ArticlePDF AvailableLiterature Review

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

Authors:

Abstract and Figures

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 specialised 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 characterised 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 utilising wireless telecommunication services. Botswana has recently experienced a 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 specialised 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 private telecommuni
Content may be subject to copyright.
PUBLIC HEALTH
PERSPECTIVE ARTICLE
published: 11 December 2014
doi: 10.3389/fpubh.2014.00275
Scaling up a mobile telemedicine solution in Botswana:
keys to sustainability
Kagiso Ndlovu1*, Ryan Littman-Quinn1,2, Elizabeth Park1, Zambo Dikai 1and Carrie L. Kovarik1,2
1Botswana-UPenn Partnership, Gaborone, Botswana
2Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
Edited by:
Richard Wootton, University Hospital
of North Norway, Norway
Reviewed by:
Laurent Bonnardot, Paris Descartes
University, France
David A. Simonyan, Centre hospitalier
universitaire de Québec, Canada
*Correspondence:
Kagiso Ndlovu, P O Box AC 157 ACH,
Gaborone, Botswana
e-mail: kaygndlovu@gmail.com
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 Partner-
ship (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 can-
cer 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, includ-
ing a strong need for unwavering senior management support, establishment of solid local
public-private partnerships, and efficient project sustainability plans. Sustainability mile-
stones included the development and signing of a Memorandum of Understanding (MOU)
between the Botswana government and a private telecommunications partner, the publi-
cation 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 Ser-
vices 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).
Keywords: mobile telemedicine, store-and-forward telemedicine, mHealth, public-private partnerships, national
eHealth strategy, sustainability, low-resource setting
INTRODUCTION
Investing in a sustainable telemedicine solution that is relevant
to the current health needs is an important milestone any nation
would strive to achieve. Nonetheless, making such an investment
in a resource-limited environment does not come easy as there
are many challenges to overcome including, the buy-in of leader-
ship from key stakeholders. Botswana is the first in Africa to invest
in a nationwide mobile telemedicine scale-up project through its
Ministry of Health (MoH). This project is in partnership with the
Botswana-UPenn Partnership (BUP), the Orange Foundation of
Botswana and 5AM Consultancy group. Formal discussion among
key project stakeholders began after the completion of the pilot
projects in 2010, and in 2012 the MoH officially agreed to scale-up
the solution, formally known as “Kgonafalo” (2). The Kgonafalo
mobile telemedicine system covers four medical specialties being
oral health, dermatology,radiology, and cervical cancer screening,
all of which involve visual inspection and follow the same work-
flow. The Kgonafalo project aims to improve access to specialized
healthcare service delivery throughout Botswana hence improv-
ing patients’ outcomes and also reducing hospital congestion in
the few available referral facilities.
BACKGROUND AND PROBLEM STATEMENT
Access to specialized health care continues to be a challenge across
the African continent (3). This is mostly brought about by the
limited number of specialized medical doctors in African coun-
tries as compared to developed continents. In order to augment
the limited access to health care, many African countries have
www.frontiersin.org December 2014 | Volume 2 | Article 275 | 1
Ndlovu et al. Sustainable mobile telemedicine scale-up: Botswana
implemented innovative mobile health (mHealth) pilot project
solutions (3). Most of these pilot solutions address public health
problems, infectious disease epidemics and pandemics, psychoso-
cial problems such as addiction and suicide, and other social
problems such as family planning and smoking cessation, rather
than access to specialty care. In addition, the majority of African
countries have not yet scaled up mHealth pilot solutions to evalu-
ate their nationwide impact, and no mobile telemedicine programs
have been nationally implemented (3). Despite the development
of innovative mHealth solutions, there has always been another
challenge among many African health systems being that of
inefficient information communication technology (ICT) infra-
structure characterized by slow bandwidth (3). The recent ICT
advancements revived hope for telecommunication technology as
a tool to improve health care service delivery through innova-
tive solutions such as telemedicine or telehealth. Telemedicine is
the use of telecommunications technology for medical diagnostic,
monitoring, and therapeutic purposes where distance and/or time
separates the patient and health care provider (4). While others use
the broader term telehealth to focus on all health interactions using
telecommunications services, many refer to telemedicine in spe-
cific domains by using the prefix“tele” with the respective specialty
such as teleradiology, teledermatology, and so on. In general, tele-
phone only service is not considered to be true telemedicine (4).
The high penetration coupled with low cost of mobile technolo-
gies places it well as the ideal telemedicine tool for low-resource
settings.
The presence of mobile technology has changed many lives in
Africa and nearly two-thirds (65%) of households in 23 countries
in sub-Saharan Africa had at least one mobile phone in 2013, with
median growth of 27% since 2008, and median annual growth
of 5% (5). The 2013 report by the International Telecommuni-
cation Union (ITU), predicts that there will soon be as many
mobile-cellular subscriptions as people inhabiting the planet,
with the figure set to nudge past the seven billion mark early
in 2014 (5). The report further states that more than half of all
mobile subscriptions are now in Asia, which remains the power-
house of market growth and by the end of 2013 overall mobile
penetration rates will have reached 96% globally, 128% in the
developed world, and 89% in developing countries (5). Given the
fast growth of mobile technologies, security is a major concern
particularly when it comes to health information. Network secu-
rity standards and protocols for mobile telecommunications have
advanced over the past years (6). Internet data security proto-
cols such as the secured version of hyper-text transfer protocol
(HTTPS), the Secure Socket Layer (SSL) encryption standard, and
the Advanced Encryption Standard (AES) are some of the recom-
mended security measures for the transmission of sensitive data
over mobile networks (6). The Health Insurance Portability and
Accountability Act (HIPAA) continues to offer encryption stan-
dards on Patient Health Information (PHI). The HIPAA demands
that all HIPAA covered businesses prevent unauthorized access
to “Protected Health Information.” PHI includes patients’names,
addresses, and all information pertaining to the patients’ health
and payment records (7).
Some uses of telemedicine include facilitation of access to
health care in underserved rural communities especially for
specialty care, closer monitoring of patients in their homes in
urban or rural settings especially frail elderly or those with chronic
disease and “outsourcing” of non-direct care services such as
radiology and pathology.
Telemedicine can be classified according to the following cat-
egories; office or hospital-based telemedicine, which is an inter-
active substitute for face-to-face encounter utilizing live video
conference with a medical doctor (4). The other type is what is
commonly known as the store-and-forward telemedicine, which
is purely asynchronous, that is, non-real-time encounter (4). The
asynchronous type of telemedicine is more suitable for low-
resource settings because of the slow bandwidth challenge. The
other telemedicine category is the home-based telemedicine which
entails monitoring of patient at their homes or in a nursing care
facility (4).
In Botswana, the doctor to patient ratio is at 3.1 per 10,000 and
this has resulted in an over-burden of the few specialist doctors
available (8). Patients travel long distances hence taking longer
times before receiving specialized attention resulting in complex
cases and sometimes loss of lives. About 84% of the population in
Botswana lives within a 5-km radius and about 95% live within an
8-km radius from a health facility (8).
