Looking Beyond COVID-19: Can Telemedicine Help Reduce Health Inequity?
Dear Editor
We have read with interest the editorial by Greenhalgh et al. (BMJ 2020;368:m998) regarding the potential use of video consultation in response to the ongoing covid-19 pandemic.
Indeed, telemedicine, “the remote diagnosis and treatment of patients by means of telecommunications technology” [1], has been a useful tool in previous pandemics, including former coronavirus outbreaks such as SARS-CoV and MERS-CoV [2]. We would like to highlight here another potential role of telemedicine, i.e. fighting health inequality.
COVID-19 has highlighted the importance of an integrated global health strategy and has again exposed the challenges faced by over 400 million people who do not have access to essential health services [3]. Africa, on average, has one medical doctor per 3324 inhabitants and one nurse or midwife per 995 inhabitants. Europe, in comparison, has one doctor for every 293 inhabitants and one nurse or midwife per 123 inhabitants [4]. There are similar patterns in terms of life expectancy. In Europe, the average person lives to the age of 76-81, whereas in Africa, between 53-60. Life expectancy and the causes of health inequity are complex, and outside of the scope of this article, however, we propose that telemedicine has the potential to improve access to healthcare in low-and-middle-income countries (LMICs) and that it can help break down some of the potential barriers within healthcare systems.
The Virtual Doctor’s charity experience thus far has largely been in rural Zambia, where we have been working alongside the Ministry of Health for over 10 years. We use a bespoke telemedicine app to enable UK-based volunteer doctors to give remote telemedical advice to healthcare professionals in the field. We currently support 140 rural health centres in Zambia and 6 in neighbouring Malawi. These are run by clinical officers (COs), who will have completed a 3-years medical training program, before they are employed as the first point of contact for healthcare within a community. Our service is text-based, with the option to send images, rather than using video-calls. This is partly due to the environment within which our service has developed with intermittent data bandwidth for video calls in much of rural Zambia. It also means that UK volunteers can answer queries at a time that suits them working around their NHS commitments.
Within many LMICs, there is often considerable variation in terms of workforce distribution: the majority of larger healthcare facilities, and hence healthcare workers, are usually focused around larger cities, and patients in rural areas may have to travel hundreds of kilometres, often on foot, or at significant personal expense, to see a doctor. There are often associated indirect costs, such as loss of income and the need to find temporary accommodation. In combination, these factors may prevent patients from seeking appropriate treatment, which can lead to worsening health inequity. Telemedicine, and the ability to connect rural healthcare workers with speciality doctors, is one tool to help address this. Patients presenting to their local health centre can discuss their condition with a CO. If the CO needs further advice, they can send a referral virtually to get a remote opinion within 24 hours.
To date we have answered over 5000 cases, and 90% of the time the advice given has improved patients’ symptoms. It has prevented referral to hospital in 76% of cases and 94% of the time the advice given was judged educationally beneficial by the COs. The service is also helping to reduce professional isolation and to improve the resilience of healthcare workers who can often be posted to isolated rural clinics away from friends and family. There is growing recognition of the potential reciprocal benefits that working within global health can have to home institutions [5]. This has been confirmed by our own experiences, and the technology we have developed in sub-Saharan Africa will soon be used by GPs and care homes within the South-East of England.
We look forward to seeing how telemedicine develops, both within and between Countries, as we cautiously come out of lockdown.
The Authors are members of The Virtual Doctors Medical Team. The Virtual Doctors are a registered charity in the UK and Zambia, that provide remote telemedical advice to rural health centres across Zambia. To find out more, get involved or make a donation please visit: https://www.virtualdoctors.org/
Rapid Response:
Looking Beyond COVID-19: Can Telemedicine Help Reduce Health Inequity?
Dear Editor
We have read with interest the editorial by Greenhalgh et al. (BMJ 2020;368:m998) regarding the potential use of video consultation in response to the ongoing covid-19 pandemic.
