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The State of Ehealth and Telemedicine in East Africa

Nyamweya is a global researcher with many years of experience on practical research on a diversity of topics

Executive Summary

The East African Community is currently working at improving its healthcare system, including delivery and consumption through informatics and eHealth systems. The integration and expansion of eHealth systems by countries in the EAC region has provided growing and substantial opportunities with both external and internal collaborators that deals with ICT infrastructure and eHealth solutions. This report looks into the state of eHealth and telemedicine within the East African region. The key areas of focus are the state of infrastructure for eHealth and telemedicine, the key players involved, services offered, and the contribution of eHealth and telemedicine as it regards to UHC. In addition, the report has also assessed key challenges facing eHealth and telemedicine in the region, country ranking in adoption and usage, and the unexplored opportunities in this area. Accordingly, it is noted that despite generally poor infrastructure in the area of broadband and network connectivity, there has been a significant level of development as the member countries in liaison with the private sector are working to improve the same. In addition, implementation of eHealth and telemedicine is a process that needs various players who includes the governments, regulators, private sector, mobile operators, pharmaceutical firms, IT/software companies, content players, device vendors and even patients. Generally, the EA countries appear to be conscious of the role that eHealth plays and have been agile in ensuring that the technology is integrated in the healthcare systems. Nonetheless, effective implementation is marred by notable challenges which include; low level of literacy among citizens, poverty which hinders low-class citizens to access necessary gadgets, internet or power to facilitate access and usage of eHealth, and poor infrastructure including lack of power. Despite these, eHealth and Telemedicine has seen a remarkable improvement to accessibility of health services by many citizens, reduced the cost of health services delivery and consumption, enhancement of public health through increased awareness, as well as increasing the skill level for healthcare expertise. These aspects, especially increased access and a reduction to cost of healthcare services are fundamental features required for effective achievement of the universal health coverage.


Table of Contents

1.0 Introduction. 4

2.0 E-health and Telemedicine- Definitions. 4

3.0 Infrastructure Assessment of e-health and Telemedicine in EA.. 5

4.0 Key Players in e-Health and Telemedicine. 6

5.0 Services offered in the eHealth and Telemedicine industry. 7

6.0 Challenges facing eHealth and Telemedicine in EA.. 7

7.0 Country Rankings on Adoption of eHealth and Telemedicine in East Africa. 9

8.0 The contribution of eHealth and Telemedicine to East Africa’s Universal Health Coverage (UHC) 11

9.0 Unexplored opportunities in eHealth and Telemedicine. 12

10. Conclusion. 13

References. 14


The state of e-health and telemedicine in East Africa

1.0 Introduction

A realization of effective Telemedicine and eHealth services are currently presumed to be an important goal being pursued by member countries within the East African region. Accordingly, countries in the East African region are aggressively spearheading deliberate strategies alongside development of sustainable goals to ensure success in the roll-out of eHealth and telemedicine in their respective countries. Nonetheless, it ought to be considered that unlike developed countries, the countries in question have competing demands on the limited resources. In this regard, the aggressive strategies on the achievement of these goals amidst the prevailing challenges stir a lot of interests in relation to the efficacy and goals. The purpose of this report is to evaluate the state of e-health and telemedicine in East Africa.

2.0 E-health and Telemedicine- Definitions

E-health generally refers to provision of healthcare services using electronic means and via the internet. The World Health Organization (WHO, 2021) defined eHealth as the use of communication and information technologies for delivery of health services. It is also used not only for the purposes of treating patients, but also creating awareness and education programs for patients and healthcare workers, conducting research, monitoring and managing public health and tracking diseases. Common platforms include mobile phones, social media and networking sites, the internet and email platforms.

Telemedicine on the other hand, refer to use of electronic software and communication for the purpose of offering clinical services to consumers without personal contact. This technology is increasingly being used by healthcare providers to manage chronic conditions, follow up visits, and undertake specialized consultations, management of medical conditions and other clinical services that can be offered remotely through audio or video connections. In essence, telemedicine enables healthcare practitioners to assess, diagnose and treat patients without personal visits through the use of telecommunication technology. In the last decade, the technology has gone through massive revolution and gaining momentum in the context of healthcare infrastructure across the world (Chiron Health, 2021).