In 2009, the Botswana MoH introduced the Integrated Patient
Management System (IPMS) aimed at improving daily processes
in health facilities and also leading to the creation of a single patient
health record which is accessible across all health facilities. The full
benefits of such an IPMS in Botswana have been hindered by the
traditional landline, non-robust ICT infrastructure. Botswana is
mentioned to have 87% of households with at least one mobile
phone in 2013 and with 3% average annual growth since 2008 (5).
Also a significant improvement has been recorded on Botswana’s
mobile telecommunication networks such as EDGE, GPRS, 2G,
3G, and the most recent 4G connections. The ICT challenges faced
by the MoH in Botswana have inspired innovative ways of offer-
ing health care service including a telemedicine solution utilizing
mobile devices.
PILOT PROJECTS
Over the past 4 years, BUP has piloted four mobile telemedi-
cine projects in the specialties of women’s health (cervical cancer
screening utilizing visual inspection with acetic acid), radiology,
oral medicine, and dermatology (1). Mobile telemedicine has
been implemented in 15 locations in Botswana, 27 clinicians have
been trained, and 696 cases have been successfully managed (see
Table 1).
PILOT PROJECT WORKFLOW
Healthcare workers were provided with smart phones equipped
with a built-in camera and data-enabled subscriber identity mod-
ule (SIM) cards donated by the Orange Foundation of Botswana.
The organizational structure of each mobile telemedicine project
includes an in-country medical specialist, an international spe-
cialist (the only position that is not held by a MoH employe),
a national specialty manager, a referral site coordinator, and the
referring health care workers. All four mobiletelemedicine projects
used the same model in which the healthcare worker collects perti-
nent clinical history and associated images pertaining to a complex
Frontiers in Public Health | Public Health Education and Promotion December 2014 | Volume 2 | Article 275 | 2
Ndlovu et al. Sustainable mobile telemedicine scale-up: Botswana
Table 1 | Number of locations, clinicians trained and mHealth cases
(January 2011 to September 2013).
Specialty Locations Clinicians
trained
Number of
cases
Cervical cancer screening 1 2 356
Teledermatology 2 5 126
Oral telemedicine 10 16 160
Teleradiology 2 4 54
Total 15 27 696
patient case utilizing a smartphone with a telemedicine applica-
tion (1). Before gathering patient information, a consent form
is filled with the patient to allow them to indicate whether they
would like to participate in the study or not. The collected his-
tory and images are then sent via mobile phones directly by the
referring health care worker to an in-country remote specialist for
consultation. The specialist uses the information to diagnose the
illness and recommend an appropriate course of treatment. The
in-country specialist also has the option of forwarding the case to
an international specialist for further input and collaboration. The
national specialty manager is the uniting force for each program,
working to train the health care workers on site, as well as coordi-
nating all parties involved in the scaling up and sustainability of
their program.
Some of the benefits identified from the pilot studies include
avoiding lengthy waiting times for hospital treatment, cost sav-
ing in petrol during referrals, reduction in patient’s long distance
travels, and quick medical attention hence improving patient out-
comes (1). The pilots also indicate that MoH nurses and other
health care workers involved in the scale-up project will gain more
knowledge as they regularly interact with the telemedicine solu-
tion through uploading of cases and viewing specialists’ responses
over time.
In addition, a business research study was conducted by five
University of Botswana MBA students in collaboration with Uni-
versity of Pennsylvania Wharton MBA students during the pilot.
The purpose of the study was to assess the cost-benefit analysis of
a mobile telemedicine solution across all the four medical special-
ties in Botswana and also propose a sustainable business model.
After conducting an economic research analysis, the MBA students
found out that the mHealth intervention provided cost savings per
patient visit over the first year of implementation.
PILOT PROJECT’S MOBILE DEVICES
The initial pilot studies utilized the Sony Ericsson C905 to
take images and collect patient information on proprietary soft-
ware from a US-based software company, ClickDiagnostics. All
patients’ data were sent to a central database server where spe-
cialists accessed them prior to making a diagnosis. Refer Table S1
in the Supplementary Material for a summary of the technical
specifications for the Sony Ericsson C905 mobile device.
During 2011, the pilot technology transitioned to use the T-
Mobile myTouch 3G Slide Android phones, which allowed part-
ners to use the Open Data Kit (ODK) open-source software
supported by a local IT group called PING. Refer Table S2 in
the Supplementary Material for technical specifications for the
T-Mobile myTouch 3G slide mobile device.
PILOT PROJECT’S MOBILE APPLICATION
Customized software from ClickDiagnostics was initially utilized
to capture patients’cases dur ing the pilot project phases. The cases,
each consisting of at least thirty unique medical data fields and
one to multiple photographs, were sent from the phones over
a data-enabled mobile network and stored on a secure database
over the internet. The ClickDiagnostics software was later replaced
by an open-source mobile application, the ODK, which also cap-
tured pertinent patients’ information on mobile smartphones. The
choice of the ODK was influenced by the fact that it is free software
available on the Internet and has been tried and tested by a commu-
nity of open-source developers, and it is easy to upgrade without
losing data when newer versions are installed. The other advantage
with ODK was its flexibility when creating and customizing forms
for data entry. The ODK forms also captured patients’data, which
were later saved for transfer to an online database on a cloud based
infrastructure.
PILOT PROJECTS OBJECTIVES AND EVALUATIONS
Each of the pilot projects focused on specific objectives and was
evaluated based on the respective objectives as shown below:
Cervical Cancer Screening: Evaluating the use of mobile phone
telemedicine for cervical cancer screening (9).
• Teledermatology: Determining the reliability and validity of
mobile teledermatology in HIV positive patients in a resource-
limited setting (10).
• Teledermatology: Evaluating patients’ perception of mobile
teledermatology (11).
Oral telemedicine: Evaluating feasibility of using mobile phone
images to diagnose oral medicine cases (12).
• Teleradiology: Evaluating mobile phone image concordance
with in-person examination of plain film chest x-rays (13).
SCALE-UP PROJECT
The benefits reported by pilot project users were vital to the adop-
tion of Kgonafalo system into the MoH’s long-term strategy (1).
The business study’s promising results coupled with observed
improved patient outcomes as a result of the pilot projects, con-
tributed to the MoH support and setting aside funds to support
Kgonafalo.
The MoH ultimately committed a budget from the Oral Health
Clinical Services recurrent budget to support the Scale-Up of
Kgonafalo for oral medicine, dermatology, radiology, and cervical
cancer screening.
