This paper illustrates an example of telemedicine applied in remote areas with limited resources through the presentation of a case-study of tele-consultation network in Siwa Oasis, one of the pristine desert environments in the world.
Egypt has made significant progress over the past 2 decades towards achieving the Millennium Development Goals (MDG), with particular regard to MDG 4 targeting child mortality, which have been declining significantly in the period 1990-2005.
Notwithstanding the high drop percentage, in UNICEF “State of the World’s Children” Report, Egypt is ranked only 77th in terms of under 5 years old child mortality rate. Child mortality therefore remains a problem, which is primarily the effect of household economic status and availability of health services.
Moreover, inequities in survival of children among different geographic areas remain a serious challenge as highlighted in Egypt Human Development Report (EHDR) 2008, which captures significant disparities among different geographic areas in under 5 years old child mortality rate.
The use of Information Communication and Technologies (ICTs) in the delivery of medical care can play a critical role in achieving the ultimate goal of improving health in poor communities with limited resources. In particular, telemedicine can have a positive impact on the quality of health care provided in those remote areas with very limited access to advanced medical technologies.
An example of telemedicine applied in a remote area with limited resources will be illustrated in this paper through the presentation of the case study of tele-consultation network in Siwa Oasis, one of the last pristine desert environments in the world.
Through this joint initiative, the Siwa main hospital has been connected to the Pediatric Department of the El Shatby Hospital in Alexandria. The intervention aims at improving children health care services through tele-consultation and continuous professional training of doctors by introducing e-learning techniques. The trial of this model, as reflected in the deployment and pilot tests of the project, confirms the benefits of ICT for health care provision and medical education.
Case of Siwa teleconsultation initiative:
The “Tele-consultation on Child Health” is a joint initiative which aims at reducing child morbidity and mortality in Siwa district, in Matrouh governorate, through teleconsultation and e-learning techniques.
Siwa is an oasis that occupies a surface of approximately 1125 km2 and is situated in a remote location about 800 km from Cairo, 300 km southwest of the Mediterranean city of Mersa Matruh and 70 km east to the Libyan border. The population reaches 20,000 inhabitants living across Siwa town and several villages.
Child health care remains one of the top priorities of the government in Egypt. The Government’s efforts in assigning a sufficient number of health care providers in the Frontiers Governorates have been crucial in improving health care in the District. Due to lack of experienced doctors and high-end treatment facilities in Siwa Hospital, difficult- to-diagnose and medically complex cases of children in Siwa are generally referred to Matrouh and/or Alexandria Hospital. The distance to these referral hospitals (more than 300 km) often causes additional health hazards and sometimes even death of patients during transit.
This 1-year pilot project aims to use ehealth techniques to strengthen the capacities of h]ealth care providers and enhance knowledge acquisition and skills of medical students in Siwa Hospital.
Despite being in early stage, the tele-consultation project is proving to be quite an effective tool. Regular communication conferences are being held, whereby physicians in Siwa prepare cases for which they require consultation from the pediatric department of Alexandria El Shatby Hospital. During the regular video conference, teaching staff often decide to hold specialized video conference with professors of different specialties. Health care personnel from Siwa Hospital are also participating on a biweekly basis in the scientific video conference meetings held in the pediatric department in Alexandria.
An interactive mechanism is set for the teaching process and assessment of students from the Faculty of Medicine of Alexandria University. These sessions prepare students to deal with patients in real life situations. Whilst the continued medical education to the health care providers in Siwa Hospital, is implemented through e-learning packages, in form of lectures, thesis and researches on a specific station accessible to Siwa physicians or through allowing access of health care providers to the most updated medical journals from the library of Alexandria pediatric department.
“The Siwa joint initiative is an effective partnership between MCIT (through Egypt ICT Trust Fund) support, UNDP development knowledge of the country, the technical capacity of The Child and Adolescent Health Unit (CAH) of WHO-EMRO, and the IT capability of private companies.”
