Room 1: Country Experience in Implementing Telehealth Services

Telehealth for improved access, coverage and availability of quality service 

Patients in remote areas of Ghana face geographical barriers to health services. These barriers include poor transport networks, limited access to healthcare providers, and inadequately resourced health facilities resulting in high mortality and morbidity rates for diseases that may be easily treated.

Prior to the COVID-19 pandemic, the Ghana Ministry of Health, the Ghana Health Service, the National Health Insurance Authority, the Ambulance Services of Ghana, Millennium Promise partnered with the Novartis Foundation to roll out a telehealth model after a successful pilot in the Ashanti region.  The telehealth model is developed around the frontline health worker, with digital technology allowing for the centralization of healthcare expertise. The doctors, experienced nurses and midwives, who are staffing the teleconsultation centre at the referral hospital 24/7, are coaching and guiding less-skilled community health workers in their patient care.   The objective is to expand access to quality care for populations in remote rural areas, reducing transport times and costs for patients and avoiding unnecessary referrals. 

This is an efficacious intervention for addressing the unavailability, unaffordability or inaccessibility of healthcare services amidst the pandemic for many people in Ghana and beyond. In 2016, more than half of all teleconsultations could be resolved directly by phone, including 31% that avoided referrals. This reduces the burden on referral facilities helping to address the patient to bed ratio challenges in these facilities. It also strengthens the health system by empowering community health workers and improving the quality of care with a direct impact on patient health outcomes.

Considering the contextual complexities of our communities and the health system, how do we ensure that this efficacious intervention becomes effective with no remote area left behind.

https://www.novartisfoundation.org/past-programs/digital-health/ghana-t…

Addressing questions 1 and 2

Hello Everyone,

My name is Belynda, and I am very happy to be your moderator for this 1st week of this e-consultation.  Telehealth is gaining increasing relevance especially during this COVID-19 pandemic and has the potential to enhance the efficient and effective delivery of essential health services and health system resilience in low- and middle-income countries. The pandemic has also further heightened the critical role innovative digital solutions play in the provision of essential health services. This discussion room provides a space for discussants to share experiences of their own and reflect on the challenges and lessons learned in the implementation of telehealth. It will be refreshing to hear your thoughts and insights on how we could use telehealth to promote access to essential health services and products. Your thoughts/insights can be shared in English, but the platform can also translate the text of pages into over 100 languages (use the “Select your Language” option at the top right of SparkBlue). Kindly use this function to translate comments in other languages, and feel free to post in the language you feel most comfortable with.

At the end of each of the 4 weeks of this consultation we will pin a summary to the top of the page. Kindly spare some time to contribute your thoughts and experience! And do reach out if you have issues posting,

We look forward to interacting with you!

Posting on behalf of UNDP Pakistan

1. UNDP Pakistan supported the Federal Ministry of Health to introduce an innovative telehealth platform as part of the COVID response in 2020. While several private tele-medicine platforms were available in Pakistan at the time, there were limited in scope and outreach and UNDP felt there was more space to engage tele-medicine platforms to enhance the National COVID response. Following discussions with the Federal Ministry of Health, UNDP then engaged a partner to assist the design and roll-out of the Tele-ICU pilot in Pakistan and in parallel provided technical assistance to support the Ministry of Health to institutionalize tele-medicine through policy and legislative changes with support from the UNDP Office for Technology, Innovation and Sustainable Development as well as the Regional Office in Bangkok. 

https://www.pk.undp.org/content/pakistan/en/home/blog/2020/how-telemedicine-is-helping-in-the-fight-against-covid-19--and-w.html

Posting on behalf of UNDP Pakistan

2. With the total of 0.919% of GDP spent on public healthcare, there are currently less than 100 intensivists to meet the needs of Pakistan, requiring at least 500 more to face the pandemic. While these 70 critical care experts were available in the major cities of Pakistan, a large number of small intensive care/ High dependency units suffered due to lack of human resource. To tackle this challenge UNDP, in collaboration with the Government of Pakistan and Sehat Kahani initiated one-of its kind Tele-ICU Project last year with an aim to build capacity and assure access to critical health services safely through a virtual platform. 

While our partner Sehat Kahani already had a functioning and successful telemedicine platform with 27 e-clinics across the country, with UNDP support the platform was modified under the Tele-ICU project in order to meet the needs of both public and private hospitals and clinics as well as critical care experts who were the intended users of the modified platform.

Posting on behalf of UNDP Pakistan

4. Wins: The Telemedicine Platform has proved to be an asset in the screening, triaging, and referral of the COVID-19 cases identified all around the country. Through this model around 5,000 doctors and medical staff have been provided medical education and telehealth training while thousands of patients have now received virtual consultations. Additionally, 60 tele-ICUs were created across Pakistan under the UNDP supported project.

Major challenges for the implementation of this initiative include behavior change for health professionals, connectivity issues and sustainability for public hospitals although Sehat Kahani is planning a model whereby fees paid by Private Sector hospitals will help provide subsidies for public hospitals. On UNDP’s side, given we don’t have a large health portfolio, it has been complicated to provide detailed health related technical support, but we were able to leverage our digitalization and innovation teams in the CO to some extent for this work.  We have also been happy to receive guidance for BRH and Singapore UNDP teams on digital health and to share experiences with other countries in a similar situation.