TENDERING PROCESS
In 2013, the MoH Clinical Services published the Invitation to
Tender (ITT) documents for supporting the project scale-up (14,
15). This was a public invitation for both local and international
companies to submit proposals. BUP facilitated a bidders’ meet-
ing to clarify the needs of the system and answer questions by
local IT businesses. Six local companies some of which were
in collaboration with international firms submitted their tender
proposals.
www.frontiersin.org December 2014 | Volume 2 | Article 275 | 3
Ndlovu et al. Sustainable mobile telemedicine scale-up: Botswana
The three most competitive proposals were evaluated using a
template developed by the MoH projects unit. A team of three
members conducted the tender evaluation process. The Procure-
ment Department advised on financial evaluations of the propos-
als and the project’s main contact person came from the MoH
Clinical Services Department. The successful proposal evaluation
stage led to the tender selection and award process toward the most
competitive bidder.
The tender was awarded in December 2013 to 5AM Holdings.
The process of developing and publishing the ITT, then evaluating
the proposals and choosing the winner occurred over the course
of 1 year and 5months.
Talks with the MoH IT management in January 2014 resulted in
an agreement to have the Kgonafalo system hosted on serversat the
MoH headquarters. This is one way of ensuring continual system
support and ownership of the project by the main stakeholder.
PUBLIC-PRIVATE PARTNERSHIPS
An MOU was signed in 2013, between the Orange Foundation of
Botswana and the MoH. The MOU detailed collaboration roles
for each partner in support of the project for the next 3 years. The
MOU mentions 19 locations across Botswana as initial project
scale-up sites. The Orange Foundation of Botswana committed to
donating all mobile devices together with customized SIM cards
loaded with data bundles for the project. The process of developing
and finalizing the contents of the MOU with respective technical
and legal units occurred over the course of 1 year and 7 months.
After the signing of the MOU, The Orange Foundation of
Botswana through the support of BUP, identified test mobile
devices to be evaluated by all Kgonafalo system users. A successful
mobile device evaluation and test session was conducted by spe-
cialty managers for the project and user feedback was documented
and shared with the Orange Foundation of Botswana.
SCALE-UP PROJECT’S TECHNICAL DETAILS
Based on feedback from the pilot studies, the BUP provided rec-
ommendations to Orange Botswana concerning the specifications
requirements for mobile devices for each specialty area. The
Orange Foundation of Botswana identified the Alcatel One Touch
Idol Ultra 6033X smartphone, in consultation with the BUP. Refer
Table S3 in the Supplementary Material for a list of technical details
for the selected Alcatel smartphone following test session across
the four specialist areas (see Table 2 for feedback from the test
sessions).
In addition to donating mobile devices, the Orange Foundation
of Botswana also donated customized SIM data bundles to support
connectivity of mobile devices with the system central database.
Confidentiality of sensitive patient information is an integral com-
ponent of the Kgonafalo system. None of the patient’s data is
compromised or made accessible through the Orange Botswana
servers and network. This has been made possible through the
adoption of security protocols such as the SSL encryption, AES,
and HIPAA encryption standards on both the mobile application
and the enterprise system.
The Orange Foundation of Botswana released an updated net-
work coverage map showing their nationwide 3G, EDGE, and
GPRS coverage (16). The Network Coverage Map from the Orange
Foundation of Botswana alongside the Kgonafalo expansion loca-
tions map are included as part of the Supplementary Material
Figure S1.
SUSTAINABILITY STEPS
Sustainability is a major goal of the Kgonafalo project. Sustain-
ability here refers to the life-long operation of Kgonafalo mobile
telemedicine solution. Close working relations among the project
stakeholders contributed to numerous processes, documents, and
presentations being developed to ensure that expansion of the
project are conducted responsibly and with a focus on local own-
ership and drive. In order to achieve this goal,the project partners
have developed operational and economical milestones as shown
below.
Operational milestones
Information technology (development, maintenance and
support) supporting the mHealth system is supported by local
IT groups and utilizes open-source software.
Table 2 | Summary of phone users’ feedback across the four medical specialties.
Oral health Dermatology Radiology Cervical cancer screening
Phone screen Phone screen is the right size Perfect screen size The screen size is big enough Screen is just the right size
Picture quality Picture quality is excellent Excellent picture quality Good pictures captured by the
device
The pictures are of good
quality
Protective
cover
Protective cover is needed Needs protective cover Device is fragile and needs some
covers
The device needs a cover
since it is too slippery
Zoom Perfect zoom range Zoom range is just what is
needed
Zoom range is about the right length Zoom range is a bit limited,
doesn’t go as far as we would
want it
Training More training needed Some level of training is
needed to first time users
More training required on how to
capture perfect images
A lot of training is needed on
the touch screen features
Battery It’s a good device with long
battery life compared to
previous models
The device is well suited for
dermatology and its battery
lasts longer
A good phone model with high long
battery life
Generally it is a good device,
we are happy about the
device battery life
Frontiers in Public Health | Public Health Education and Promotion December 2014 | Volume 2 | Article 275 | 4
Ndlovu et al. Sustainable mobile telemedicine scale-up: Botswana
Implementation preparation and training conducted by a local
IT group.
Phone user service-level general support provided by Orange
Botswana.
• Phone user service-level SIM card and connectivity support
provided by Orange customer service.
• MOU and MOA signed between local public and private
partners developed as necessary.
• Policies on mHealth phone usage and staff job descriptions
(developed by MoH) that contributed to the project.
Strategic responsibilities incorporated into the job descriptions
of high level MoH, BUP, and Orange positions.
Financial milestones
Pilot/feasibility study operational expenses supported by donors,
but smaller expenses (e.g., travel and accommodation for
trainings and workshops) shared by local partners.
All operational expenses of system absorbed by local partners,
but donors help support costs associated with transitioning sys-
tems to local ownership and providing technical advice and
assistance when necessary.
Long-term roles, responsibilities and benefits of all stakehold-
ers established (Donors can support by conducting cost-benefit
analysis and business model research).
• Long-term MOUs and/or operational expenses included in
recurrent budgets for local public and private partners.
Efforts have been focused on four main components of sus-
tainability: local customization, local ownership, public-private
partnerships (PPP), and the IT provider business model. Empow-
erment of local ownership and drive are consistently encouraged
throughout the scale-up project. A significant amount of planning
and major decision making is left with specialty managers and site
coordinators who have embraced the projects and pursued initia-
tives to improve them. The specialty managers organize and run
training workshops and sensitization programs for local health-
care workers, allowing them to raise awareness of telemedicine
and mHealth. Specialty managers and site coordinators devel-
oped the idea of telemedicine awareness posters to hang in all
the field sites. Refer Figure S2 in the Supplementary Material for
both Setswana and English versions of the mobile oral telemed-
icine awareness posters. In another step toward local ownership,
an official mHealth help desk is currently being developed for all
mHealth phone users, which will feed into the existing MoH help
desk system. One major sustainable component of Kgonafalo is
the fact that it is institutionalized into existing government health
programs that can receive budget attention.
