Telemedicine in South Africa

Although South Africa has been one of the late starters in the telecommunications game, in just a few years it has caught up and become a world leader among developing countries, says Dr Salah Mandil, the World Health Organisation’s Director on Health Informatics and Telematics. South Africa is now ahead of many other countries in terms of the number of sites connected up and in the range of medical procedures being applied. But South Africa does have the advantage of being able to learn from the lessons of other countries, the most important being that the space-age technology has to be woven into the threads of everyday routine and made a part of the system instead of being set aside as a special project.

The main hurdle the project has encountered is the unreliable telephone system in remote areas, but its planners are exploring ways of using radio frequencies and satellite systems instead.

"Information communication is the great divider or the great leveller," says Mandil, citing the fact that there are more phones in New York city than there are on the whole of the African continent. "In 1996 sub Saharan Africa had only five phone lines and 142 radios per 1 000 population and the question that is asked is how can we take hi-tech into rural Africa when we don’t even have simple phones," he says. "The answer lies in skipping a level of technology - the phone lines - and going straight to digital wireless networks as practical interim solutions for the problems of infrastructure."

At present, says Shaheen Khotu, Director of the South African Health Department’s National Health Information System, there are 30 sites - almost all community or district hospitals which are linked to larger central hospitals - and amongst the services on offer are radiology, pathology, opthamology, ultrasound and antenatal screening. The technology also plays an important part in conducting research, in collecting statistical data, and in training.

The first phase of the project has cost R10 million to set up, with most of the funds being spent on the medical equipment at each end such as the scanner and the microscope rather than on the computer link. Phase two of the project, which will begin next month, involves extending the same technology to a further 71 sites, mostly clinics, across the country and to linking up with other medical centres in the SADC region. This phase is expected to cost a further R20 million.

"Despite the distance between the patient and the specialist, the service is as good as if the specialist was sitting next to the patient," says Khotu. Other great advantages are that telemedicine saves the patient the inconvenience and cost of travelling all the way to the specialist centre and that a diagnosis and treatment can be given straight away.

The new technology bridges the gap between the highly specialised and curative services located in urban areas and the poor health services in rural areas. It provides a way of sharing skills and cutting through the problems caused by geographic isolation, scarcity of doctors and poor transport systems, says Khotu.

The focus of the telemedicine project is on supporting primary health care services, particularly for women and children. Specialists located at major medical centres can supervise routine pre-natal care and sonogram examinations which are carried out by midwives, thus reducing perinatal and neonatal mortality rates. Surgeons can obtain frozen section results of pathological tissue specimens while the patient is still under anesthesia and complete the treatment without having to bring the patient back to theatre for a second operation. Internal medicine specialists can make use of high resolution cameras to study skin and mucosal lesions and assist in the diagnosis and control of sexually transmitted diseases and HIV/AIDS. Radiologists can provide immediate diagnosis to victims of trauma and patients requiring emergency medical attention, and for all of these, early diagnosis and intervention enables them to catch the diseases while they are still at a preventable or curable stage.

In order to deliver these services, the telemedicine system conducts regularly scheduled electronic clinics which means that doctors in designated centres are available at regularly scheduled times to provide consultations. However, the carrying capacity or bandwidth needed to transmit a given amount of information within a fixed period of time still serves as a practical limit to the size, cost and capability of the telemedicine system. The South African project is working with international groups including British and Italian aerospace to overcome these problems.

But as the technology is used more and more, and as these obstacles are overcome, patients will begin to use cost-effective primary health care services at community centres rather than to seek treatment at tertiary hospitals. And that is the whole aim of the system – that people can be treated effectively and conveniently, close to their homes. As Shaheen Khotu says, it is the people and not the technology that determine the success of the system.

Is Telemedicine really working?

Dr Sam Gulube, who works at the Medical Research Council, has been given the task of evaluating the South African national telemedicine system. "The future of telemedicine in South Africa seems to be in good hands because the first phase of the National Telemedicine system has been welcomed by the young doctors doing their community services in the remote parts of the country," he says. The young clinicians described telemedicine as an effective information communications technology that improved their ability to diagnose and manage difficult medical conditions and reduced feelings of professional isolation.

In a nutshell, telemedicine can be an important strategic tool in delivering equitable health care and educational services irrespective of distance and the availability of specialised expertise particularly in rural areas.

The initial idea in 1998 was to implement the telemedicine system in three phases over a period of five years. Since then, there have been concerns raised about various technical problems and project management, but overall the response has been positive. Doctors doing their community service in the remote health facilities of the Free State reported that the telemedicine system enhances their confidence in diagnosing and managing various medical conditions particularly those related to trauma and chest diseases and they felt that the system was able to reduce the number of transfers. In the North West Province the community service doctors noted that the system enabled them to differentiate between chronic TB lesions and occupational lung diseases such as asbestosis and lung cancers. A number of transfers were avoided by enabling the doctor to correctly diagnose the lung disease rather than transfer the patient to a higher level of care because of uncertainty about the diagnosis. The system was noted to be useful in detecting bone tumours from symptomatic patients. Some of the symptoms that were thought to be from arthritis were found to be from bone tumours requiring a drastic change in management.

