Document(s) 23 of 31

Introduction

South Africa is similar to most other sub-Saharan African countries in facing a substantial burden of disease with limited human and financial resources. South Africa is a relatively large country of over one million square kilometres, with a total population of 45 million. Its people are almost equally divided between rural (46%) and urban areas. With a gross domestic product of US$200 billion, South Africa has one of the largest economies in Africa and accounts for about a quarter of the entire gross domestic product of the continent. Despite this, it has an official unemployment rate of 26% and an unofficial unemployment rate of 41%. About 50% of its people live below the poverty datum.

Burden of disease

The burden of disease in South Africa is great. Until recently, it had more HIV-positive people than any other nation. HIV prevalence in adults aged 15 years or older is 17% and the incidence of tuberculosis is 1.3%.¹ Data from 2000 show HIV/AIDS as the greatest cause of death (30%), with cardiovascular disease (17%), intentional and unintentional injuries (12%), non-HIV-related infectious and parasitic disease (10%), and malignant neoplasms (8%) as the next major causes.²

Health provision

Public health services and budgets are devolved from the national Department of Health (DOH) to provincial Departments of Health, with some primary health care services being provided by municipalities. The annual health care expenditure by the government is US$158 per capita.¹ There is a major inequality in health care funding, with private expenditure per person about six times higher than public sector expenditure per person.³ By African standards, South Africa is relatively well supplied with doctors, with 77 doctors per 100 000 people,¹ but again the distribution of doctors is skewed, with the provincial hospital sector being served by 24 doctors per 100 000 people and 10 specialists per 100 000 people. On average, 34% of the medical posts in the public health sector are vacant.³

Telecommunications

Africa did not benefit from the substantial telecommunication infrastructure roll-out and deregulation that occurred during the dot.com boom. As in most African countries, telecommunication in South Africa is still tightly regulated, with the government following a policy of ‘managed liberalization’. There has until very recently been a telecommunication monopoly. A licence for a second service provider has now been awarded, but services have yet to commence. The government has 37% and 30% shareholdings in these two service providers, respectively.⁴ International bandwidth is provided by undersea cable (SAT 3) and satellite. Although plans for an additional undersea cable running up the east coast of Africa (EASSY) are well developed, the project appears to be stalled at present. Satellite services are licensed to one company, which is totally owned by the Department of Communications.

Internet access charges in South Africa are relatively high when compared with those in industrialized countries, with 20 hours of Internet access costing US$33 per month, compared with US$15 per month for the USA. Similarly, ISDN costs are high, with a 30-minute ISDN link to the USA (at 128 kbit/s) costing US$15.80.⁵ ISDN and ADSL access is available in most cities and towns. Wireless coverage is limited by legislation, but it is hoped that Wimax will be made available by several large municipalities. In an attempt to provide low-cost bandwidth facilities, the government has established a state-owned company, but it has yet to trade.⁴

Mobile phone coverage is good and uptake is high. 3G and HSDP services are available in most cities, and GSM coverage is estimated at 93%. Data for the year 2004 indicate that 36% of South Africans have mobile phone access. Local figures suggest that access to a mobile phone may be as high as 75%.⁴

Lack of bandwidth, especially in rural areas, is a major problem facing telemedicine delivery in South Africa. All provincial hospitals are linked to the government network (Govnet). Access to computers with Internet access for doctors and nurses is limited in many rural hospitals and clinics, with doctors having to send store-and-forward cases from home using local Internet service providers. In KwaZulu-Natal, most hospitals have access to a total bandwidth of 128 kbit/s, which must be shared across all sectors of the hospital. Migrating videoconferencing from ISDN to IP is not feasible as yet, because of the limited bandwidth. ISDN access is not always easy to obtain, and delays of up to a year for installation are not uncommon. Likewise, support from the telecommunication company is poor, and the time from registering an ISDN line problem to a repair visit can be several months. ADSL, while available in most cities and larger towns, is dependent on the state of the local telephone exchanges. A survey conducted in 2006 showed that fewer than half of the hospitals in KwaZulu-Natal could be provided with ADSL if requested.