3.0 Infrastructure Assessment of e-health and Telemedicine in EA Snapshot Kenya and Ugandas ehealth innovations are being spurred by a strong private sector. On the other hand, Rwanda’s health sector is being spurred by a strong public sector which has led to increased investment in technology, health as well as the regulatory environment. Concerning health financing, Uganda and Kenya private and public sector financial solutions are yet to reach the mass market. However, in Rwanda and Tanzania, financing of public health including ehealth is done through the public sector. Pertaining to innovation support systems and the environment, Uganda is at a much earlier phase for healthcare innovation compared to Kenya. On the other hand, Rwanda has focused itself on improving the extant public sector infrastructure (Duke, 2016).

Technological Infrastructure

In East Africa context, the development of e-health and Telemedicine is spearheaded by the governments, as well as the private sector. A report by GBC Health (2019) articulates that both the governments and the private sector have contributed immensely to the infrastructure that facilitates health interventions on the digital arena. In this regard, most of the countries in the region including Uganda, Tanzania, Rwanda, and Kenya have been placing a significant level of invested on broadband internet infrastructure since 2009. To this point, the broadband internet covers most parts of the countries owing to the national broadband strategies. Alongside these is the state-funded and large scale infrastructure development that aims to increase the internet accessibility for citizens. Furthermore, the African Continent Free Trade Agreement signed by members of the African community has not only encouraged more innovations in telemedicine and e-health but also offered opportunities for larger market. For instance, a review by Njoroge et al (2017) revealed that in Kenya, the number of digital health projects has been rising since 2010. They include and not limited to the national digital health information systems such as the open-source platform DHIS2 which is widely deployed alongside other diverse forms of electronic patient records.

The development of e-health and telemedicine has been even entrenched in the local health systems. The report by the Federal Ministry for Economic Cooperation and Development (FMECD, 2020) discloses that many hospitals and healthcare structures across East Africa have invested in proprietary information systems some of which are highly complex. Some of these systems constitute of 30+ modules which require an exchange and connection of data with diverse systems in other departments. However, as established by FMECD (2020), only a few of the systems allow for seamless smartphone applications and integration of telemedicine. Accordingly, the so called vendor-lock in system has subsequently lead to market inflexibility which has consequently hampered innovation and competition. This owes to the fact that switching to a suitable or advanced system is often costly.

Physical infrastructure

Since early 2000s, there has been a significant growth of product developments and health innovations, thanks to new private investments. This growth has created a massive potential for even greater impact and the potential for upscaling. GBC Health (2019) reports that the countries in the region have implemented several telemedicine projects. Some of the projects make use of mobile phones in supporting healthcare delivery, remote data collection, home care, education and awareness, responding and reporting disease outbreaks, communicating and provision of treatment options for clients, responding to emergencies and remote monitoring. Currently, Ugandas healthcare management have trained a massive number of its workers to use a mobile health system identified as mTRAC for the purpose of reporting medicine stocks across the nation. On the other hand, Rwanda is the only nation globally to employ drone technology in the delivery of blood supplies, thanks to a partnership with ZiplineInc, a robotic company based in Carlifornia. On the other hand, Airtel Tanzania, the second largest telecommunication firm inTanzania offers free service to facilitate text messages to pregnant mothers and infant care.

Economic Infrastructure

Despite the vast expansion and use of eHealth and telemedicine in EA context, their full exploitation has been hampered by the availability of basic infrastructure including cellular network coverage, electrical power, and broadband internet services. Sadly, most of the countries in the EA region are ranked among those with the slowest internet speeds globally. What is more, the cost for telemedicine such as virtual consultations is only affordable to those within the upper and middle class society of the EA society. It needs to be considered that most people within the EA and Africa by extension live below the poverty line, implying that tele-health services are still inaccessible to those within the lower class (Chinye-Nwoko et al 2020). Apart from poor infrastructure, other challenges hindering effective implementation of eHealth and Telemedicine in EA include insufficient technical expertise to run and manage the programs, low levels of literacy, limited funding for innovations, and poor power supplies (Ministry of Health, Kenya, 2021).