FUTURE DIRECTION
Looking ahead, the MoH is interested in expanding the Kgonafalo
project to cover more medical specialties and subsequently cover
the whole country. The system has already been built to interface
with the MoH electronic medical record system, IPMS; however,
there could be more opportunities to interface with more IPMS
modules. The data and images captured in Kgonafalo could be
used for educational purposes as well as to feed into future deci-
sion support systems at the MoH. During the scale up, separate
funding will be set aside by the MoH for maintenance and oper-
ational support services once the service-level agreement with the
local IT group comes to an end.
CONCLUSION
BUP, MoH, and the Orange Foundation of Botswana have suc-
cessfully embarked on a country-wide mobile telemedicine project
following successful pilot studies. When not properly planned for
and mitigated, scaling up such a project can lead to major set-
backs. Kgonafalo has received substantial support from all local
stakeholders. The project has attracted local ownership through
the PPP engagement. Since the tender award stage, project plan-
ning and management by the local partners has been efficient and
timelines have been met. The success of the pilot projects and
recent scale-up achievements shows that if properly managed, the
Kgonafalo solution could be of significant value to Botswana’s
healthcare system. The project’s major benefits include substantial
reduction of unnecessary referral costs and improved patient out-
comes. A number of challenges have been encountered but did not
divert stakeholders’ focus from the project’s goals. Recent project
developments include the procurement of 42 mobile devices by
the Orange Foundation of Botswana and the development of beta
version of the mobile telemedicine solution by the engaged local
IT group. The success of the scale-up project is largely influ-
enced by senior managements’ support and commitment to the
project. Ongoing strong local partnerships and support by spe-
cialty managers are equally important for the scale-up project to
be a success.
SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found
online at http://www.frontiersin.org/Journal/10.3389/fpubh.2014.
00275/abstract
REFERENCES
1. Littman-Quinn R, Chandra A, Schwartz A, Fadlelmola F, Ghose S, Luberti A,
et al. mHealth applications for telemedicine and public health intervention in
Botswana. Proceedings of the IST Africa Conference. Gaborone: International
Information Management Cooperation (2011). p. 1–11.
2. Littman-Quinn R, Mibenge C, Antwi C, Chandra A, Kovarik CL. Implemen-
tation of m-health applications in Botswana: telemedicine and education on
mobile devices in a low resource setting. J Telemed Telecare (2013) 19(2):120–5.
doi:10.1177/1357633X12474746
3. World Health Organization. MHealth: New Horizons for Mobile Health Through
Mobile Technologies: Second Global Survey on E-Health. (2014). Available from:
http://www.who.int/goe/publications/goe_mhealth_web.pdf
4. William R, Hersh MD.Telemedicine for the Medicare Population:Update, Evidence
Report/Technology Assessment Number 131. Portland, OR: Oregon Evidence-
Based Practice Center (2006).
5. ITU Statistics. The World in 2013: ICT Facts and Figures. (2013). Available
from: http://www.itu.int/net/pressoffice/press_releases/2013/05.aspx#.VEYA-_
mUdpA
6. Greene LR. Wireless broadband deployment & other latest technology trends.
13th ITU Sub-regional Meeting. Yangon (2006). Available from: http://www.itu.
int/ITU-D/treg/Events/Seminars/2006/subregional_clmv/docs/1-6-1-green.pdf
7. Five Steps to HIPAA Security Compliance. (2013). Available from: http://www.
hipaa.com/category/security
8. Sinha N, Onyatseng G. The nursing labour market in Botswana: an economic
analysis. Botswana J Afr Stud (2012) 26(46).
9. Quinley KE, Gormley RH, Ratcliffe SJ, Shih T, Szep Z, Steiner A, et al. Use of
mobile telemedicine for cervical cancer screening. J Telemed Telecare (2011)
17(4):203–9. doi:10.1258/jtt.2011.101008
www.frontiersin.org December 2014 | Volume 2 | Article 275 | 5
Ndlovu et al. Sustainable mobile telemedicine scale-up: Botswana
10. Azfar RS, Lee RA, Castelo-Soccio L, Greenberg MS, Bilker WB,
Gelfand JM, et al. Reliability and validity of mobile teledermatology In
human immunodeficiency virus-positive patients in Botswana: a pilot
study.JAMA Dermatol (2014) 150(6):601-607. doi:10.1001/jamadermatol.2013.
7321
11. Azfar RS, Weinberg JL, Cavric G, Lee-Keltner IA, Bilker W, Gelfand JM, et al. HIV
positive patients in Botswana state that mobile teledermatology is an acceptable
method for receiving dermatology care. J Tele med Telecare (2011) 17(6):338–40.
doi:10.1258/jtt.2011.110115
12. Tesfalul M, Littman-Quinn R, Antwi C, Ndlovu S, Motsepe D, Phuthego M,
et al. Evaluating the impact of a mobile oral telemedicine system on medical
management and clinical outcomes of patients with complicated oral lesions in
Botswana. Stud Health Technol Inform (2013) 192:1074.
13. Schwartz AB, Siddiqui G, Barbieri JS, Akhtar AL, Kim W, Littman-Quinn R, et al.
The accuracy of mobile teleradiology in the evaluation of chest X-rays. J Telemed
Telecare (2014). doi:10.1177/1357633X14555639
14. Republic of Botswana. Tender No. MTC/MOH/CLS/SER/7481/13032013/. Min-
istry of Health, Clinical Services Department.
15. Republic of Botswana. Tender No. MTC/MOH/CLS/SER/7771/22082013/. Min-
istry of Health, Clinical Services.
16. Orange Foundation. Network Coverage Map. (2014). Available from: http:
//www.orange.co.bw/mobile/coverage.php
Conflict of Interest Statement: The authors declare that the researchwas conducted
in the absence of any commercial or financial relationships that could be construed
as a potential conflict of interest.
Received: 05 June 2014; accepted: 25 November 2014; published online: 11 December
2014.
Citation: Ndlovu K, Littman-Quinn R, Park E, Dikai Z and Kovarik CL (2014) Scal-
ing up a mobile telemedicine solution in Botswana: keys to sustainability. Front. Public
Health 2:275. doi: 10.3389/fpubh.2014.00275
This article was submitted to Public Health Education and Promotion, a section of the
journal Frontiers in Public Health.
Copyright © 2014 Ndlovu, Littman-Quinn, Park ,D ikai and Kovarik. This is an open-
access article distributed under the terms of the Creative Commons Attribution License
(CC BY). The use, distribution or reproduction in other forums is permitted, provided
the original author(s) or licensor are credited and that the original publication in this
journal is cited, in accordance with accepted academic practice. No use, distribution or
reproduction is permitted which does not comply with these terms.
Frontiers in Public Health | Public Health Education and Promotion December 2014 | Volume 2 | Article 275 | 6
... Technological barriers to the adoption of virtual health in Africa include poor internet connectivity [54], unreliable electricity supply [22,31,55], insufficient or unavailability of ICT infrastructure, inadequate or inappropriate virtual health infrastructure [49,56] and high cost of telecommunication equipment [36]. Additionally, malfunctioning of computing devices due to technical problems is a hindrance to the utilization of telemedicine and telehealth [30]. ...