Telemedicine governance

In 1995, the new government formed the National Health Information Systems Committee of South Africa, tasked with designing a comprehensive national health information system for South Africa. Under the auspices of this Committee, a National Telemedicine Task Team was formed in 1998, to implement a national telemedicine strategy for South Africa. Four technical teams were established to work on telemedicine protocols, network infrastructure, legal licensure and ethical issues, and teleeducation. These teams were active until 2001, by which time Phase One of the national telemedicine strategy had been implemented. While the national DOH has a Telemedicine Director, management and implementation of telemedicine services was devolved to provincial level during the Phase One project. In order to coordinate this at a provincial level, the Health Act of 2004 requires Members of the Executive Council at provincial level to form a committee that will ‘… establish, maintain, facilitate and implement health information in the province’. The provinces have taken different approaches to telemedicine. In most provinces, telemedicine is seen as part of the duties of the provincial representatives attending the National Health Information Systems Committee, who may or may not be interested in telemedicine. As a result, telemedicine activity has been limited or non-existent in some provinces. Other provinces have appointed specific telemedicine committees, some of which have been extended to include academic input from the medical schools. Only a few provinces actually provide a budget and posts for telemedicine, but this is slowly changing.

The national telemedicine strategy planned for three phases of development of tele-medicine. Only Phase One was implemented and, after evaluation, it was decided not to continue with the project. However, after several years of relative inactivity, there has been renewed interest in telemedicine. The national DOH is developing a new strategic plan for 2008–2013. The Presidential National Commission on Information Society and Development is working on an e-health White Paper, the Departments of Communications and Trade and Industry have included e-health in their most recent strategic plans, and the Meraka Institute of the Council for Scientific and Industrial Research (CSIR) is developing an e-health strategic plan.

The Medical Research Council (MRC) of South Africa has a Telemedicine Lead Programme tasked with evaluating existing and planned telemedicine systems, coordinating national telemedicine activities and establishing tele-education for health care professionals. The eight medical schools in the country have been slow to participate in telemedicine. The University of KwaZulu-Natal is the only medical school with an academic department of Telehealth, and the Walter Sisulu University has a Telemedicine Unit.

Telemedicine background

Telemedicine in South Africa began in the early 1990s, with: radiologists linking CT scanners in Provincial Hospitals in KwaZulu-Natal to the Academic Radiology Department;⁶ neurosurgeons in the province providing a teleradiology-assisted service;⁷ rural doctors using email-based store-and-forward telemedicine for dermatology, orthopaedics and radiology; and ophthalmologists linking with Moorfields Hospital in London.⁸ At the Walter Sisulu University Medical School, store-and-forward telepathology services have been used since 1995, with links to the Armed Forces Institute of Pathology in Washington and various pathology departments in Europe.⁹

Phase One of the National Telemedicine Strategic Plan was implemented between March 1999 and September 2000, establishing 28 telemedicine sites in six of the nine provinces. Telemedicine services offered included store-and-forward teleradiology using scanned X-ray films, tele-ultrasonography (both real-time and store-and-forward), store-and-forward telepathology and tele-ophthalmology. Of these projects, only the teleradiology service linking three rural hospitals with the Pretoria Academic Hospital could really be deemed a success. In the first 9 months of the Pretoria service, 264 radiographic studies (10% of all the studies performed) were sent for specialist radiologist reporting.¹⁰ Over the years, this developed into a useful CT scan radiology service with the neurosurgical department, but the service ended when the department moved into a new building with no ISDN line access. Tele-ultrasonography, trialled in the Northern Province and KwaZulu-Natal, was used occasionally and then stopped, and the tele-ophthalmology project in KwaZulu-Natal was beset with software problems and never started.

This lack of success meant that the second and third phases of the project, to expand telemedicine capabilities to 71 and then to 200 sites, was not undertaken. The second phase was then changed to an educational project linking the eight medical schools, with the expectation that they would initiate shared tele-education projects throughout the country. Although the medical schools were supplied with videoconference units, this project lacked the support of the deans of the medical schools, and never started.

Many lessons were learned in this process, and were similar to those experienced by others. These can be summarized as follows:¹¹

• Failure to fully appreciate the need for a well-structured change management plan
  
  
• Lack of participatory buy-in from doctors at the sending and receiving sites
  
  
• Inadequate training and support
  
  
• Failure of provincial Departments of Health to take ownership and commit human and financial resources to the devolved project.