Indeed, telemedicine, “the remote diagnosis and treatment of patients by means of telecommunications technology” [1], has been a useful tool in previous pandemics, including former coronavirus outbreaks such as SARS-CoV and MERS-CoV [2]. We would like to highlight here another potential role of telemedicine, i.e. fighting health inequality.
COVID-19 has highlighted the importance of an integrated global health strategy and has again exposed the challenges faced by over 400 million people who do not have access to essential health services [3]. Africa, on average, has one medical doctor per 3324 inhabitants and one nurse or midwife per 995 inhabitants. Europe, in comparison, has one doctor for every 293 inhabitants and one nurse or midwife per 123 inhabitants [4]. There are similar patterns in terms of life expectancy. In Europe, the average person lives to the age of 76-81, whereas in Africa, between 53-60. Life expectancy and the causes of health inequity are complex, and outside of the scope of this article, however, we propose that telemedicine has the potential to improve access to healthcare in low-and-middle-income countries (LMICs) and that it can help break down some of the potential barriers within healthcare systems.
The Virtual Doctor’s charity experience thus far has largely been in rural Zambia, where we have been working alongside the Ministry of Health for over 10 years. We use a bespoke telemedicine app to enable UK-based volunteer doctors to give remote telemedical advice to healthcare professionals in the field. We currently support 140 rural health centres in Zambia and 6 in neighbouring Malawi. These are run by clinical officers (COs), who will have completed a 3-years medical training program, before they are employed as the first point of contact for healthcare within a community. Our service is text-based, with the option to send images, rather than using video-calls. This is partly due to the environment within which our service has developed with intermittent data bandwidth for video calls in much of rural Zambia. It also means that UK volunteers can answer queries at a time that suits them working around their NHS commitments.
Within many LMICs, there is often considerable variation in terms of workforce distribution: the majority of larger healthcare facilities, and hence healthcare workers, are usually focused around larger cities, and patients in rural areas may have to travel hundreds of kilometres, often on foot, or at significant personal expense, to see a doctor. There are often associated indirect costs, such as loss of income and the need to find temporary accommodation. In combination, these factors may prevent patients from seeking appropriate treatment, which can lead to worsening health inequity. Telemedicine, and the ability to connect rural healthcare workers with speciality doctors, is one tool to help address this. Patients presenting to their local health centre can discuss their condition with a CO. If the CO needs further advice, they can send a referral virtually to get a remote opinion within 24 hours.
To date we have answered over 5000 cases, and 90% of the time the advice given has improved patients’ symptoms. It has prevented referral to hospital in 76% of cases and 94% of the time the advice given was judged educationally beneficial by the COs. The service is also helping to reduce professional isolation and to improve the resilience of healthcare workers who can often be posted to isolated rural clinics away from friends and family. There is growing recognition of the potential reciprocal benefits that working within global health can have to home institutions [5]. This has been confirmed by our own experiences, and the technology we have developed in sub-Saharan Africa will soon be used by GPs and care homes within the South-East of England.
We look forward to seeing how telemedicine develops, both within and between Countries, as we cautiously come out of lockdown.
The Authors are members of The Virtual Doctors Medical Team. The Virtual Doctors are a registered charity in the UK and Zambia, that provide remote telemedical advice to rural health centres across Zambia. To find out more, get involved or make a donation please visit: https://www.virtualdoctors.org/
References
1 – What is Telehealth? NEJM Catalyst Feb 2018 https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0268
2 – Ohannessian R, Duong TA, Odone A Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action. JMIR Public Health Surveill. 2020 Apr-Jun; 6(2): e18810 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7124951/
3 – WHO https://www.who.int/mediacentre/news/releases/2015/uhc-report/en/
4 – WHO World Health Statistics 2020 https://www.who.int/data/gho/whs-2020-visual-summary
5 – Carbone S, Wigle J, Akseer N, Barac R, Barwick M, Zlotkin S Perceived reciprocal value of health professionals’ participation in global child health-related work. Globalization and Health volume 2017;13:27 https://link.springer.com/article/10.1186/s12992-017-0250-8
Competing interests: No competing interests