Legal Infrastructure

In the ehealth ranking above, the East African Countries are ranked according to this order, Uganda, Tanzania, Rwanda, Kenya, Zimbawe, Mozambique and Zambia. Indeed, the government of Uganda has been focal in integrating ICT on its healthcare systems to enable and support healthcare operations, facilitate access to information, decision making and management aspects. Furthermore, the government, the private sector and partners have endeavored to invest in diverse healthcare initiatives and programs to improve healthcare delivery through ehealth and telemedicine (Republic of Uganda, 2016). On the other hand, Tanzania places high priority on health as envisioned on its Vision 25 Development policy. As such, the government of Tanzania has strived to deliver effective, quality, curative, rehabilitative, and preventive health services across all levels. Tanzania’s health policy is focused at improving the well-being and health of all citizens and being responsive to the health needs of the populace. In this regard, Tanzania has established a robust ICT/eHealth regulatory authority that facilitates development and implementation of eHealth and telemedicine (USAID, 2016).

For Rwanda, the government has decentralized the health system and facilitates its development through community based health insurances which are known as “mutueles de sante”. This entails establishing local organizational and human capacity of health service providers, as well as a significant level of investment on eHealth, telemedicine and innovative solutions for healthcare (Hill and Mercado 2015). Kenya on the other hand, has a prolific eHealth vision whose focus is to develop accessible, efficient, patient friendly, secure, and equitable healthcare systems enabled by ICT. Through the ministry of health, the government has in place a special eHealth unit and strategy that concentrates on five key aspects. These includes; telemedicine, mHealth, information services for subjects, eLearning, and healthy information systems (HIS) (Federal Ministry of Economic Cooperation and Development, 2021).

Accordingly, the national governments and regulators in the East African countries have endeavored to create awareness as well as establish a level playing field for other players including the private sector for a competitive performance. This is out of the realization that ethical considerations and regulations have a strong impact on the mainstream adoption of e-health services by consumers or their significant others. For instance, recently, the governments in this region designed and approved standard guidelines for utilization of mobile devices was focused at reducing the risk of low level of adoption attributed to non-interoperability among medical gadgets

4.0 Key Players in e-Health and Telemedicine

As earlier mentioned, e-health and telemedicine in east Africa is found to be spearheaded by the respective governments and the private sector. There are approximately 20 ehealth operators in EA. In Kenya for instance, there is Afya-Plan,

Major organizations spearheading eHealth revolution in Kenya include;mHealth Kenya, Kenyas ICT board, the Ministry of Health, OneMed Pro, and Marc Mitchel as well as local mobile network providers such as Safaricom and Airtel. There is also Afya Plan, Micrive Infinite and Redhunt( which also works in diverse countries). In Uganda, the ministry of health is at the forefront in ensuring fast and wide intergration of ICT use in healthcare. Other private organisations include private hospitals, OneMed Pro Uganda, Diva, ClinicPesa, Kaaro Health, Ask withouth Shame, USAID/Uganda, and the Uganda Healthcare Federation. In Tanzania, there is Tanzania government, USG CDC, and numerous other Tanzanian and international public and private sector partners. However, less than 1% of these organisations are international and include Ask Withouth Shame, Micive Infinite, IRIS, and Konnecttiv (a Berline based agency working at the intersection of technology in Africa and other parts of the world (Tech Entrepreneurship Initiative, 2020). The consumers also play a key role in fast adoption of the e-health ecosystem. This is because their consumptions mean a return on investment or profit for the rest of other players who include mobile operators, pharmaceutical companies, content players, Software/IT firms, and device vendors (Deloitte, 2012).