At the same time as the telemedicine project was being rolled out, the Nkosi Albert Luthuli Central Hospital was built and commissioned in Durban, KwaZulu-Natal in 2002. It is a paperless hospital, and has exposed its staff to aspects of telemedicine through the use of radiology and pathology PACS.

Telemedicine projects

With the relative inactivity of most of the provincial Departments of Health, telemedicine activity was taken up by other agencies and academia. The South African Defence Force together with the MRC developed a mobile laboratory with satellite communication and telemedicine capability.¹² However, no information has been published about its subsequent deployment. The MRC developed a test bed in Mpumalanga Province, linking two clinics and a hospital to the Pretoria Academic Hospital by videoconference. Limited data are available on its use: in 2002, 78 videoconference sessions took place – 68 teleconsultations and 10 tele-education sessions. This has been extended to a wireless network, and a teleradiology project is planned.

In collaboration with the University of Stellenbosch, the MRC has developed a ‘home-grown’ primary health care workstation for use in primary health care facilities run by nurses and part-time doctors and dentists. It has been trialled intermittently over the past two years at the Grabouw Community Health Centre, with an ISDN-based link to the Tygerberg Academic Hospital. The unit has been designed to be used by health professionals who have limited or no previous computing experience. Features include:¹³

• removal of the need to interact with the operating system
  
  
• a simplified alphanumeric input device
  
  
• integrated and intelligent video control
  
  
• a document interface that is familiar to the local users
  
  
• seamless integration of peripheral devices
  
  
• a back-up power source
  
  
• use of open-source, loyalty-free software.

The experience has revealed some of the common challenges associated with starting telemedicine services in environments where there is a shortage of staff at both the sending and receiving sites:

• Adequate buy-in has to be obtained from users.
  
  
• The service must be integrated into the normal workflow of the hospital.
  
  
• Incentives should be offered for already overworked staff to use telemedicine, which is seen as an additional and time-consuming burden.
  
  
• There should be a local telemedicine champion to drive the changes.

The unit has been used predominantly for teledermatology and paediatric consultations.

Various other enthusiast-driven telemedicine projects have commenced. At the Walter Sisulu Medical School in the Eastern Cape Province, the telepathology services that started in the 1990s have migrated to the iPath platform, with an iPath server located in Umtata. In the first 4 years, 36 pathology cases were referred for international opinion.⁹ This service was then expanded to include a teledermatology project, with a general practitioner in a small town in a rural area sending 110 cases in 6 years.¹⁴ An innovative wireless solution, developed by the CSIR, was piloted in a rural Eastern Cape clinic staffed by a nursing sister. The region does not have telephone coverage, and images are sent via a webcam, with a simultaneous voice link, to a doctor in another town.¹⁵ The activity in the Eastern Cape has resulted in the formation of an active telemedicine committee within their DOH. They have set up an education centre with Internet and videoconference facilities in East London, and they are embarking on a large-scale project linking 23 sites, focusing on teleradiology, teledermatology and tele-spirometry. The project is not yet fully functional, and has yet to be evaluated.

A different approach has been taken in KwaZulu-Natal. In 2002, the University of KwaZulu-Natal established an academic department of telehealth, with a mandate to assist the provincial DOH in developing telemedicine, conduct research in telehealth, and develop academic programmes in telemedicine and medical informatics. In addition to the long-standing teleradiology and teleneurosurgery services in the province, a store-and-forward tele-ophthalmology service has been running between a peripheral hospital and the academic ophthalmology department for several years. When last audited, this service had referred 282 cases in 18 months and had saved 82% of the patients an unnecessary transfer to the academic unit, 118 km away. Despite efforts, it has not yet been possible to replicate this service in any of the other 64 provincial hospitals. A real-time teledermatology service has been running between one hospital and the medical school for several years. At audit in 2006, 132 patients had been seen over 27 months, with 80% being saved a transfer. This service has been replicated in two other hospitals, and further sites are planned. Store-and-forward teledermatology services have been running in parallel, with cases sent from 23 hospitals.