Posting on behalf of UNDP Pakistan

5. UNDP continues to engage on the policy level with the Digital Health team in the Ministry of Health, the Ministry of IT and the National Database and Registration Authority (NADRA) to support further efforts to enhance policy-making around digital health and tele-health specifically via the Digital Health Strategy which is underway and was also supported by technical assistance for UNDP, although with a smaller footprint given our funding scenario for this line of work.

Many thanks Evelyn for sharing this very useful insight which clearly demonstrates the utility of telehealth in low resource settings. I would also reiterate your  thoughts on ensuring that we support  these interventions  to make them sustainable and effective. This is because often times some of these interventions are project based, so how do we sustain the gains after the project is over, what kind of support will be needed to expand the coverage of these interventions

This is very true Belynda. The sustainability of interventions is mostly taken for granted. It becomes important when the intervention begins to face challenges in the real world when in fact it should have been the first point of consideration. I believe the discussions will help us to change the narrative.

 Many thanks Marya for kindly sharing your insights on UNDP's support. Particularly noteworthy is the provision of support to institutionalize telemedicine whilst also providing technical assistance for the roll out. This approach is really critical to guarantee sustainability of interventions

Sharing a great platform in Sri Lanka related to this discussion. 

https://www.odoc.life/

I would like to highlight an innovative, low-cost disease surveillance system from Kenya. This case example is illustrated in the background paper developed specifically for this e-discussion (please check out the paper!).

In 2019, the Kenyan mobile network operator Safaricom, partnered with the Ministry of Health and Korea Telecom (KT) to launch ‘Safiri Smart’. The platform was originally developed by KT as part of their Global Epidemic Prevention Project. Safiri Smart offers a free low-tech solution that uses short code or USSD to alert subscribers about disease outbreaks and epidemics. Subscribers need to opt-in to the services, and they can receive information about the disease, such as symptoms signs to observe, and preventative measures. The technology also allows people to report their symptoms, allowing health officials to monitor potential focal points of disease outbreak. This system was introduced in Kenya prior to the COVID-19 outbreak to help the surveillance of disease spread of diseases such as yellow fever, cholera, Ebola. However, Safiri Smart provided an important tool for disease surveillance in Kenya during the COVID-19 pandemic.

Are there similar experiences in other countries, where they have implemented a low-cost and highly adaptable disease surveillance system? Or have repurposed the use of an existing digital solution for the COVID-19 response - what were your challenges and lessons learned in this process?

Dear all. Amitrajit Saha, UNDP Team Leader HHD for Africa here. In responding to Q1., let me share Bhutan’s digital tracking system for COVID vaccination (https://www.bt.undp.org/content/bhutan/en/home/presscenter/pressrelease…). In addition, it was wonderful to learn from Bhutan govt. representative today on how they successfully rolled a remarkable COVID vaccination program in the country. He also raised the question of a hiccup they had: elder/more senior community health workers found it tougher to adapt digital and mobile tools. Which brings me to some issues I want to raise

1. How do we quickly sensitize/capacity build primary/grassroots healthcare workers and/or volunteers on digital tools to enable swiftly moving from paper-based to digital M&E and reporting tools? Some examples of successful, evaluated training of HCP to use digital reporting systems would be helpful.

2. What procurement and budgeting provisions do we need to make, to quickly transform a paper-based LMIS to a digital one? Cash amount/proportion of budgets from anyone who’s had this experience?

3. What support we may need to provide national governments to transform, with corporate partners, the primary digital infrastructure and/reach of internet/mobile and broadband data at affordable prices? Any lessons? There exists big Urban/Rural divide in access to the Internet is a big reality in Sub Saharan Africa? Any examples of support to strengthen internet coverage from countries will be helpful for us in Africa.

4. Finally, together with your examples, am looking for examples of strong frameworks that ensure patient confidentiality, and strengthen data security for government, CSOs and the individual client?

 Thanks. 

Amitrajit Saha the point you make about challenges of uptake for some populations is a real one. Elderly persons, people with disabilities, people who cannot read and write [even if fluent in app languages], rural populations are all groups that must be taken into consideration while rolling out telehealth services, otherwise there is a real risk of lack of acceptance/uptake.

Room 2 of this e-discussion asks the important question - What are the key approaches in improving acceptance, broad uptake/usage and sustainability of telehealth services? How can service providers effectively build awareness and use of telehealth services among community members and health professionals, and promote their retention on these platforms? it touches on some of the questions you asked. I wonder what your thoughts on these are? Maryam Inam it looks like there is much to be learned from the Pakistan example. Please feel free to share your thoughts and continue this conversation in Room 2.

Thanks

Dear all, my name is Nora Nindi Arista, Project Manager for STRATEGIC project in UNDP Indonesia. I would like to share telehealth in Indonesia and our support in the development of telehealth services in Indonesia.

