Developing Telemedicine:

Benefits for rural people

Alex Perera Western Province roving corr

In promoting e-health, expatriate experts (particularly experts in the areas of health and ICT) can make a significant contribution by bringing their knowledge, skills and expertise. After the war President Mahinda Rajapaksa made an open invitation to experts from expatriate communities to come back and give their fullest support to the development of the country. It is gradually happening now

Following is the interview the Daily News had with Dr Rohana Puspakumara MP. He had been a district medical officer (DMO) as well as a medical officer of health (MOH) in Moneragala and Badulla districts for many years before he entered politics. He had also been the Health Minister in Uva Province for many years. In Parliament during debates he raised the point of developing telemedicine in Sri Lanka

Q: What is telemedicine -tele-health?

A: Telemedicine has been traditionally defined as the practice of medicine at a distance using videoconferencing, computer and communications technologies. The terms, telehealth and e-health were later coined in an attempt to include allied health, distance education and Internet applications. My definition of telemedicine incorporates telehealth and e-health concepts and includes any use of electronic means to extend health care services and health sciences education to points of need in a timely manner.

Q: What are the benefits of telemedicine-telehealth?

A: The two major general benefits of telemedicine-telehealth are improved access to specialty care and patient convenience.

There are several other real benefits such as improved patient compliance, improved continuity of care, decreased patient travel time, decreased travel time for physicians who would otherwise travel to remote sites for visits and/or clinics.

Q: Do you think this telemedicine services are useful to Sri Lanka?

A: Yes. I am sure that employing information and communication technology (ICT) to deliver health care at distance (i e telehealth or e-health) would be useful to address at least some of the problems in our country. In the early 1990s, there was a general expectation that e-health would solve main problems in health care in developing countries.

But I don’t think that this is the only solution for all our problems in health sector. But when we consider areas such as Moneragala, Polonnaruwa and the districts in North and East of Sri Lanka where the problem of specialist doctors is very high, this will be an ideal solution. When I was the Health Minister in Uva Province I tried to provide telemedicine services from Badulla to Mahiyangana area.

Q: What is the role of the government in promoting telemedicine/e-health services?

A: The Government as the policy-making organization plays a pivotal role in formulating regulations in the health sector.

The contribution of the government is particularly important in Sri Lanka where the public health system is usually the major provider of services. Government policies often have a significant impact on governing, financing and regulating the health sector in our country.

We in recent years have recognized the importance of ICT in our economic development and social progress. We have also initiated our national policies towards integrating ICT into our economic plans. In the Mahinda Chintana policy, a prominent place is given to develop ICT in all sectors of our economy.

However due to various reasons this happened slowly in the health sector. I believe that this has been the major cause of the slow progress of e-health in our country. But now it seems there is a progress in this sector.

Q:What are the reasons for non-adoption of telemedicine - e-health services in our country?

A: Before answering this question it is better to have a look at the things happening in this regard in other developing countries. Herewith I would like to be based on a research done on this subject by Sisira Edirippulige, Rohana B Marasinghe, Vajira, H W Dissanayake, Palitha Abeykoon and Richard Wootton. According to them the lack of awareness of the benefits among policy makers is the major reason.

The health - medical sector is a very sensitive area where traditional ways of working have evolved over centuries and, as a result, there is resistance to change. Health is also closely linked with privacy and security concerns. Therefore, the introduction of ICT into health care institutions may not be as straightforward as in other sectors, such as commerce and education.

Lack of evidence about the benefits of e-health may be another reason for policy makers being unaware of e-health.

Even in industrialized countries, there is a dearth of hard evidence with regard to the successful use of e-health. Similar evidence from a country such as ours is even scarcer. The lack of a sustainable business case to demonstrate cost-effectiveness is the root cause.

Although policy makers in developing countries are aware of the benefits of e-health, for a range of reasons they are reluctant to include this tool in their ICT initiatives. First, this may be due to limited financial capability. Policy makers are more likely to spend their limited resources on interventions that are known to produce health gain, such as sanitation, clean drinking water and vaccination, rather than funding e-health projects.

The critical state of the health sector and its financial limitations may not allow policy makers to change their traditional patterns of spending health funding, even when they are aware of the benefits of e-health. In some of the wealthier developing countries that have good health care services, there seems to be a lack of people within the health sector who can champion the cause of e-health with policy makers.