Fledgling synchronous services have commenced in paediatric surgery, plastic surgery and psychiatry. Store-and-forward burn management and diabetic retinopathy screening programmes have also started. Through various externally funded initiatives, there are now 35 hospitals in KwaZulu-Natal with videoconference facilities, not all of which are currently active. The provincial DOH, while being supportive of these initiatives, has not taken ownership of telemedicine. As a result, it has only provided limited technical support, and has not yet provided a specific telemedicine budget. This has recently changed with the provision of posts for telemedicine, the development of a strategic plan and a budget for telemedicine, and the formation of a joint DOH and university Telemedicine Steering Committee for the province.

The national Department of Science and Technology has funded a consortium of the MRC, the Meraka Institute of the CSIR and the University of KwaZulu-Natal in a major three-year project in KwaZulu-Natal. The project will investigate various bandwidth solutions in rural areas, aiming to achieve a minimum of 512 kbit/s. It will also compare the locally produced primary health care workstation with a Chinese tele-medicine workstation that has been acquired through a bilateral government agreement, and will conduct research into the development of appropriate administrative and financial models for the use of telemedicine in the South African public health care sector. Other aims are to investigate cultural and ethical matters relating to the use of telemedicine in rural communities, to conduct telemedicine training, to develop a telemedicine hub site and establish a virtual hospital to support the hospitals in the province, and to develop capacity in telemedicine through masters and PhD programmes. It is hoped that this project will result in a sustainable model for telemedicine in South Africa.

The Free State, Northern Cape and North West Province were the other three provinces that received telemedicine infrastructure in Phase One of the national telemedicine project. Their services in teleradiology and tele-ultrasonography have stopped. The Free State is actively investigating the establishment of telemedicine in the province, and has been considering a web-based PACS system for province-wide teleradiology.

The three provinces that were not part of Phase One were Gauteng, the Western Cape and Limpopo. In Limpopo, a telemedicine steering committee was established in June 2006. Videoconferencing was set up between four hospitals. With the assistance of the MRC and the University of KwaZulu-Natal, an ambitious telemedicine and tele-education programme began in the third quarter of 2007. The project includes dermatology, emergency medicine, psychiatry, dentistry, ENT, orthopaedics and surgery.

In Gauteng, work is under way to develop teleradiology in the provincial hospitals. In the Western Cape, an email-based store-and-forward telemedicine project has been running for several years between three district hospitals and the Tygerberg Children’s Hospital.¹⁶ A pilot store-and-forward teledermatology project has been started by the MRC and the University of Cape Town, with nursing sisters at four rural sites sending images and case histories back to a dermatologist in Cape Town.¹⁷

Telemedicine in the private health sector has not been well documented. One large hospital group and some large radiology practices use teleradiology and commercial PACS to transport and store X-ray images and reports, and pathology practices are following suit. There are several informal reports of images being captured during arthroscopic and endoscopic surgery and being sent by email for another opinion. There is at least one ophthalmologist who is sending photographs of retinal images to a colleague for second opinion.

At present, there are no telepsychiatry services in South Africa, but two services and a psychiatry tele-education programme are planned. With recent changes to the Mental Health Act and the requirement to treat psychiatric patients at district and regional hospital level for at least 72 hours, telepsychiatry may prove to be a major growth area. While videoconferenced patient follow-up is relatively common in the industrialized world, it is not yet being used in South Africa. This may be because of the shortage of doctors and the lack of telemedicine site coordinators.

Some novel applications have been developed in South Africa. Cell-Life is a mobile phone and Internet method of monitoring HIV patient adherence to antiretroviral medication.¹⁸ SIMpill is a device that utilizes mobile phone technology and SMS text messages to monitor patients’ medication compliance. When a patient opens the pill bottle to take their medication, an SMS text message is sent to a central server. If the patient fails to open the pill bottle within a defined time, the server sends an SMS message to the patient’s mobile phone and, if there is repeated non-compliance, to the patient’s physician.¹⁹

Tele-education

Staffing of rural hospitals has been a long-term problem in South Africa. The Government has had to employ doctors from other countries in order to maintain services in some rural areas. In 2004, there were 240 Cuban doctors working in South Africa. A recent press release reported that 1000 doctors are to be recruited from Tunisia, Cuba, Iran and elsewhere to work in rural areas. Studies of the factors that influence local doctors’ decisions to work in rural hospitals have identified salaries and professional isolation as key issues. The government has improved salaries through the provision of a scarce skills allowance. Tele-education and telemedicine have been cited as ways of overcoming professional isolation, and the National Telemedicine Strategy included tele-education as an important component of the strategic plan. The attempt to get the eight medical schools to jointly develop a national teaching programme was not successful, and individual medical schools have undertaken tele-education.