Remarkable efforts of the Government of Egypt in ICT sector at the national level have had a dramatic effect on the diffusion of technology. The creation of an enabling policy environment is fostering technology use and is encouraging national and international investments in ICT infrastructure, development and a skilled workforce.
At the implementation level of Siwa Joint Initiative, active support from the Ministry of Communication, Information and Technology (MCIT) and the Ministry of Health and Planning (MOHP) were provided. Apart from facilitating the whole implementation process, technical human resources and materials were also made available to the project. The private sector also played a significant role, since part of the funding came from the Corporate Social Responsibility (CSR) of private companies. Joining efforts with other stakeholders such as development agencies is crucial not only for the purpose of reducing investment costs, but also for minimizing the political risks that may exist in many developing countries.
The Siwa joint initiative is an effective partnership between MCIT (through Egypt ICT Trust Fund) support, UNDP development knowledge of the country, the technical capacity of The Child and Adolescent Health Unit (CAH) of WHO-EMRO, and the IT capability of private companies.
Lack of a legal framework: One of the main challenges of telemedicine in Egypt, is the gap in the legal framework. Telemedicine being a recent practice in the country, its development has created new legal challenges. At a global level, extensive discussions are being held concerning the risks and complex legal problems associated with telemedicine-based health care services. While developing an enabling legal framework, the Government of Egypt should foster a supportive, transparent, legal and regulatory framework that addresses the use of telemedicine in safeguarding the rights of patients. Issues concerning the privacy of identifiable health information, the reliability and quality of health data, as well as medical liability are to be considered while developing the legislative framework. Other areas that prompt concerns are the right of health professionals to exercise telemedicine, accreditation and authorization schemes to provide telemedicine services, and issues surrounding liability or recognition of professional qualifications. However, when defining the legal framework, policy makers should ensure that telemedicine does not in any way reduce the quality of the health care services provided to the public.
Lack of professional development and educational opportunities: Health care personnel in remote areas are not exposed to opportunities of professional development and training. The project seeks to provide continuous education to local medical staff through video conferencing. Moreover, efforts are being made to promote the education and training component and increase confidence and trust in telemedicine as an effective tool for education. Currently, a proposal from the Dean of the Faculty of Medicine of Alexandria University is being evaluated for encouraging doctors from Alexandria with economic incentives to carry out 10�20 hours/week of teleconsultation. On the other hand, hours spent on teleconsultation from Siwa doctors will form part of the traineeship required by the Master Program organized by Alexandria University.
Sustainability: The sustainability of telemedicine services is a multidimensional matter that should consider technical, financial and human resources aspects. When planning the technical sustainability, easy-to-use software that require minimum training skills and hardware that are durable and of low maintenance should be considered. The financial sustainability remains one of the most challenging aspects of telemedicine.
In addition, pilot projects used for demonstrating the cost-effectiveness and benefits of telemedicine should also be made sustainable. Potential initial capital sources could be explored with the Private Sector, private donations, development agencies etc. However, sponsors of such pilot projects must have a clear plan from the start about how the project can continue after the sponsorship comes to an end.
This project not only showed the satisfaction of medical users both in Siwa and Alexandria about the services provided to them, but also highlighted the technical difficulties in establishing a functional teleconsultation platform that provide services on a regular basis. High cost of Internet services (compared to developed countries) as well as acquisition costs for computers and medical devices are major obstacles for a wider implementation of telemedicine applications. However, the first stage of this pilot project showed that teleconsultation has the potential to improve the utilization of health resources available in Siwa. Rather than simply importing expertise from outside, the local health teams are strengthened and supported through continuous training and education. Moreover, it serves as a practice platform for undergraduates students with real life situations.
Finally, Siwa teleconsultation platform is reducing the disparity in the delivery of health services between the developed centers and the isolated and less assisted areas, thus contributing to improve health care for children in rural and underserved areas.
In conclusion, we believe that joining efforts among various actors can be strongly value-enhancing and key for success.