Scaling up a Mobile Telemedicine Solution in Botswana: Keys to Sustainability

Abstract

Effective health care delivery is significantly compromised in an environment where resources, both human and technical, are limited. Botswana’s health care system is one of the many in the African continent with few specialized medical doctors, thereby posing a barrier to patients’ access to health care services. In addition, the traditional landline and non-robust Information Technology (IT) network infrastructure characterized by slow bandwidth still dominates the health care system in Botswana. Upgrading of the landline IT infrastructure to meet today’s health care demands is a tedious, long, and expensive process. Despite these challenges, there still lies hope in health care delivery utilizing wireless telecommunication services. Botswana has recently experienced tremendous growth in the mobile telecommunication industry coupled with an increase in the number of individually owned mobile devices. This growth inspired the Botswana-UPenn Partnership (BUP) to collaborate with local partners to explore using mobile devices as tools to improve access to specialized health care delivery. Pilot studies were conducted across four medical specialties, including radiology, oral medicine, dermatology, and cervical cancer screening. Findings from the studies became vital evidence in support of the first scale-up project of a mobile telemedicine solution in Botswana, also known as “Kgonafalo.” Some technical and social challenges were encountered during the initial studies, such as malfunctioning of mobile devices, accidental damage of devices, and cultural misalignment between IT and healthcare providers. These challenges brought about lessons learnt, including a strong need for unwavering senior management support, establishment of solid local public-private partnerships, and efficient project sustainability plans. Sustainability milestones included the development and signing of a Memorandum of Understanding (MOU) between the Botswana government and a private telecommunications partner, the publication and awarding of the government tender to a local IT company, and the development and signing of a Memorandum of Agreement between the Ministry of Health Clinical Services department and the local tender winner. The initial system scale-up is scheduled to occur in 2014 and to ensure the project’s sustainability, the system is aligned with the national eHealth strategy and local ownership of the project remains at the forefront (1).

The pitfalls of scaling up evidence-based interventions in health

“…They related to cost-effectiveness, equity, harms, ethics, bottom-up/top-down scaling-up, and the context in which the EBI was scaled up (see Figure 2). To discuss them, we identified 45 scaling-up studies that raised these difficulties, of which 13 were on costeffectiveness estimates or cost-analysis models [22][23][24][25][26][27][28][29][30][31][32][33][34], 14 on equity [35][36][37][38][39][40][41][42][43][44][45][46][47][48], four on harms [16,[49][50][51][52], three on ethics [53][54][55], six on top-down implementation [42,[56][57][58][59][60], and eight on contextual problems [40,43,[61][62][63][64]…”

“…The scaled-up harm pitfall: harms as well as benefits may be amplified by the scaling-up Scaling-up EBIs risks amplifying their harms as well as their benefits [49][50][51]. For example, in their study about scaling-up male circumcision in the context of HIV prevention, Kilima et al reported severe bleeding, delayed wound healing, and wound sepsis as the most frequent adverse effects [49].…”

Cervical cancer data and data systems in limited‐resource settings: Challenges and opportunities

“…In Zambia, a system for telemedicine and quality assurance that combines mobile telecommunications and digital cervicography played a vital role in improving and scaling up visual inspection with acetic acid (VIA)‐based cervical cancer screening . A similar approach using smartphones to capture and transmit digital cervical images has been successfully tested in Madagascar, and scaled‐up in Botswana . Taking mobile digital image capture a step further, an enhanced visual assessment (EVA) system tested in Kenya combines a smartphone‐integrated colposcope with a decision‐support job aid that records data on VIA test results, treatment decisions, and follow‐up/rescreen dates.…”

“…42,43 A similar approach using smartphonestocaptureandtransmitdigitalcervicalimageshasbeen successfullytestedinMadagascar, 44 andscaled-upinBotswana. 45,46 Takingmobiledigitalimagecaptureastepfurther,anenhancedvisual assessment (EVA) system tested in Kenya combines a smartphoneintegrated colposcope with a decision-support job aid that records dataonVIAtestresults,treatmentdecisions,andfollow-up/rescreen dates.Theembeddedmobileportalallowsuploadandreal-timedata aggregation and monitoring and evaluation. 47 In other applications, data exchange over mobile networks has been facilitated by cloudbased data storage, 48 multimedia messaging service or MMS, 44 and electronic medical pathways.…”

Adoption of Information and communication technologies for early detection of breast and cervical cancers in low- and middle-income countries

“…Motivated by the successes in using ICTs for women's cancer prevention in higher-income countries, [7][8][9][10][11] the goal of this article was to examine the extent to which this potential has been explored in low-resource settings, where there is great need and potential. We examined the peerreviewed and gray literature on the use of ICTs for prevention (screening and early detection) of breast and cervical cancers in LMICs.…”