In 2001, as part of an e-health learning initiative, the Free State Department of Health set up an interactive satellite broadcast system, and now offers health care training at 40 venues. Their last evaluation included over 2200 users. After the cessation of Phase One telemedicine services in KwaZulu-Natal, the local university approached the provincial DOH, in 2001, and was given approval to use the videoconferencing infrastructure for postgraduate medical education. Equipment has been upgraded, and postgraduate teaching sessions are multicast from the Nelson R Mandela School of Medicine to four other academic sites. In 2006, 765 hours of tuition in 17 academic programmes were shared by videoconferencing. A total of over 72 000 person-hours of tuition were offered in 2006, with approximately 40% of participants situated at rural hospitals. The medical school also shares its teaching sessions with other provinces, including the Walter Sisulu Medical School and the East London Medical Complex in the Eastern Cape, and the Polokwane Hospital in Limpopo. International teaching has taken place in collaboration with several countries in North Africa, Europe and North America.

The Walter Sisulu University has begun postgraduate teaching by videoconferencing, and the Universities of Stellenbosch and Pretoria have offered postgraduate courses by satellite TV. The University of the Witwatersrand has been funded to start a videoconferenced academic programme in public health. The College of Radiology of South Africa, aware of the extreme shortage of radiologists in the academic sector, funded a pilot project to share postgraduate teaching sessions between all eight medical schools by videoconference. The first four sessions have been completed, and are being evaluated before a decision is made to continue the project.

Mindset Health is a partnership between the Mindset Network, the national DOH and Sentech (the Government-owned satellite information and communication technology service provider), which aims to deliver large-scale health education and health promotion. This is achieved through the development of digital health education material delivered by video, by multimedia computer lessons and print, and by daily satellite broadcast to 200 hospitals in South Africa, with on-demand satellite datacasts for health care staff. The TV receivers for the satellite broadcasts are usually placed in the outpatient departments of rural hospitals. The initial focus has been on tuberculosis and HIV/AIDS.²⁰

Telemedicine training

Since the Phase One project, there has been very little formal telemedicine training for health care workers. In Mpumalanga, several members of staff were sent to China to be trained on a Chinese telemedicine unit in expectation of its deployment. In the Eastern Cape, a telemedicine training workshop was arranged under the auspices of the Regional Impact of Information Society Technologies in Africa project. Training has also been provided by the MRC, the Walter Sisulu University and the University of KwaZulu-Natal to specific individuals participating in projects.

At postgraduate level, the principles and potential of telemedicine and medical informatics are included in several Masters in Public Health programmes. Formal training in telemedicine is offered at the University of KwaZulu-Natal, where students can take a Masters in Public Health degree with specialization in telemedicine or a Master of Medical Science in telemedicine.

Legislation and guidelines

The DOH is drafting a Telemedicine Act that will address matters such as licensure, consent, data security and patients’ rights. With the shortage of doctors in South Africa, there is a need for a pragmatic approach to the issue of licensure, so that the country can take advantage of international telemedicine services. It is hoped that the Act will be enabling and not restrictive. At the same time, the Health Professionals’ Council of South Africa is drafting ethical guidelines for telemedicine. While these initiatives are well intentioned, they may be premature, as there is as yet an insufficient base of physicians and nurses with practical experience in telemedicine in South Africa to fully appreciate and debate the implications of some the proposals in the Act. Legislation that may be appropriate for an industrialized country may not be appropriate in a developing country with a shortage of doctors and nurses, and may indeed obstruct the use of telemedicine.

Conclusions

Telemedicine in South Africa appears to be at a crossroads. While its potential is apparent, it is not yet clear whether the potential can be realized in an environment in which there are human resource constraints at both the sending and receiving sites. Despite several years of activity, the volume of telemedicine use is still very low, and most services must be considered as being still in the pilot phase. Efforts to date have been hampered by several common factors. These include lack of buy-in from provincial governments, lack of support from health professionals, lack of technical support, insufficient training, failure to provide site coordinators, lack of administrative and financial models for the public sector, and failure to understand the complexity of change management.

