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Sifelani Tsiko Agric, Environment and Innovations Editor
Healthcare institutions have become risky places for both patients and healthcare workers as the novel coronavirus (COVID-19) battle rages on in the country. Steps have been taken by the Government to mobilise resources for frontline healthcare workers to secure tools to combat this deadly pandemic. Since the start of the lockdown in March, a number of measures of lockdowns, social distancing and the uptake of personal protective equipment (PPEs) to limit transmission have been taken up. But these measures are insufficient to stop the overstretching of the country’s healthcare systems that were already overwhelmed before COVID-19. In this report, Sifelani Tsiko (ST), our Agric, Environment and Innovations Editor speaks to Dr Admore Jokwiro (AJ), a Nyanga district medical officer and e-health (informatics) expert about the potential of telemedicine in Zimbabwe.

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ST: Can you briefly tell us what telemedicine is all about?

AJ : Telemedicine refers to the use of ICTs (information communication tools), where distance is a critical factor, for the purposes of treating a patient (consulting, examining and prescribing medicines).There are two broad classes of telemedicine synchronous which refers to live real-time telemedicine contact such as with telephone (audio only) and or video-conferencing (audio visual) or asynchronous where clinical records are sent by store and forward methods such sending records by email to a specialist who reviews and then sends back a medical opinion to guide the management of a patient.

Telemedicine has been around for more than two decades but is a relatively new tool in Zimbabwe. It is critical to highlight that telemedicine is not a practice or new way of doing things but it is a tool which enables health practitioners to do more than they can without it.

ST: In light of the escalating Covid – 19 pandemic, some health experts say there is a need to re-imagine how healthcare services can be delivered in Zimbabwe. What do you think can be the role of telemedicine in supplementing the existing model of healthcare delivery in Zimbabwe?

AJ: It is clear that Covid-19 has reshaped how we conduct business in virtually every facet of our lives. And it has done so in a such a short space of time. Some of the key interventions for reducing spread have included lockdowns, social distancing and minimising contact. Where contact cannot be avoided, we have to use personal protective equipment. However, PPEs are expensive and also in short supply. The needs of our people have not changed and Covid-19 is not the only disease out there. There are people with chronic illnesses such as hypertension, HIV and diabetes. These people need constant reviews and refills of their medications. Pregnant women need monitoring of their pregnancies. New patients also need medical advice without necessarily going out to places where they may be exposed to highly contagious infections like Covid-19. This is where telemedicine comes in. Telemedicine provides that tool which enables doctors and other health workers like nurses, physiotherapists to meet with their patients on virtual platforms and give medical advice along with e-prescriptions which can be electronically mailed to their pharmacists of choice. Telemedicine will provide access for thousands of patients who are currently failing to go to hospitals or private practitioners as a result of Covid-19.

 ST: What do you think Zimbabwe and all the stakeholders need to do support the growth of e-health in Zimbabwe in the fight against Covid -19?

AJ: I believe three things are key for growth of e-health in Zimbabwe that is infrastructure, funding and regulation. e-Health infrastructure (hardware and software) are essential for provision of services and these infrastructures must meet the standards such as security and interoperability to ensure confidentiality, integrity and availability of health care data both for the purposes of treatment and surveillance. Funding is key for establishment and maintenance of the telemedicine programs and therefore issues such as reimbursement of services offered need to be addressed beforehand. Where telemedicine has been successful, for example, in the US, programs are backed by good financial models. Regulation is central to the guidance of service provision and ensuring quality assurance therefore regulations must be put in place to guide telemedicine provision. At high-level strategy and policy must be put in place to guide these three essential elements.

ST: Can you tell us more about the telemedicine project that you have run in Nyanga district? How successful has been this project?

AJ: The Nyanga Telemedicine project was born out of our initial pilot at Nyatate clinic in 2015 within the same district. The current pilot is now covering six clinics within the same district and is jointly supported by ministry of health, ministry of ICTs, POTRAZ and ITU. This pilot project commenced in late 2018 and has been running for close to 16 months now. We have had varied responses in terms of use with Nyafaru and Tombo leading the way followed by Avilla, Mt Melleray, Fombe and lastly and ironically Nyatate clinic. However, the fact that we have installed internet in these sites has improved communication in general at all sites due to the availability of wi-fi, the fact that we now have six volunteer doctors on the team who offer their services for free , the fact that we have sent four nurses and a doctor for telemedicine training in India and that we have had some patient stories where the intervention by teleconsultants resulted in diagnoses and lifesaving interventions compel us to conclude that this has been a successful implementation.

ST: What were some of the problems you encountered in the implementation of this e-health project in Nyanga? What can be done to overcome some of these problems in such rural settings?

AJ: Electricity outages, internet unavailability, lack of a full time telemedicine coordinator for the project, low morale among the clinic staff who are not motivated to provide the service are some of the leading challenges and this is what accounts for the reason why some clinics have a high usage compared to others. We need to provide power backups e.g. solar and also motivate the clinic staff to enable them to offer the service to the communities. We also need to educate the communities to be aware that the service is available.

ST: e-Healthcare platforms require software development and the installation of expensive new hardware. How can countries such as Zimbabwe overcome such barriers?

AJ: Zimbabwe can leverage on countries that have already developed these systems such as India and by establishing partnerships and also building local capacity with local tertiary institutions like what we are beginning to see from the Harare Institute of Technology is the way to go. I believe in the last few weeks we have seen two e-Health interventions come out of HIT around Covid-19 surveillance and these must be supported and harnessed for good.

 ST: The healthcare industry is very rigid and has cumbersome regulations on safety and privacy of patients and healthcare providers. What can be done to ensure our laws are less rigid and reduce compliance costs?

AJ: Rather than re-inventing the wheel it is important to again learn and adapt to our context what we have seen from the west and India in digital/e-health. The Medical and Dental Practitioners Council of Zimbabwe has been really pro-active and recently, it issued a circular allowing telemedicine use in light of the Covid–19 pandemic.

Unfortunately, healthcare funders under the Association of Healthcare Funders of Zimbabwe (AHFoZ) have not responded positively and have declined to reimburse telemedicine services. This is not progressive and further engagements must follow.

However, I feel e-health policy and strategy would be the good starting points at ministry of health level and I am aware this is work in progress. Once these are in place this would then guide the development of the other pieces. I also think the time is now ripe for Zimbabwe to establish a health informatics community and this community would provide e-health expertise in Zimbabwe.

ST: Healthcare institutions are in a survival mode and have been slow in adopting telemedicine technologies despite the presence of better IT infrastructure in the country. How can hospitals address issues to do with low IT budgets, complicated legacy systems and lack of human resources?

AJ: This is a tough question as a lot of it rests around funding and our economy has not provided such flexibility. But another challenge is that even in planning health IT budgets are not prioritized and therefore given low budgets. To address the issues, you have highlighted one key intervention would be investing in the training of health informaticians. These are healthcare workers who include doctors, nurses and other healthcare specialists who are then trained in health information/IT systems. This is important as for you to implement a successful health IT project you need both medical knowledge and IT knowledge. For example, big hospitals like Parirenyatwa or Sally Mugabe Central Hospital must have a medical office led by a health informatician.

ST: Looking ahead, how do you see the country’s e-healthcare systems evolving in the coming decade or so?

AJ: I see that we are going to digitize most of our health services in the coming five years. There will be an increased reliance on health IT for service provision both in the public and private sectors. We are going to see the arrival of robots and drones within the health space in Zimbabwe in such fields as robotic surgery, transportation of provisions and also 3D printing. Our tertiary institutions are going to train and produce more health informaticians. Nursing informatics will also be a recognised specialisation.