NAME: EUGENE OGWANG
REG. No: 2018/MMED/074/PS
COURSE: COMPUTER SCIENCE, INFORMATION TECHNOLOGY AND TELEMEDICINE.
TOPIC: ADOPTION OF TELEMEDICINE IN THE HEALTHCARE SYSTEM IN UGANDA: A CASE STUDY OF m-HEALTH.
FACILITATOR: DEBORAH NATUMANYA
DATE OF SUBMISSION: 13/04/2019
Background: Mobile technology has rapidly grown and expanded in Africa, infact, its labelled the worlds fastest growing Mobile region. For this reason, most African countries, Uganda inclusive have started to see m-Health grow. This review explores m-health adoption in Uganda, the challenges its faced with and the possible recommendations to these issues. Methods: A systematic electronic literature search was conducted to access peer reviewed journals and articles concerning m-health in Uganda using HINARI, PubMed, free medical journals.com and Web of Science data bases. Results: Review of these texts reveals that in as much as m-health is starting to make positive impact in Ugandas health sector, its greatly faced with numerous impediments which span beyond the obstacles infrastructure which is the most stressed hindrance in most of the articles. Conclusion: There is yet insufficient proof of the effectiveness of m-Health. The m-Health landscape is still faced with many challenges which have led to stalling of many of the projects in their beginner stages. It cant be relied on as an independent intervention to resolve the existing health challenges problems.
Keywords: m-Health, Uganda, Africa, MoH, ICT, Challenges.
MoH: Ministry of Health
ICT: Information and Communication Technology
UN: United Nations
UNESCO: United Nations Educational, Scientific and Cultural Organization
UNICEF: United Nations Childrens Fund
WHO: World Health Organization
MDGs: Millennium Development Goals
SMS: Short Message Service.
Introduction: m-Health refers to all that includes mobile technology that facilitates the communication in the health sector such as reporting irregularities and corruption, creating awareness and informing about diseases as well as reminding patients about health visits, vaccinations and treatments 1. Mobile telemedicine aims to provide rural clinicians with specialist consultations, avoiding lengthy waiting lists and long distance travels. Use of mobile telemedicine provides physicians with a means of diagnosing, triaging and treating complex cases, and also serves as a method of collecting large quantities of data that can be analyzed for research and evaluation
In a recent survey, over 70% of African countries reported having implemented at least one m-health application. These applications address public health problems such as management of chronic disease; infectious disease epidemics and pandemics; psychosocial problems such as drug abuse, addiction and suicide; and social problems such as family planning and smoking cessation.2
m-Health has become the focus of a wide range of projects across the region that aim to address crucial inadequacies that cripple rural African health care in particular. Unfortunately, great the enthusiasm for mobile technology is not backed by conclusive evidence of the impact of m-Health projects3 In fact, despite the availability of a growing body of research on m-Health in Africa, insight in the complexities of cost-benefit, scalability, transposability, continuity and technology adoption remains limited.
Fewer than 10% of the above mentioned 70% African countries who have implemented at least one m-health application have evaluated their m-health projects1. The aim of this review, which is to assess a body of scholarly literature in order to explore and explain, and eventually move beyond, the unconstructive ambiguity that marks the evidence of m-Health in Uganda. It thus provides a systematic analysis of reported success factors as well as obstacles, with an emphasis on the obstacles to m-health in Uganda.
To identify the challenges within m-Health in Uganda for organisations, health facilities and the people of Uganda.
To suggest the possible ways through which organisational structures and the sustainability of m-Health projects can be improved.