... Weak ICT infrastructure and services within the health sector, the inadequate human capacity to plan and apply eHealth solutions, limited awareness of eHealth and weak leadership and coordination. [30] Perspective Botswana Oral health, dermatology, radiology, and cervical cancer screening ...
Article
Full-text available
Since the outbreak of COVID-19, the attention has now shifted towards universal vaccination to gracefully lift strict COVID-19 restrictions previously imposed to contain the spread of the disease. Sub-Saharan Africa is experiencing an exponential increase of infections and deaths coupled with vaccines shortages, personal protective equipment, weak health systems and COVID-19 emerging variants. Some developed countries integrated telemedicine to reduce the impacts of the shortage of healthcare professionals and potentially reduce the risk of exposure, ensuring easy delivery of quality health services while limiting regular physical contact and direct hospitalization. However, the adoption of telemedicine and telehealth is still nascent in many sub-Saharan Africa countries. Therefore, this study reflects on progress made towards the use of telemedicine, virtual health care services, challenges encountered, and proffers ways to address them. We conducted a systematic literature review to synthesise literature on telemedicine in sub-Saharan Africa. The study revealed that telemedicine provides unprecedented benefits such as improving efficiency, effective utilization of healthcare resources, forward triaging, prevention of medical personnel infection, aiding medical students' clinical observation and participation, and assurance of social support for patients. However, the absence of policy on virtual care and political will, cost of sustenance of virtual health care services, inadequate funding, technological and infrastructural barriers, patient and healthcare personnel bias on virtual care and cultural barriers are identified as limiting factors to the adoption of virtual health care in many African health systems. To alleviate some of these barriers, we recommend the development of robust policies and frameworks for virtual health care, the inclusion of virtual care in the medical school curriculum, supporting virtual care research and development, increasing health funding, removing monopolisation of telecommunication services, developing of virtual health solutions that address eccentricities of African health systems.
... Due to high mobile penetration in Botswana, the Botswana-UPenn Partnership (BUP) Health Informatics (HI) team has conducted various mHealth projects to address this information gap, some of which include txt2MEDLINE, an USSD text messaging system allowing Botswana clinicians to send queries and receive medical information from journal abstracts and Botswana treatment guidelines [53], and "Kgonafalo," a national mobile telemedicine referral system [53]. In 2013, Orange, one of 3 major telecommunications companies in Botswana, extended free access to Wikipedia under the Wikipedia Zero Initiative by waiving data charges to all customers in the Middle East and Africa, thereby allowing an avenue for free access to online information. ...
... Due to high mobile penetration in Botswana, the Botswana-UPenn Partnership (BUP) Health Informatics (HI) team has conducted various mHealth projects to address this information gap, some of which include txt2MEDLINE, an USSD text messaging system allowing Botswana clinicians to send queries and receive medical information from journal abstracts and Botswana treatment guidelines [53], and "Kgonafalo," a national mobile telemedicine referral system [53]. In 2013, Orange, one of 3 major telecommunications companies in Botswana, extended free access to Wikipedia under the Wikipedia Zero Initiative by waiving data charges to all customers in the Middle East and Africa, thereby allowing an avenue for free access to online information. ...
Article
Background: Since the UN Human Rights Council's recognition on the subject in 2011, the right to access the Internet and information is now considered one of the most basic human rights of global citizens [1,2]. Despite this, an information gap between developed and resource-limited countries remains, and there is scant research on actual information needs of workers themselves. The Republic of Botswana represents a fertile ground to address existing gaps in research, policy, and practice, due to its demonstrated gap in access to information and specialists among rural health care workers (HCWs), burgeoning mHealth capacity, and a timely offer from Orange Telecommunications to access Wikipedia for free on mobile platforms for Botswana subscribers. Objectives: In this study, we sought to identify clinical information needs of HCWs of Botswana and their perception of Wikipedia as a clinical tool. Methods: Twenty-eight facilitated focus groups, consisting of 113 HCWs of various cadres based at district hospitals, clinics, and health posts around Botswana, were employed. Transcription and thematic analysis were performed for those groups. Results: Access to the Internet is limited at most facilities. Most HCWs placed high importance upon using Botswana Ministry of Health (MoH) resources for obtaining credible clinical information. However, the clinical applicability of these materials was limited due to discrepancies amongst sources, potentially outdated information, and poor optimization for time-sensitive circumstances. As a result, HCWs faced challenges, such as loss of patient trust and compromises in patient care. Potential solutions posed by HCWs to address these issues included: multifaceted improvements in Internet infrastructure, access to up-to-date information, transfer of knowledge from MoH to HCW, and improving content and applicability of currently available information. Topics of clinical information needs were broad and encompassed: HIV, TB (Tuberculosis), OB/GYN (Obstetrics and Gynecology), and Pediatrics. HCW attitudes towards Wikipedia were variable; some trusted Wikipedia as a reliable point of care information resource whereas others thought that its use should be restricted and monitored by the MoH. Conclusions: There is a demonstrated need for accessible, reliable, and up-to-date information to aid clinical practice in Botswana. Attitudes towards Wikipedia as an open information resource tool are at best, split. Therefore, future studies are necessary to determine the accuracy, currency, and relevancy of Wikipedia articles on the health topics identified by health care workers as areas of information need. E. Park et al. / International Journal of Medical Informatics 95 (2016) 8-16 9 More broadly speaking, future efforts should be dedicated to configure a quality-controlled, readily accessible mobile platform based clinical information application tool fitting for Botswana.
... Additionally, medical practitioners have little experience of using eHealth for healthcare provision. Although not sustained, a number of mHealth initiatives have been implemented in Botswana to support priority health programmes through a coalition of public and private partners [17][18][19][20][21][22][23][24]. While these mHealth implementations existed, they were not linked to any eRecord systems. ...
... It was also found that the only mHealth implementation recognised by the MOHW, the Kgonafalo mobile telemedicine programme, was not linked to any eRecord system. Kgonafalo was a store and forward mobile phone-based telemedicine programme supporting dermatology, cervical cancer, oral health, and radiology [17]. Interviewees identified four major themes requiring attention: 1) eHealth legislation and governance; 2) eHealth software and infrastructure; 3) data standards, security, and Unique Patient Identifier; and 4) capacity building [26]. ...