Other than the above mentioned players, pharmaceutical firms are also a powerful medium in the roll out and implementation of e-health and telemedicine. This is because they are involved in collection of patient and market data and information on consumption of medicine. Despite these, Deloitte (2013) notes that pharmaceutical companies have not fully integrated recent technological developments to enable them effectively perform this role. Other equally key players are mobile operators who are perceived to be a vital connection in the e-health ecosystem. They offer the connectivity that is crucially depended on by all e-health and telemedicine services. Essentially, content players, IT/Software companies and device vendors cooperate with mobile operators to facilitate innovation as well as execution and expansion of their services to the next level. Together, the players mentioned above have positioned themselves to facilitate provision of e-health and telemedicine services. Further, the partnership between the players and stakeholders is presumed to offer a critical platform for integration in supporting major developments in the e-health ecosystem (Research2Guidance, 2013).

5.0 Services offered in the eHealth and Telemedicine industry

Presently, telemedicine services in East African countries and Africa in general include intensive care services, neonatal care, occupational healthcare, child-healthcare, mental health services, nutritional health, geriatric medicine, e-pharmacy services, factory workers, geriatric medicine, farmers, trauma care, maternal healthcare, and radiological services. A report by the World Health Organization (2013) found out that with the support of WHO and other development partners, governments such Uganda, Rwanda, Kenya, and Tanzania have integrated mobile phone usage in a range of application. These includes communication of test results to patients, promotion of treatment adherence for such conditions as TB, tracking patient’s conditions, preventing and controlling health conditions such as malaria and delivering messages aimed at behavior change. In contexts such as Kenya, Uganda and Tanzania, eHealth are also being used to deliver health related awareness messages, reinforcing health behaviors, provision of pregnancy support via mobile phones, education expectant mothers on pregnancy management, as well as providing critical updates and information.

For Rwanda, the government six new health technologies. This packages aim is to respond to the healthcare needs of its citizens as well enhance the management of the healthcare system. Among these technologies include TRACNet which is used to monitor infectious diseases on a monthly level including HIV/AIDS, malaria and TB. There is also the use of telemedicine whereby; healthcare information, services and education are delivered to geographically separated communities. In addition, the nation has also integrated the use of CAMERWA which is a medical and drug being handled by the national pharmaceutical company (WHO, 2011).

6.0 Challenges facing eHealth and Telemedicine in EA Political Challenges

In most of the countries in EA, there is no proper frameworks that guides the allocation of resources, processes and even structures (such as a National Health Steering Committee) which ought to be part of a high-level governance and management set-up. Such a framework could work to exploit the capabilities and capacities of the regional economic communities (RECs) as well as the regional networks such as the East African Integrated Disease Surveillance Network (EAIDSNet). This will make it possible to leverage the collective experience and expertise of professionals from the diverse settings and different countries within the community.

What is more, some of the organizations that run various eHealth systems prefer doing their operations independently rather than coordinating their activities with others. There is generally poor coordination of mushrooming pilot projects while the health systems in most of the member countries are also weak. Accordingly, private investors, governments, implementing partners and even donors can work on a similar health matter within the same region and thus end up duplicating each other’s efforts. This challenge has been acknowledged by the Tanzania government for instance which affirmed that the prevalence of a parallel routine reporting system of HIV, IVD, PEPFAR-DATIM has been a challenge to recon (Federal Ministry for Economic Cooperation and Development, 2021).

Socio-cultural challenges

There are also other factors that have greatly impaired effective deployment of digital health in East Africa. These include lack of knowledge and awareness regarding digital health, as well as lack of interoperability of the diverse digital health systems. The high level of illiteracy among citizens in most of the countries in East Africa also means that some consumers are unable to use digital gadgets such as phones to access ehealth services (Scott and Mars, 2015).