Literature review: Health has a major impact on development and UN has acknowledged this in three of their MDGs (UN, MDG, 2013). Better health is central to human happiness and well-being. It also makes an important contribution to economic progress, as healthy populations live longer, are more productive, and save more. (WHO, 2013)
According to Tatalovi?, a journalist at The Guardian, it is not easy to achieve better health in low-income countries, many hindrances and challenges have to be considered and overcome before end goals can be attained3. Within the previous decade, Africa has witnessed the fastest growth in mobile phone subscribers in the world, estimated at 955 million in 20151. Decreasing costs of technology and telecommunication along with expanding network coverage, primary causes of such growth rates, have also stirred interest in the potential of mobile phones as devices for development. It has become the focus of a wide range of projects across the region that aim to address crucial inadequacies for instance inaccessibility and lack of information that cripple rural African health care in particular; one such project is m-health an example being the uses of SMS for immunization programs4
In an attempt to get acquainted with the field of m-Health in Uganda, I quickly noticed that very little documentation had been done regarding the challenges of m-Health projects in the country. Most of the things that were documented were successful project reports where the challenges were not elaborated on whereas the positive sides got more attention. One such report is by The Medical Concierge Group (TMCG), (a digital health enterprise incorporated in Uganda (Headquarters), Kenya and Nigeria since 2012.) which stated; since the inception of The Medical Concierge Group call center in 2012, there has been a growth of over 50,000 active monthly users across all platforms and currently with over 16,000 monthly interactions. It goes on to say The Facebook platform has since registered 13,195 followers and 23,691 WhatsApp users in December 2016. The number of twitter followers has also grown to 1,755 followers. In 2016, the TMCG Instagram page was opened and has since gained 118 followers in a period of just three months5.
The Ugandan government has also published several reports and papers, an example being the Health Sector Strategic Plan (HSSP) where the benefits and positive sides of m-Health have been highlighted 6.
I found some information about the challenges m-Health in Uganda is faced with but often it was small episodes in a larger report. Other previous researchers have described social, cultural and economic factors that influence the field. Kojo Boakye et al (2010) brings forth an example in their case study: Mobiles for Development, where poor infrastructure and bad roads hinder development and in this case a mobile phone can help to overcome the communication difficulties 7. Wicander stress that many researchers forget to point out the impact that technology can have in a negative way, such as creating a digital divide where people that have access to the technology have a huge advantage over the people who do not have any access. The challenges are rarely described and that this needs to be explored more 8.
Methods: A systematic electronic literature search was conducted to access peer reviewed journals and articles concerning m-health in Uganda using HINARI, PubMed, free medical journals.com and Web of Science data bases. The major search terms were; Adoption m-health and Uganda. In addition to these search engines, Google Scholar was used to check for other articles that met the inclusion criteria. The searches were limited to journals and articles published in English between 2007 to date were. A manual revision was done to eliminate duplication and verify the journals and articles. Full-text articles were searched manually in digital sources, and studies were excluded when access to full-text articles was not available. Exclusion criteria were: not about Uganda exclusively, article not peer-reviewed, and non-m-Health implementation (e.g. telemedicine, other types of eHealth).
Results: From a total of 11 search results, 9 studies were selected for full-text review, of which 4 studies were included in the review according to the inclusion criteria. A large number of project assessments were pilot studies or even pre-trial investigations. Furthermore, most of the RCTs were implemented at community level and not yet scaled up. Hence evidence presented on effectiveness is limited and the long-term impact is unclear. The discussion will assess the obstacles and barriers to m-Health for community health that seem most pertinent.
Discussion: This section will also provide answers to my first objective.
Shortly after a few reviews, I noticed that the central message was that m-Health should not be perceived as an independent intervention which can resolve existing health problems; neither can it be used to replace the role of conventional health care providers due to the so many challenges it still faces;
A lack of coordination, not only within the organizations implementing m-Health but in general; between different organizations involved in m-health projects. According to Blaschke at UNICEF the situation of two different NGOs implementing the same project in the same community have arisen before, and the project participants have shown confusion when having to provide two different NGOs with the same kind of information 9.