Videoconferenced tele-education for health professionals has been successful, and demand is growing. Tele-education may prove to be the catalyst for rural practitioners to become involved in telemedicine activity. There is renewed interest in telemedicine in South Africa, and this needs to be well managed and coordinated for telemedicine to succeed. To do so probably requires the formation of a national telemedicine association, bringing together the government and the provincial DOHs, universities, nongovernmental organizations, the private health sector and industry. The aim would be to ensure that mistakes are not repeated, that pilot projects are scaled up through cooperation and that local best practice is shared for the common good. If South Africa cannot make telemedicine work, then other poorly resourced African countries are unlikely to succeed.

Further reading

Mars M, Dlova N. Teledermatology by videoconference: experience of a pilot project. S Afr Fam Pract 2008; 50: 70.

References

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² Bradshaw D, Groenewald P, Laubscher R et al. Initial burden of disease estimates for South Africa. S Afr Med J 2003; 93: 682–8.

³ Health Systems Trust. Health Statistics. Available at: www.hst.org.za/healthstats/index.php?indtype_id=004002.

⁴ Esselaar S, Gilwald A, Stork C. South African Telecommunications Sector Performance Review 2006. Available at: link.wits.ac.za/papers/SPR-SA.pdf.

⁵ World Bank. ICT at a Glance Tables. Available at: web.worldbank.org/WBSITE/EXTERNAL/DATASTATISTICS/0,,contentMDK:20459133~menuPK:1192714~pagePK:64133150~piPK:64133175~the
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⁶ Corr P. Teleradiology in KwaZulu-Natal. A pilot project. S Afr Med J 1998; 88: 48–9.

⁷ Jithoo R, Govender PV, Corr P, Nathoo N. Telemedicine and neurosurgery: experience of a regional unit based in South Africa. J Telemed Telecare 2003; 9: 63–6.

⁸ Kennedy C, Kirwan J, Cook C et al. Telemedicine techniques can be used to facilitate the conduct of multicentre trials. J Telemed Telecare 2000; 6: 343–7.

⁹ Brauchli K, Oberli H, Hurwitz N et al. Diagnostic telepathology: long-term experience of a single institution. Virchows Arch 2004; 444: 403–9.

¹⁰ Gulube SM, Wynchank S. Telemedicine in South Africa: success or failure? J Telemed Telecare 2001; 7(Suppl 2): 47–9.

¹¹ Gulube SM. Evaluation Report of the First Phase of the SA National Telemedicine System (NTS). Available at: www.kznhealth.gov.za/telemedreport.pdf.

¹² Science in Africa. Telemedicine Gets Mobile. Available at: www.scienceinafrica.co.za/2004/september/telemedicine.htm.

¹³ Abrahams JF, Molefi M. Implementing telemedicine in South Africa ‘A South African Experience’. Available at: www.hrhresourcecenter.org/node/1265

¹⁴ Brauchli K, O’Mahony D, Banach L, Oberholzer M. iPath – a telemedicine platform to support health providers in low resource settings. Stud Health Technol Inform 2005; 114: 11–17.

¹⁵ Chetty M, Tucker W, Blake E. Telemedicine in the Eastern Cape Using VOIP Combined with a Store and Forward Approach. Available at: pubs.cs.uct.ac.za/archive/00000202/01/Chetty.pdf.

¹⁶ Bridges.org. The Tygerberg Children’s Hospital and Rotary Telemedicine Project. Available at: www.bridges.org/case_studies/353.

¹⁷ Colven R, Todd G, Wynchank S et al. A Teledermatology Network for Underserved Areas of South Africa. Available at: www.medetel.lu/download/2005/parallel_sessions/presentation/0407/A_Teledermatology_network.pdf.

¹⁸ Cell-Life. Cell-Life. Available at: www.cell-life.org.

¹⁹ SIMpill. Simpill. Available at: www.simpill.com.

²⁰ International Marketing Council of South Africa. Beaming Education to the Nation. Available at: www.southafrica.info/ess_info/sa_glance/education/mindsetedu.htm.

Document(s) 23 of 31