Some doctors said that before the introduction of telemedicine in their facilities, many trauma patients complaining of neck pain were transferred unnecessarily because primary care providers were not able to read cervical spine x-rays. Now with the teleradiology system, primary care providers are able to institute appropriate management in their community health facilities without having to transfer the patient to urban tertiary centres. One case of a walk-in traumatic cervical spine dislocation was diagnosed within few minutes using the system and the patient was immediately immobilised and transferred thereby avoiding further injury. Some trauma patients had cervical abnormalities that were not initially recognised at the remote sites. The diagnosis was made by the specialist radiologist by teleradiology and appropriate management was instituted. Because of all these successes, the provincial tertiary institution has requested that, for the time being, all trauma spine x-rays from the telemedicine site must be read by the specialist radiologist through the teleradiology system. The current practice is that the primary doctor in charge reads the x-rays and specialist consult is requested as needed.

The tele-ultrasound antenatal application for the first phase of the National Telemedicine system was designed to move the pre-natal ultrasound services from the provincial referral centre to the remote and rural community health centres. The purpose of tele-ultrasound is to:

• Train health care providers in the use of ultrasound service for pre-natal care
• Provide tele-consultations for pre-natal care
• Provide diagnostic and management services for complicated pregnancies.

Antenatal tele-ultrasound consultation has primarily been used to train primary care providers and to consult with an obstetrician about complicated pregnancies. A number of cases that would have been transferred for further investigation have been managed locally without transferring the patient to the tertiary site because primary care providers have been able to seek the advice of specialists using this system.

In evaluating the project, Dr Gulube has looked at:

• How it has improved access to care for dis-advantaged communities
• How it has improved quality of care
• Whether it is cost-effective or not.

His evaluation confirms many issues identified by other international telemedicine projects. Almost all of the South African sites had operated for less than 9 months at the time of his evaluation, and five of 28 sites were still experiencing serious technical problems 9 months into the operational stage. Most of the time the outcomes are not quantifiable and can not really be converted into Rands and Cents. The comparison in the evaluation study was between the telemedicine system and the system in the absence of telemedicine. In some parts of the country, the telemedicine pilot was undertaken without a comparable system, because telemedicine was used to provide a service that was not available before, while in other parts telemedicine was used to improve the quality of care, he says.

An important take home message from Dr Gulube is that telemedicine is not a substitute for face-to-face medical practice, but rather it is a tool to complement the current health care delivery in South Africa.

Case Study: Northern Province

The vast stretches of land and the sparse population in the Northern Cape made it the ideal site for implementing telemedicine, whose main aim is to link people and facilities over vast distances and difficult terrains.

Jeanette Hunter, who runs the service for the provincial health department in the Northern Cape, says the decision to implement tele-ultrasound specifically between Kimberley and Kuruman was triggered by the fact that a large proportion of maternal deaths in Kimberley Hospital were made up of women who were transferred from the Kuruman area. There were also no medical specialists employed at Kuruman Hospital.

The initiative, which began in May last year, involves the head of obstetrics and gynaecology from the receive site, and community doctors and a primary health care sister at the send site. So far, she says, 12 cases have been discussed over the telemedicine system and only four high risk patients were eventually transferred to Kimberley Hospital - a definite decrease in the number of cases referred. Telemedicine also provided an opportunity for community doctors in the district hospitals to learn the basic elements of ultrasonography.

The problems encountered have been mainly technical. The link was supposed to be set up in 1999, but it only became operational last year because the incorrect lines had been installed. Telkom corrected the mistake and the proper bandwidth ISDN lines were installed. The initial modem also had to be replaced and problems are still being experienced with the store and forward function.

There were also problems with personnel as the people who had been trained left after a few months and the province had to start training all over again. The community doctors sent to Kuruman were not properly orientated and were reluctant to use the equipment, which meant that the system was not used for the last six months of last year. However an undertaking has been reached with Kimberley Hospital that all community doctors will be briefed and will receive hands on training before being deployed to Kuruman Hospital.

There are a number of ways that the project can be taken forward in the Northern Cape, says Hunter. Since the numbers involved in antenatal, obstetric and gynaecological consultations are so small, the equipment would be more cost effectively applied if consultations were extended to other specialities like mental health, ENT, radiology and dermatology, she says. The equipment could also be more actively applied to interactive video conferencing as a teaching medium, and a link should be established between Kimberley Hospital and a tertiary institution like Universitas in Bloemfontein for medical consultations, she says.

*By Kathryn Strachan, Health Systems Trust, South Africa. First published in HST Update No. 59, February 2001. Thanks to the Author and to Fatima Suleman / HST for the kind cooperation.