Lack of involvement by key institutions like the ministries of health and Information Communication and Technology in the different m-Health projects in the country. Project duplicates are thus not checked due to a lack of its control (UNICEF, 2012b)
Corruption: remains a big challenge not in the health and ICT sectors alone, but throughout both government and private sectors. In November 2012, Uganda was involved in a corruption scandal in which big sums of donor funds were embezzled in the office of the prime minister. Al Jazeera claims that millions of aid money (USD) had been stolen and embezzled from officials and put into private accounts of individuals. Several Ugandan officials were suspended and there was an investigation. As a result of the scandal, many donors such as the European Union, United Kingdom, Sweden and Norway decided to withdraw their donations to the Ugandan Government. (Al Jazeera, 2012)
Lack of funding; Many donors are willing to fund short term projects expecting that projects become self-sustainable by the time their contracts run out, which usually is not the case. Many m-Health projects thus fail to continue thereafter 9.
Poor Communication between donors and the implementers on ground has on several occasions led to failure to reach a common understanding. In a report by Dr. Kibairu some donors do not ask the receivers what they are in most need of but instead provide them what the donor himself thinks is most useful for the receivers. (Dr. Kibairu 2013)
Scaling-up: low scalability rates usually because most of the projects start out as pilots and stop running due to lack of money
Languages and Literacy: According to the UNESCO, in 2012, 70.2% percent of the Ugandan population over 15 years could read and write (UNESCO, 2014). The numbers however do not specify in what language. English however was spoken by only 10-20% of Ugandans as at 2011 10. This becomes a major challenge in communication and the organizations expressed concern and said this is a hindrance in many projects; they have however also noted that there is great improvement over the years and that this might not be a major problem in the future.
Infrastructure: in as much as there is marked improvement in telecommunication in the country over the past years, infrastructure still remains a big challenge. Due to a lack of proper broadband services coupled with weak internet connections in rural areas, the growth, efficiency and coverage of m-health still remains greatly limited 4.
Lack of policies, guidelines, laws and standards for using telemedicine in Ugandas health system: African countries, Uganda inclusive currently show the lowest rates of national telemedicine policy. (WHO 2010)
Conclusion of Results: Its true that m-Health is being used in Ugandas health sector to improve patient outcomes through quality services in measurement and monitoring, evaluation/assessment/diagnosis, interventions/treatments/ rehabilitation, and workflow and collaboration. However, there is yet insufficient proof of the effectiveness of m-Health 3.Through the reviews, I have found many different hinders in the field of m-Health in Uganda. The obstacles m-health is facing covers issues beyond infrastructure hindrance which is the most stressed hindrance in most of the articles. The problem of short donor funding duration , high donor demands and little knowledge have led to stalling of several m-Health schemes; Coupled with all the above mentioned; a project landscape with many challenges is what we mostly have. By coming to these conclusions I will in the next section try to bring up some applicable recommendations to tackle these issues which will also accomplish my second objective
Recommendations: Among the major messages is that m-Health should not be perceived as an independent stand-alone intervention which can resolve existing problems; neither can it be used to replace the role of conventional health care providers.
Because m-Health is a new field I will suggest further research in not only m-Health but in the separate fields of mobile phone technology and health issues. The field is changing rapidly and the factors that influence the field are changing with it, this makes it important to continue
I believe that the organizations involved need to start putting communication higher on the agenda and collaborate more with each other.
Government should consider increasing funding toward m-Health development in the country to avoid total reliance on donors. One study argues that, in this respect, a national ownership of m-Health cannot be overemphasized 8
The higher institutions like the ministries of Health and ICT should be more involved for purposes of guidance and establishment of regulations and coordination.
Educate the population about m-Health to increase awareness and fill in the
Knowledge gap of the field.
In line with the conceptual articles, literature reviews also stress that particularly crucial to the success and failure of m-Health projects are cultural and contextual issues. Therefore, careful integration of m-Health into the various existing cultural systems is crucial. Projects have proven to be most successful when they have been adjusted to fit the local context and language.
Creating benchmarks and initiating ways to communicate and create a stronger organizational network can be a way of overcoming some of the different challenges. The different part players have to be aware when they use the mobile phone that it is a tool and not an answer in itself and that many factors affect the field.
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Health Sector Strategic Plan III 2010/11-2014/15 by Ministry of Health, Government of Uganda
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Landguiden Uganda, Afrika. (Country Guide to Uganda, Africa), 2007.