Economic Challenges

Olu et al (2019) attests that in order for the universal health goals to be effectively achieved, then elements such as resilient communities, health system and equitable access to economic and social determinants of health have to be in place. For now, these are notable areas of concern for most of the member countries within the East African community. Practically, there are many people who are still unable to access ehealth facilities including the internet and the required infrastructure due to the cost involved.

7.0 Country Rankings on Adoption of eHealth and Telemedicine in East Africa

The European Space Agency (ESA) did a survey in 2020 on the health systems and eHealth potential in sub-saharan African countries. The study’s overall purpose was to analyze the general health systems and developmental stage for 28 member countries in the region. The actual study entailed visits to key stakeholders in the healthy systems, as well as government authorities. The key variables under this research included availability of programs for basic national e-health and e-government platforms, nationwide connectivity and communication structure, impact on population health, financial base and commitment and the political will and interest on eHealth and Telemedicine. Accordingly, the ranking indicates nations which at this point could be regarded to be promising and with sustainable investments in digital tools and eHealth. The results of the ranking are as indicated in table 1.1 below;

Country

Rank

Uganda

1

Tanzania

2

Rwanda

3

Kenya

4

Zimbabwe

5

Mozambique

6

Zambia

7

Table 1.1: eHealth Priority Ranking of East African countries (adopted from ESA Interoperability study, 2020)

From the table above, Uganda leads the rank in eHealth and telemedicine implementation, followed by Rwanda, Kenya, Zimbabwe and lastly Mozambique. What this means is that Uganda has the most expansive roll-out in ICT application within the healthcare among other EA communities. It has also committed a larger financial position for eHealth related programs which has subsequently lead to the most impact.

8.0 The contribution of eHealth and Telemedicine to East Africa’s Universal Health Coverage (UHC)

Innovative strategies including the implementation of eHealth are necessary in ensuring the achievement of the all crucial universal health coverage in African context. Despite the attempt by the governments to deploy the eHealth and telemedicine systems on a wider scale, their full implementation has been impaired by several challenges. In light of these, the subject of digital health has gained a lot of interest from a global perspective as a basis for innovation that aims to address the underlying challenges towards attainment of universal health coverage. Consequently, many African nations including those within the EA community have implemented pilot projects and digital health initiatives to achieve their UHC goals. In particular, eHealth has seen improvement in management of diverse health services especially at the sub-national levels, enhanced the efficiency in management of large and massive public health data, improvement of public health via utilization of wearable gadgets with ability to monitor, transmit and analyze important signs to central or personal repositories. Nonetheless, a report by Stanford Business finds that still, over half of the population, that is 50% are still unable to access quality healthcare services. In light of this, technology seeks to transform healthcare delivered by increasing the reach of the services even by people in remote areas. If well implemented, the percentage of people able to access quality healthcare are presumed to reach approximately 80%.

Programmatically, eHealth and telemedicine have been effectively applied in prevention of communicable and non-communicable diseases such as child and maternal health, HIV/AIDS management, cancers, provision of medical products and critical medicines, supply management in the healthcare system, immunization among others. Apparently, these diverse applications of eHealth and telemedicine have depicted a potential for scale up as well as promising results as it regards to attainment of UHC. Moreover, the use of eHealth and telemedicine has had notable potential benefits which includes improvement on the accessibility of health care services especially for those in rural areas and places that are hard to reach, and improved access and knowledge to health information for both consumers and health workers, subsequently leading to increased uptake of the services and improved efficiency and productivity on the part of health workers (Olu et al 2019). Additionally, digital technologies have also led to a general reduction in the cost and efficiency in delivering healthcare services. In Kenya for instance, the average cost of an outpatient visit varies from KES 467 (USD 5.36) to KES 1,618 (USD 18.60), depending on the hospital visited. However, eHealth has reduced the average cost to between KES 267 (USD 5.36) to KES 1000 (USD 10.60) (USAID, 2015).