Reluctance to use e-health may also stem from certain prejudices. Policy makers in developing countries may regard e-health as a family of methods imported from the industrialized world that have little relevance in their own countries. E-health may even be seen as the imposition of new methods from the Western world or former colonial authorities, i.e. as a form of neocolonialism.

Even when they have an understanding of the benefits of e-health, policy makers in developing countries may be hesitant to use it owing to a lack of expertise, infrastructure, technical knowledge and skills. Starting an e-health project requires the presence of people with a certain level of technical expertise, and this may not be available in many developing countries. In addition, the telecommunication infrastructure in developing countries is still limited. These factors make it difficult for developing countries to launch e-health projects on their own.

Aspects such as inertia, reluctance to change and a lack of political will are also important factors that prevent policy makers from considering e-health as an alternative for addressing health problems in developing countries. Reluctance to change traditional methods of practice has been a serious obstacle to integrating e-health in the industrialized world too. The introduction of a new practice is always demanding and in that respect the role of champions or enthusiasts is extremely important.

According to the above researchers another important factor is that perhaps due to a combination of the factors mentioned above, is the need for long-term investment in tele - health and e-health, in order to build an infrastructure and the human resources required to demonstrate success.

This is impeded by the relatively short political cycle, which requires short-term political rewards for investments. Situation in our country was more or less similar to this. Now it is being changed. Therefore we can keep hopes.

Q: What are the strategies that you see to promote e-health at national level?

A: One way of addressing the problems outlined above is to make policy makers alert to the benefits of e-health. There needs to be a systematic way of making them aware of the current state of e-health practice and successful applications.

It is important to make them aware of aspects of e-health that are applicable in our country. To do so, improving access to the evidence base in e-health is extremely important. Making updated information about successful e-health projects available to policy makers is one way of achieving this goal. Enthusiasts within the health sector, both IT and health professionals, may also play a pivotal role in making policy makers aware of the benefits of e-health.

The importance of e-health education has so far been overlooked. Evidence shows that access to systematic education in e-health is limited in both industrialized and developing countries. Systematic education in e-health for health personnel must be at the heart of any strategy designed to facilitate e-health.

An understanding of the benefits of e-health, current applications, technical requirements and the ethical/legal aspects would enable health professionals to adopt this new technique. In this task, local academics and researchers can play an important role. It is important to encourage academics to publish the outcomes of any e-health projects internationally. By doing so, local academics and health scientists can influence policy makers to facilitate the wider use of e-health.

On the other hand, policy makers must adopt an open-minded approach to these new changes. Political will and commitment are important elements in bringing about changes in our country. The willingness of policy makers to use ICT in health is important in integrating this tool into the health sector.

While the continuing brain drain is a serious problem in our country, little attempt has so far been made to use expatriate communities to the benefit of the development of the country. This is certainly not a problem specific to e-health. However, in promoting e-health, expatriate experts (particularly experts in the areas of health and ICT) can make a significant contribution by bringing their knowledge, skills and expertise.

After the war President Mahinda Rajapaksa made an open invitation to experts from expatriate communities to come back and give their fullest support to the development of the country.

It is gradually happening now. Mobilization of them must be promoted, as these people have knowledge and skills not only in the subject area, but also about specific needs and cultural issues. From the policy makers’ side there must be an attitudinal change to accept and facilitate these experts.

In any environment, however, change is driven by individuals who have the motivation and desire to do so. When we consider about our country, where national level e-health initiatives have lagged behind, there are numerous anecdotal examples of successful institutional level initiatives driven by such champions of e-health. Thus, it is clear that what is lacking is not resources or finances but leadership.

Identifying such individuals within the health care system of the country and providing the necessary support to them to bring about the desired change are very important.

Q: Do you see any role of international agencies regarding this?

A: Of course. International agencies such as the World Health Organization (WHO), the United Nations (UN), the World Bank and certain regional organizations such as SAARC have recognized the value of ICT in development. In fact the WHO has been instrumental in promoting e-health in a number of ways.

In Sri Lanka regarding telemedicine and e-health two projects in 2001, two projects in 2003 and one project in 2005 have been done with the help of WHO. I haven't got any information regarding the things happened recently. If there is a progress I am very happy about it.

Q: As a Parliamentarian and a medical doctor, do you think telemedicine and e-health will make a new trend in health sector in Sri Lanka?

A: I am very sure about it. As I had been a DMO and an MOH in many rural areas I know how doctors and patients suffered when they were in need of services of specialist doctors. If we are serious in implementing this sort of a service the rural people will be more benefitted.