Article
Full-text available
Background The proliferation of mHealth solutions and eRecord systems is inevitable in developing countries, and ensuring their bi-directional interoperability is essential. Interoperability has been described as the ability for two or more systems or components to exchange information and use the information that has been exchanged. Given the importance of linking mHealth solutions to eRecord systems in the developing world, a suitable interoperability framework is required to provide an agreed approach to interoperability and specify common elements. Although eHealth interoperability frameworks exist in the literature, none meet all the requirements for linking mHealth solutions to eRecord systems in developing countries. The aim of this paper was to describe the design and development of a conceptual framework for linking mHealth solutions to eRecord systems in Botswana, as an exemplar. Methods An iterative and reflective process was adopted, supported by existing literature and research including consultations with eHealth experts, and guidance from existing frameworks. These collectively identified key elements, concepts, and standards relevant and essential for framework design and development. Results The mHealth-eRecord Interoperability Framework (mHeRIF) was developed which highlights the need for: governance and regulation of mHealth and eRecord systems, a national health information exchange, and which interoperability levels to achieve. Each of these are supported by integral themes and concepts. It also addresses the need for regular review, accreditation, and alignment of framework concepts and themes with a National eHealth Strategy Interoperability Development Process. To demonstrate the framework’s applicability, a proposed architecture for the Kgonafalo mobile telemedicine programme is presented. Conclusion Interoperable mHealth solutions and eRecords systems have the potential to strengthen health systems. This paper reports the design and development of an evidence-based mHeRIF to align with, build upon, and expand National eHealth Strategies by guiding the linking of mHealth solutions to eRecord systems in Botswana and other developing countries facing similar circumstances.
... Although not sustained, a number of mHealth initiatives have been implemented in Botswana to support priority health programmes through a coalition of public and private partners [14][15][16][17][18][19][20][21]. ...
... It was also found that the only mHealth implementation recognised by the Ministry of Health and Wellness (MoHW), the Kgonafalo mobile telemedicine programme, was not linked to any eRecord system. Kgonafalo was a store and forward mobile phone-based telemedicine programme supporting dermatology, cervical cancer, oral health, and radiology [14]. Interviewees identi ed four major themes requiring attention: 1) eHealth legislation and governance; 2) eHealth software and infrastructure; 3) data standards, security, and Unique Patient Identi er; and 4) capacity building [23]. ...
Preprint
Full-text available
Background: The proliferation of mHealth solutions and eRecord systems is inevitable in developing countries, and ensuring their bi-directional interoperability is essential. Interoperability has been described as the ability for two or more systems or components to exchange information and use the information that has been exchanged. Given the importance of linking mHealth solutions to eRecord systems in the developing world, a suitable interoperability framework is required to provide an agreed approach to interoperability and specify common elements. Although eHealth interoperability frameworks exist in the literature, none meet all the requirements for linking mHealth solutions to eRecord systems in developing countries. The aim of this study was to describe the design and development of a conceptual framework for linking mHealth solutions to eRecord systems in Botswana, as an exemplar. Methods: An iterative and reflective process was adopted, supported by existing literature and research including consultations with eHealth experts, and guidance from existing frameworks. These collectively identified key elements, concepts, and standards relevant and essential for framework design and development. Results: The mHealth-eRecord Interoperability Framework (mHeRIF) was developed which highlights the need for: governance and regulation of mHealth and eRecord systems, a national health information exchange, and which interoperability levels to achieve. Each of these are supported by integral themes and concepts. It also addresses the need for regular review, accreditation, and alignment of framework concepts and themes with a National eHealth Strategy Interoperability Development Process. To demonstrate the framework’s applicability, a proposed architecture for the Kgonafalo mobile telemedicine programme is presented. Conclusion: Interoperable mHealth solutions and eRecords systems have the potential to strengthen health systems. This study reports the design and development of an evidence-based mHeRIF to align with, build upon, and expand National eHealth Strategies by guiding the linking of mHealth solutions to eRecord systems in Botswana and other developing countries facing similar circumstances.
... 12,17,18,20,22 While provider hotlines are in routine use in HICs, there has been insufficient use and evaluation of their effectiveness in LICs. 19,23 In LICs, opportunities for providers to keep abreast of evidence-based information and to have point-of-care access to actionable information are limited. 24 This is supported by prior studies in Cameroon by our group 25-37 and others. ...
Article
Full-text available
Purpose: The purpose of this NIH-funded protocol is to adapt (Aim 1) and pilot test (Aim 2) an mHealth intervention to improve maternal and child health in Cameroon. We will adapt the 24/7 University of Alabama at Birmingham Medical Information Service via Telephone (MIST) provider support system to mMIST (mobile MIST) for peripheral providers who provide healthcare to pregnant and postpartum women and newborns in Cameroon. Methods: In Aim 1, we apply qualitative and participatory methods (in-depth interviews and focus groups with key stakeholders) to inform the adaptation of mMIST for use in Cameroon. We use the sequential phases of the ADAPT-ITT framework to iteratively adapt mMIST incorporating qualitative findings and tailoring for local contexts. In Aim 2, we test the adapted intervention for feasibility and acceptability in Ndop, Cameroon. Results: This study is ongoing at the time that this protocol is published. Conclusion: The adaptation, refinement, and pilot testing of mMIST will be used to inform a larger-scale stepped wedged cluster randomized controlled effectiveness trial. If successful, this mHealth intervention could be a powerful tool enabling providers in low-resource settings to deliver improved pregnancy care, thereby reducing maternal and fetal deaths.
... The high mobile phone penetration rates in Sub-Saharan Africa [10] offer opportunity of using mobile health (mHealth) interventions of improving adherence to antiretroviral therapy (ART) and retention in care. Although there is suggestive evidence of benefit of digital technology for HIV care on ART adherence and retention in care [8,11] there are concerns about scalability and sustainability of these interventions [12]. ...
Article
Full-text available
Introduction Evidence shows benefit of digital technology for people living with human immunodeficiency virus on antiretroviral therapy adherence and retention in care, however, scalability and sustainability have scarcely been evaluated. We assessed participants’ willingness to pay a fee for mHealth “Call for life Uganda” support, a mobile-phone based tool with the objective to assess sustainability and scalability. Methods “Call for Life study”, approved by Makerere University, School of Public Health research & ethics committee, at 2 sites in Uganda, evaluated a MoTech based software “CONNECT FOR LIFE™” mHealth tool termed “Call for life Uganda”. It provides short messages service or Interactive Voice Response functionalities, with a web-based interface, allows a computer to interact with humans through use of voice and tones input via keypad. Participants were randomized at 1:1 ratio to Standard of Care or standard of care plus Call for life Uganda. This sends pill reminders, visit reminders, voice messages and self-reported symptom support. At study visits 18 and 24 months, through mixed method approach we assessed mHealth sustainability and scalability. Participants were interviewed on desire to have or continue adherence support and willingness to pay a nominal fee for tool. We computed proportions willing to pay (± 95% confidence interval), stratified by study arm and predictors of willingness to continue and to pay using multivariate logistic regression model backed up by themes from qualitative interviews. Results 95% of participants were willing to continue using C4LU with 77.8% willing to pay for the service. Persons receiving care at the peri-urban clinic (OR 3.12, 95% CI 1.43–9.11.86) and those with exposure to the C4LU intervention (OR 4.2, 95% CI 1.55–11.84) were more likely to continue and pay for the service. Qualitative interviews revealed mixed feelings regarding amounts to pay, those willing to pay, argued that since they have been paying for personal phone calls/messages, they should not fail to pay for Call for life. Conclusions Payment for the service offers opportunities to scale up and sustain mHealth interventions which may not be priorities for government funding. A co-pay model could be acceptable to PLHIV to access mHealth services in low resource settings. Clinical Trial Number NCT 02953080.