Thanks to eHealth and telemedicine, there is now real time transmission of public health information that subsequently facilitate timely decision making, improvement on the capability to monitor the health system and related programs. Other notable benefits include addressing the financial, physical, and sociocultural barriers on equitable access to digitalization and health of health insurance programs with a focus to make them more efficient. In light of these, digital health harbors the potential to expand the affordable health services and good services to the last mile, which is one of the most important prerequisite for attainment of universal health coverage (Bloom et al, 2017). Nonetheless, as argued by Shuvo et al, (2015) for these benefits to be fully realized, then the eHealth and telemedicine have to be aligned with the national health development goals, health priorities, and more essentially when they meet the needs of citizens. Moreover, there would be more value if the authorities strive to make the benefits cost effective, context specific and offered at a higher scale.

9.0 Unexplored opportunities in eHealth and Telemedicine

From the above analysis, it is evident that most countries within the East African community including Uganda, Tanzania and Kenya have embraced the utilization and telemedicine application. This is a means of enhancing public health and health care delivery for its citizens. In these countries, the growth in the communication and information technology industry has been to a great benefit especially to the rural populace. In addition, this development has also established opportunities for novel innovations and other application within the context of healthcare to support positive outcomes particularly as it regards to areas of surveillance, disease prevention and control (Scott and Mars, 2015). However, as noted by Kiberu et al (2017), a majority of ehealth programs are simple proof-of concepts and which may not only be unsustainable in the long run but also demonstrated in implementation within a small context. Therefore, there is potential for eHealth and Telemedicine to serve a wide population and be of benefit to as many people as possible. Furthermore, the authorities involved need to work out on making the projects sustainable in theory and in practice.

The failure or rather full and effective implementation of eHealth projects with EA countries have been attributed to a number of factors. As Identified by Luna et al (2014), among the factors that have hindered the success of implementation include poor research design, poor initial planning, and lack of technology readiness, insufficient computing skills, poor planning, and lack of change management. Accordingly, it is crucial for healthcare and policy managers to ensure sufficient initial planning and more critically make good use of extant resources for sustainable and successful eHealth projects. More so, developing nations including Kenya, Tanzania, Uganda and the rest of East African countries ought to learn from the experiences of other countries that have successfully adopted and implemented e-Health systems such as South Africa, Ethiopia and Rwanda to success innovate and implement their sustainable e-Health programs. If well explored, eHealth and telemedicine is a big potential for business players who are poised to rock in a considerable level of profit. According to a report by African Business, (2016) attributed to the International Finance Corporation, there are plentiful opportunities in the African healthcare sector which is approximated to be worth $35bn. Furthermore, the demand for improved healthcare provision is increasing on a regular basis, thanks to urbanization, and improved infrastructure (African Business, 2016).

10. Conclusion

This report has looked into the state of eHealth and telemedicine within the East African region. The key areas of focus were the state of infrastructure for eHealth and telemedicine, the key players involved, services offered, and the contribution of eHealth and telemedicine as it regards to UHC. In addition, the report has also assessed key challenges facing eHealth and telemedicine in the region, country ranking in adoption and usage, and the unexplored opportunities in eHealth. Accordingly, it is noted that despite generally poor infrastructure in the area of broadband and network connectivity, there has been a significant level of development as the member countries in liaison with the private sector are working to improve the same. In addition, implementation of eHealth and telemedicine is a process that needs various players who includes the governments, regulators, private sector, mobile operators, pharmaceutical firms, IT/software companies, content players, device vendors and even patients. Generally, the EA countries appear to be conscious of the role that eHealth plays and have been agile to ensure the technology is integrated in the healthcare systems. Nonetheless, effective implementation is marred by notable challenges which include low level of literacy among citizens, poverty which hinders low class citizens to access necessary gadgets, internet or power to facilitate access and usage of eHealth, and poor infrastructure including lack of power. Despite these, eHealth and Telemedicine has seen a remarkable improvement to accessibility of health services by many citizens, reduced the cost of health services delivery and consumption, enhancement of public health through increased awareness, as well as increasing the skill level for healthcare expertise. These aspects especially increased access and a reduction to cost of healthcare services are fundamental features required for the universal health coverage.

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