epidemic7. In many villages in remote mountains of Nepal, the health centres often lack basic essential drugs and this leads to frequent deaths from preventable causes like diarrhoea8.
So, although overall health statistics in countries have improved a lot, the situation in the remote areas often remains abysmal. Thus, the current health system is inadequate in addressing these challenges and newer technology is needed.
The World Health Organization (WHO) has defined telemedicine as9
Telehealth is revolutionizing the delivery of healthcare services, particularly in situations where distance plays a critical role. This innovative approach utilizes information and communication technologies to enable healthcare professionals to exchange valid and timely information for the purposes of diagnosis, treatment, and disease prevention. By harnessing the power of telecommunication, telehealth aims to advance the health of individuals and communities alike.
According to the WHO, there are three basic components of telemedicine9:
The patterns of use of telemedicine can be divided into four main types9:
Acute vs. Chronic care:
Telemedicine, when integrated into existing health system, can be effective both for acute and chronic medical care.
One important example of this is the e-ICU system (Fig. 1)
Figure 1: Theoretical model for the e-ICU system (as depicted by Rathod et al14)
As can be seen in this framework, multiple ICU patient data are collected from camera, sensors, infusion pumps etc and sent to a central server, from where the data is sent to the concerned intensivist. The advantages of this system are standardization of care across multiple ICUs, inclusion of multiple professionals in the care pathway and enabling round the clock care. Also, this system reduces personnel movement in and out of the ICU, thereby reducing the risk of infections both for patient and staff. Disadvantages of the system include the need for initial large-scale investment in technology which may be difficult for LMICs, the possibility of power cuts in remote areas which may wipe out the data and finally, the chance of data leakage14. Also, the intensivists need to be technically adept for the system to function effectively.
Another acute medicine setting where telemedicine has been effective is burn care15. Furthermore, Taiwan, has shown that the use of telemedicine in acute care can reduce the need of patient transport, especially of air ambulance16. Thus, for LMICs, telemedicine is a means of reducing healthcare costs too.
The value of telemedicine in chronic care is well established. The age-old model of recurrent hospital visits for refilling prescriptions and/or routine physical examination is slowly being phased out as it’s becoming clear that most of the OPD activities can be conducted online. Even the OPD visits in a busy hospital are time-constrained and often fail to address the concerns of the patient fully. This is where telemedicine can be effective.
Meta-analyses have shown that telemedicine is equivalent to in-person visits for numerous chronic conditions17. In conditions like hypertension and dyslipidemia, non-adherence is a massive problem18. Telemedicine can help in better medicine reconciliation, to have in-depth discussions with the patient which can improve health literacy19 ultimately leading to better adherence. It has been also noted that in hypertension, telemedicine sessions often encourage the patient for self-monitoring, which leads to better blood pressure control19. Finally, in countries like India where most people are employed in unorganized sectors like construction business, single hospital visit, even at a government facility wherein all treatments are free, is still a massive financial burden for many patients. A day spent in hospital means incurring the costs of two-way transport for patient and accompanying person(s) as well as loss of daily wages for all concerned. Telemedicine can help people avoid this financial loss.
Initial planning for Telemedicine:
However, before telemedicine can be effectively implemented in LMICs, there is need of meticulous planning as pointed out by the WHO (figure 2).
Figure 2: Steps of planning for Telemedicine (WHO: Consolidated telemedicine implementation guide, 2022)
According to this framework, there are the following four steps of planning:
The key considerations are depicted in figure 3.
Figure 3: Main considerations for making Telemedicine successful (Goodridge et al, 201620)
Technology for telemedicine does not only include the devices required for monitoring and consultation, but also the power supply and internet services. Currently, the technology is at par with the needs for remote medical services. But for LMICs, the main consideration is cost. While the synchronous consultation via video or audio call is feasible for most, the other sophisticated devices like ICU sensors or AI-enabled hospital beds may be inaccessible for many. Many of the corporate hospitals in LMIC are now using tele-radiology through PACS, but the system is out of reach for smaller centres.
However, many countries like India are trying to make their own lost-cost medical devices to make the technology accessible to the masses21. Such use of local technology will make telemedicine infrastructure more feasible. Digital transformation of healthcare also requires reliable power supply. While conventional grid supply of electricity is often unreliable in countries like India, this barrier can be overcome with help of renewable energy sources. For example, in the remote villages of Sundarbans, India a microgrid of solar power has been built and this has led to better use of rechargeable electronic equipment22.
Legislations regarding telemedicine:
The main push for enabling legislations supporting telemedicine came after the Covid pandemic. While relevant laws were being discussed in many countries earlier, this pandemic led to quick enactment in many cases9.
Australia passed the “Telehealth Determination” legislation and officially recognized telemedicine as a channel of service delivery. Germany also passed the digital healthcare act not only to help telemedicine but also to provide guidelines for insurance. India passed the Telemedicine practice guidelines just before the national lockdown in 2020, March23. The United States of America also published the “Digital Health Implementation Playbook” to enable physicians practice Telemedicine24. Proper legislation and government policy has helped in the integration of telemedicine in Ghana and Rwanda in public health programs. In Kenya, BYON8 is an AI-based digital physician program that is being tried for primary care25.
However, in some countries, although regulations are present, they are often considered prohibitive and impractical25. One example is the telemedicine framework developed by Health Professions Council (HPCSA) of South Africa25.
Thus, all concerned stakeholders including insurance providers, politicians, community workers, physicians and internet service providers must cooperate and coordinate in order to facilitate telemedicine.
Telemedicine for special populations:
There are certain segments of the population for whom healthcare is “remote” due to other reasons.
One example is the LGBTQ people. A survey in the USA found that such sexual minorities often face multiple barriers in the health system26. These include refusal of treatment, stigma among healthcare workers and hostility from other people in a hospital. Thus, these people often avoid physical visits to healthcare facilities. In such cases, Telemedicine can be of much help in increasing their access to care.
The second group for which digital health can be a blessing is physically challenged persons. All over the world, disabled people have significantly less access to healthcare27. In countries like India, most health centres do not have architectural modifications (like ramp or elevator) needed by disabled people to access a building. Also, other factors like cost of transportation and unsympathetic behaviour of health staff often deter these patients from going to a hospital28. In such cases, telehealth can address their unmet needs to a great extent.