... Botswana has identified mHealth as a means of improving healthcare provision and delivery [9]. Past localised efforts have been made to use mHealth in four clinical areas [24], but none were linked to any eRecord system(s). ...
Article
Full-text available
Background Significant investments have been made towards the implementation of mHealth applications and eRecord systems globally. However, fragmentation of these technologies remains a big challenge, often unresolved in developing countries. In particular, evidence shows little consideration for linking mHealth applications and eRecord systems. Botswana is a typical developing country in sub-Saharan Africa that has explored mHealth applications, but the solutions are not interoperable with existing eRecord systems. This paper describes Botswana’s eRecord systems interoperability landscape and provides guidance for linking mHealth applications to eRecord systems, both for Botswana and for developing countries using Botswana as an exemplar. Methods A survey and interviews of health ICT workers and a review of the Botswana National eHealth Strategy were completed. Perceived interoperability benefits, opportunities and challenges were charted and analysed, and future guidance derived. Results Survey and interview responses showed the need for interoperable mHealth applications and eRecord systems within the health sector of Botswana and within the context of the National eHealth Strategy. However, the current Strategy does not address linking mHealth applications to eRecord systems. Across Botswana’s health sectors, global interoperability standards and Application Programming Interfaces are widely used, with some level of interoperability within, but not between, public and private facilities. Further, a mix of open source and commercial eRecord systems utilising relational database systems and similar data formats are supported. Challenges for linking mHealth applications and eRecord systems in Botswana were identified and categorised into themes which led to development of guidance to enhance the National eHealth Strategy. Conclusion Interoperability between mHealth applications and eRecord systems is needed and is feasible. Opportunities and challenges for linking mHealth applications to eRecord systems were identified, and future guidance stemming from this insight presented. Findings will aid Botswana, and other developing countries, in resolving the pervasive disconnect between mHealth applications and eRecord systems.
Article
Patients of African ancestry are not well-represented in cancer clinical trials despite bearing a disproportionate share of mortality both in United States and Africa. We describe key stakeholder perspectives and priorities related to bringing early-stage cancer clinical trials to Africa and outline essential action steps. Increasing Diversity, Market Access, and Capacity in Oncology Registration Trials—Is Africa the Answer? satellite session was organized at 2021 Accelerating Anti-Cancer Agent Development and Validation Workshop. Panelists included representatives of African Organization for Research and Training in Cancer, Uganda Cancer Institute, Uganda Women's Cancer Support Organization, BIO Ventures for Global Health, Bill & Melinda Gates Foundation, the US Food and Drug Administration, Nigeria's National Agency for Food and Drug Administration and Control, Bayer, and Genentech, with moderators from ASCO and American Cancer Society. Key discussion themes and resulting action steps were agreed upon by all participants. Panelists agreed that increasing diversity in cancer clinical trials by including African patients is key to ensuring novel drugs are safe and effective across populations. They underscored the importance of equity in clinical trial access for patients in Africa. Panelists discussed their values related to access and barriers to opening clinical trials in Africa and described innovative solutions from their work aimed at overcoming these obstacles. Multisectoral collaboration efforts that allow leveraging of limited resources and result in sustainable capacity building and mutually beneficial long-term partnerships were discussed as key to outlined action steps. The panel discussion resulted in valuable insights about key stakeholder values and priorities related to bringing early-stage clinical trials to Africa, as well as specific actions for each stakeholder group.
Article
Full-text available
In sub-Saharan Africa (SSA), urgent action is needed to curb a growing crisis in cancer incidence and mortality. Without rapid interventions, data estimates show a major increase in cancer mortality from 520 348 in 2020 to about 1 million deaths per year by 2030. Here, we detail the state of cancer in SSA, recommend key actions on the basis of analysis, and highlight case studies and successful models that can be emulated, adapted, or improved across the region to reduce the growing cancer crises. Recommended actions begin with the need to develop or update national cancer control plans in each country. Plans must include childhood cancer plans, managing comorbidities such as HIV and malnutrition, a reliable and predictable supply of medication, and the provision of psychosocial, supportive, and palliative care. Plans should also engage traditional, complementary, and alternative medical practices employed by more than 80% of SSA populations and pathways to reduce missed diagnoses and late referrals. More substantial investment is needed in developing cancer registries and cancer diagnostics for core cancer tests. We show that investments in, and increased adoption of, some approaches used during the COVID-19 pandemic, such as hypofractionated radiotherapy and telehealth, can substantially increase access to cancer care in Africa, accelerate cancer prevention and control efforts, increase survival, and save billions of US dollars over the next decade. The involvement of African First Ladies in cancer prevention efforts represents one practical approach that should be amplified across SSA. Moreover, investments in workforce training are crucial to prevent millions of avoidable deaths by 2030. We present a framework that can be used to strategically plan cancer research enhancement in SSA, with investments in research that can produce a return on investment and help drive policy and effective collaborations. Expansion of universal health coverage to incorporate cancer into essential benefits packages is also vital. Implementation of the recommended actions in this Commission will be crucial for reducing the growing cancer crises in SSA and achieving political commitments to the UN Sustainable Development Goals to reduce premature mortality from non-communicable diseases by a third by 2030.
Article
This paper proposes that there should be contextual strategy development of applications’ diffusion based on the stage of mobile applications (apps) adoption already reached in a country. This is because as apps diffusion grows, the demand and supply constraints challenging the adoption of apps will change accordingly. A total of 77 countries are categorized into three clusters, Initial, Fast-Adoption, and Maturity, grouped by their adoption rates and the speeds over four-years from 2014 to 2017. With pooled and fixed-effect panel data models, this paper examines which variables out of 22 independent variables are effective in enhancing apps adoption globally. Further, by interacting two dummy clusters, Initial and Maturity with determinant variables, the study identifies the differential policy effectiveness of each determinant factor on apps adoption. The paper concludes that the three stages of apps diffusion levels have their respective effective strategy choice sets: 11 for Initial stage, 12 for Fast-adoption stage, and 13 for Maturity stage, suggesting that countries should develop their mobile apps inclusiveness strategy tailored to their context of apps adoption.
Article
Full-text available
This paper describes the use of mobile health (mHealth) projects in Botswana in public health interventions. mHealth is broadly defined to include any aspect of health care facilitated by mobile phone technology. Botswana's mobile network infrastructure makes mHealth an ideal tool to address the country's shortage of physicians and to respond to the HIV, tuberculosis (TB), and malaria burden of disease. Mobile phones are used for pediatric TB contact tracing to screen for TB disease and for collecting data on malaria outbreaks. mHealth tools also address the issue of health provider access (especially specialist consultations) given the country's relatively small population spread over a large land area. Data and camera enabled phones are used for radiology consultations, dermatology evaluations, and cervical cancer screening. The initial successes of mHealth projects in this country clearly demonstrate the potential for mobile phone technology in nationwide health care interventions.
