In the area of health, information and communication technology (ICT) represents an essential tool in medical practice. The main areas of application for which there is an obvious need for access to ICT, and for which studies show a clear benefit, are medical and surgical emergencies and also mother and child pathologies (obstetrics, gynaecology, paediatrics).

The Telemedicine

Telemedicine tools permit an exchange of information in electronic form and facilitate access to medical expertise from a distance. A doctor who finds himself far from medical expertise can thus consult colleagues at a distance in order to resolve a difficult case, follow a continued education course broadcast on the Internet, or access knowledge banks or digital libraries.

 

The potential of these tools is obvious in countries where specialists are rare and where distances and quality of infrastructure make it difficult for doctors or patients to travel. This is the case for most of the countries of sub-saharian Africa.

Rationale

District hospitals are located in areas where electricity, mobile telephony and Internet are available but where current equipment does not allow transfer of medical data to the upper end of the scale in the country, or to hospitals of high international standing.

Due to a lack of diagnostic means and the absence of specialists, care given to patients in district hospitals is often far from adequate. Delays in the implementation of treatments or unjustified evacuation can be responsible for poor use of already scarce resources and unnecessary suffering for patients. One way of improving this situation is to implement modern diagnostic means, adapted to the field, together with tools to enable long-distance mobilisation of the specialists’ expertise along with logistical support. The advantages of such an approach have been demonstrated, but there is not yet any wide scale deployment of these tools.
 

The hospital of a health district in sub-saharian Africa is usually used as an initial reference point for 50,000 to 200,000 inhabitants. There are several doctors, as well as a minimal medical and technological platform (laboratory, operating theatre, conventional radiology) which enable some difficult and urgent cases to be taken care of. Continued training for first call health professionals is also dispensed at district hospital level along with their supervision and co-ordination, as well as the collection and consolidation of field information and indicators which, going up to ministerial level, enable the health system to be managed.

 

  

Equipment required:

• Satellite aerial and terminal(VSAT)
• Laptop computer with webcam
• Data projector to equip training room (as required)

Medical equipment:

• Portable digital ultrasound scan station
• Digital electrocardiograph machine
• SOS Kit(blood pressure and glycemia monitoring)

Electric production:

• Electric supply by solar panels (as required)

 

The bandwidth shared within the same network, the solution we recommend here, costs between 2,150 and 6,000 euros per year (for a throughput of 64/128Kbps and of 256/512 Kbps respectively). This option allows basic telemedicine applications. Optimization of the shared bandwidth depends on the number of sites (video-conferencing is possible starting from 60 operational sites).

Other connection solutions exist: a dedicated individual bandwidth costs at least 3,600 euros per month, for a throughput output of 1024 Kbps. It enables on-line applications (video-conferencing, downloading of large files). It is difficult to envisage how this option would be economically worthwhile in Africa, without significant external financial support.

 

The towns and local partner communities are invited to mobilise a local resource of telediagnosticians (volunteer doctors, hospitals, aid centres). Operational support structures are necessary, at least at the level of each country concerned, to guarantee an effective mobilisation of experts and a response to questions from teleconsultations within a worthwhile timeframe.

The Network French-speaking Africa for Telemedecine (RAFT – University Hospitals of Geneva, Switzerland), has a pool of medical and technical co-ordinators available in twelve African countries, ready to extend their activities to support these new telemedicine and e-learning services. The collaborative platform of RAFT allows the teleconsultation activities to be structured by defining closed groups who can thus work in a network of confidence and make up “virtual communities”.

The co-operation of other active telemedicine networks in Africa has already been assured:

• World French-speaking Digital University, Paris, France
• World French-speaking Virtual Medical University, Paris, France
• E-Health Stakeholders’ Club (CATEL), Vannes, France
• World Health Organisation, eHealth Unit, Geneva, Switzerland
• EMISPHER telemedicine network, Charité Hospital, Berlin
• Etc ...

Training workshops for learning the manipulation of diagnostic tools are required. 3 days training should be allowed for the case of telemedicine and remote diagnosis tools, and 10 days for training in the principles of ultrasound for prioritizing emergencies and obstetrics. In both cases, distance training support is useful and easily attainable. Two additional training sessions in ultrasound scanning are also planned: on the one hand, a targeted training in imagery for emergency situations (abdominal and thoracic ultrasound scanning) which in two weeks teaches the basic techniques in directing the care of the patient and his possible evacuation to a regional hospital, as well as the realisation of emergency invasive procedures (punctures, drainages) under ultrasound guidance.

Secondly, a training focused on foetal ultrasound scanning, which generally requires a month’s training, enables pregnancy monitoring and early detection of cases which could pose problems at the time of the birth. These training programmes, together with the initiation in use of telemedicine tools, will be supplemented by distance learning courses.

 

Programming phase

A ) at the level of recipient countries:

• identification of recipient countries and sites (based on an evaluation of needs)
• agreement of the authorities concerned
• identification of local officials (national and local)

B ) at cost estimation level:

• publication of calls for tender (for connection equipment, devices and training)
• evaluation of tenders
• drawing up of an operating budget

C ) at the level of fund raising:

• identification and negotiation of potential financial partners

D) at the level of partnerships (contents):

• identification of institutional partners for development of content, support and networks

E) at communication level:

• development of a communications strategy for the whole project

Operational phase

• agreements with all recipient countries
• contracts with all suppliers
• roll-out of equipment
• field training (seminars)
• setting up of monitoring and evaluation mechanisms

 

Evaluation of the impact of these tools is necessary to demonstrate the advantages and justify the expansion of their use. The following indicators can easily be measured:

• number of scans used for diagnoses and procedures carried out under ultrasound
• number of scans which modified patient care
• number of teleconsultations which modified patient care
• number of medical evacuations avoided
• number of continued training courses followed

An evaluation of changes in practice resulting from these tools will be the subject of field studies. A measure of the improvement of the state of health of the populations will have to be carried out in the longer term.