Article
Full-text available
Although Botswana has recently been categorised as an upper middle income country, it is burdened by a scarcity of resources, both human and technological. There are barriers to patients' access to specialized care and healthcare providers' access to medical knowledge. Over the past three years, the Botswana-University of Pennsylvania Partnership (BUP) has piloted four mobile telemedicine projects in the specialties of women's health (cervical cancer screening utilizing visual inspection with acetic acid), radiology, oral medicine and dermatology. Mobile telemedicine has been used in 11 locations in Botswana, training a total of 24 clinicians and successfully contributing to the management of 643 cases. In addition to mobile telemedicine, BUP has initiated an m-learning programme with the University of Botswana School of Medicine. While successfully providing patients and providers with improved access to healthcare resources, the m-health projects have faced numerous technical and social challenges. These include malfunctioning mobile devices, unreliable IT infrastructure, accidental damage to mobile devices, and cultural misalignment between IT and healthcare providers. BUP has worked with its local partners to develop solutions to these problems. To ensure sustainability, m-health programmes must have strategic goals that are aligned with those of the national health and education system, and the initiatives must be owned and led by local stakeholders. Whenever possible, open source technology and local IT expertise and infrastructure should be employed.
Article
We assessed the diagnostic accuracy of digital photographs of plain film chest X-rays (CXRs) obtained using a mobile phone. The study was a randomized, non-inferiority trial, in which physical plain film CXRs viewed on a light box were compared with digital photographs of plain film CXRs. CXRs were selected from a database of radiology studies to show common pathologies found in Botswana associated with pneumonia, lung carcinoma, tuberculosis, pneumothorax and interstitial disease, as well as normal findings. The pre-selected diagnoses were subsequently verified by a second radiologist. Seven radiologists were randomized to review 75 plain film CXRs on light boxes before viewing 75 digital photographs, or vice versa. Their responses were considered correct if they matched the pre-defined diagnosis. For both modalities, the correct diagnosis was provided in 79% of cases; for plain film CXRs, the correct diagnosis was provided in 82% of cases and for digital photographs the correct diagnosis was provided in 76% of cases. The difference in diagnostic accuracy was -5.7% (95% CI: -10.8% to -0.5%), which confirmed non-inferiority (P < 0.001) for the primary outcome of diagnostic accuracy. A subgroup analysis demonstrated non-inferiority for lung carcinoma and pneumonia images, although non-inferiority was not achieved for pneumothorax, tuberculosis, interstitial disease or normal images. The study demonstrates that digital photographs of CXRs obtained via a mobile phone equipped with a digital camera are non-inferior to plain film CXRs.
Article
Importance: Mobile teledermatology may increase access to care. Objective: To determine whether mobile teledermatology in human immunodeficiency virus (HIV)-positive patients in Gaborone, Botswana, was reliable and produced valid assessments compared with face-to-face dermatologic consultations. Design, setting, and participants: Cross-sectional study conducted in outpatient clinics and public inpatient settings in Botswana for 76 HIV-positive patients 18 years and older with a skin or mucosal condition that had not been evaluated by a dermatologist. Main outcomes and measures: We calculated the κ coefficient for diagnosis, diagnostic category, and management for test-retest and interrater reliability. We also determined sensitivity and specificity for each diagnosis. Results: The κ coefficient for test-retest reliability ranged from 0.47 (95% CI, 0.35 to 0.59) to 0.78 (0.67 to 0.88) for the primary diagnosis, 0.29 (0.18 to 0.42) to 0.73 (0.61 to 0.84) for diagnostic category, and 0.17 (-0.01 to 0.36) to 0.54 (0.38 to 0.70) for management. The κ coefficient for interrater reliability ranged from 0.41 (95% CI, 0.31 to 0.52) to 0.51 (0.41 to 0.61) for the primary diagnosis, 0.22 (0.14 to 0.31) to 0.43 (0.34 to 0.53) for diagnostic category, and 0.08 (0.02 to 0.15) to 0.12 (0.01 to 0.23) for management. Sensitivity and specificity for the top 10 diagnoses varied from 0 to 0.88 and 0.84 to 1.00, respectively. Conclusions and relevance: Our results suggest that while the use of mobile teledermatology technology in HIV-positive patients in Botswana has significant potential for improving access to care, additional work is needed to improve the reliability and validity of this technology on a larger scale in this population.
Mobile telemedicine, which involves the use of cellular phone telecommunications to facilitate exchange of information between parties in different locations to assist in the management of patients, has become increasingly popular, particularly in resource-limited settings. In Botswana, small studies of mobile telemedicine programs suggest access to these services positively affect patients, but these programs' impact is difficult to capture given limitations of baseline and comparative data. Our observational study uses each patient receiving mobile oral telemedicine services in Botswana as his/her own control to assess the impact of these services on his/her diagnosis and management plan. At month 5 of 12 total, preliminary analysis of eligible cases (n = 27) reveals management plan discordance between clinicians submitting cases and the specialist was 68.0% (17/25), suggesting that telemedicine can result in significant changes in management of patients.
Article
Visual inspection of the cervix with application of 4% acetic acid (VIA) is an inexpensive alternative to cytology-based screening in areas where resources are limited, such as in many developing countries. We have examined the diagnostic agreement between off-site (remote) expert diagnosis using photographs of the cervix (photographic inspection with acetic acid, PIA) and in-person VIA. The images for remote evaluation were taken with a mobile phone and transmitted by MMS. The study population consisted of 95 HIV-positive women in Gaborone, Botswana. An expert gynaecologist made a definitive positive or negative reading on the PIA results of 64 out of the 95 women whose PIA images were also read by the nurse midwives. The remaining 31 PIA images were deemed insufficient in quality for a reading by the expert gynaecologist. The positive nurse PIA readings were concordant with the positive expert PIA readings in 82% of cases, and the negative PIA readings between the two groups were fully concordant in 89% of cases. These results suggest that mobile telemedicine may be useful to improve access of women in remote areas to cervical cancer screening utilizing the VIA 'see-and-treat' method.
Telemedicine for the Medicare Population: Update, Evidence Report/Technology Assessment Number 131
  • R William
  • M D Hersh
William R, Hersh MD. Telemedicine for the Medicare Population: Update, Evidence Report/Technology Assessment Number 131. Portland, OR: Oregon Evidence-Based Practice Center (2006).
Wireless broadband deployment & other latest technology trends. 13th ITU Sub-regional Meeting Available from
  • Lr Greene
Greene LR. Wireless broadband deployment & other latest technology trends. 13th ITU Sub-regional Meeting. Yangon (2006). Available from: http://www.itu. int/ITU-D/treg/Events/Seminars/2006/subregional_clmv/docs/1-6-1-green.pdf