1. Telehealth in Indonesia

The development of telehealth in Indonesia has been done since 2012. The Ministry of Health launched an internet-based telemedicine pilot project with tele-radiology and tele-electrocardiography (tele-EKG) services in 2012. Apart from tele-radiology and tele-EKG, Indonesia also uses video conferencing (VICON) based telemedicine (teleconference) in July 2013. Seeing the expanding potential of telemedicine, the Indonesian government proposes the implementation of a national scale telemedicine as the indicators for the Strategic Plan and National Medium Term Development Plan 2015-2019.

In 2016, telemedicine services were initially run with 3 main aspects which were tele-radiology, tele-EKG, and tele-USG. assigned to use this service, which is also combined with tele-consulting. in 2017 all services were executed using a single application established by the Ministry of Health. This service application uses a web-browser platform and can be accessed in all regions of Indonesia by opening www.temenin.kemkes.go.id . To ensure the spread of telemedicine implementation, the Ministry of Health is also responsible for conducting several consecutive trainings between doctors and health service provider operators. The implementation of this Temenin program is stated in detail in a ministerial decree number HK.01.07 / Menkes / 650/2017 for the Telemedicine Service Hospital and the Telemedicine Trial Program. In 2020, there are 56 facilitating hospitals and 151 managed hospitals / Puskesmas registered with Temenin, with general practitioners being the most registered doctors.

Figure 2. History of Telemedicine program by Ministry of Health Indonesia (MoH, 2017)

Telemedicine Services between Doctors and Patients

1. Telemedicine services at SehatPedia by the Ministry of Health

Sehatpedia is an e-health application developed by the Directorate General of Public Health Services at the Ministry of Health in February 2018. Sehatpedia was developed to answer three health challenges that exist in Indonesia today, namely making health services accessible to all Indonesians, increasing health awareness for the community to maintain health, and providing reliable health information to the public. Sehatpedia is an open and free online health information application that can be accessed by all Indonesians wherever they live. This allows all citizens to have equal access to health information and access.

2. Telemedicine Services for Doctors to Patients conducted by Hospitals

There are telemedicine services provided by hospitals to support their existing patients (customers) through the system that is connected to the Hospital Information Systems (HIS). Patients can be served via communication systems such as web chat, WhatsApp, phone-call and many other technologies.

Telemedicine during COVID-19 Pandemic

Since Indonesia President, Joko Widodo has officially declared COVID-19 a national disaster, telemedicine has been one of the tele-health services to reduce in person contact between doctor and patient and reach out the self-isolation COVID-19 patients. In July 2021, Ministry of Health announce that they are collaborating with 11 telemedicine platforms to provide doctor consultation services and also free medication delivery services for self-isolation patient. The telemedicine provider was:

1. Alodokter
2. GetWell
3. Good Doctor
4. Halodoc
5. KlikDokter
6. KlinikGo
7. Link Sehat
8. Milvik Dokter
9. ProSehat
10. SehatQ
11. YesDok

Besides that, Ministry of Health also developing their telemedicine website which are www.isoman.kemkes.go.id . this website also providing free doctor consultation and medication for COVID-19 patients who were self-isolating. The Ministry of Health has expanded consultation services and free medicine delivery through telemedicine services for self-isolated COVID-19 patients to 4 regions, namely Bogor, Depok, Tangerang and Bekasi (Bodetabek).

2. What health system challenges/priorities do these telehealth services aim to address? What health outcomes have been achieved?

The digital health service ecosystem in Indonesia has become a necessity, especially during the COVID-19 pandemic. Telemedicine does not only provide teleconsultation, tele-prescribing, and telenursing via chats or video call, but also collaborates with digital transportation application companies such as Gojek and Grab providing delivery of medicines to patients at home. These services can help the government identify suspected cases that should be prioritized for testing and hospitalization/quarantine in a dedicated isolation facility, and improve access to essential health services for women, children, vulnerable and poor people. With the second wave of COVID-19 in Indonesia where the new cases daily reach up to more than 50.000 new cases, the telemedicine services have supported the government to monitor and support the patient who are self-isolating to consult with the doctor and provide medication to them for free.

3. Describe the technical support that was needed for expanding the coverage and quality of telehealth services.

Based on our assessment, several challenges remain for telemedicine services in Indonesia and these are our recommendations on how to expand the coverage and quality of telehealth services especially during the outbreak:

1. The integration of telemedicine into international and national guidelines for public health preparedness (in keeping with International Health Regulations, 2005) and response.
2. The definition of national regulations and funding frameworks for telemedicine in the context of public health emergencies.
3. A strategy to quickly define telemedicine frameworks; use case scenarios; develop clinical guidelines; and standardize triage auto questionnaire and remote patient-monitoring algorithms for any outbreaks at local, national, or global scales,
4. A strategy and operational plan guiding health care providers to switch to outpatient teleconsultation and increase tele-expertise and remote patient monitoring.
5. A communication toolkit to inform and educate the population on the recommended use of telemedicine.
6. A data-sharing mechanism to integrate telemedicine providers’ data with epidemiological surveillance.
7. A scientific evaluation framework and dedicated research funds to describe and assess the impact of telemedicine during outbreaks.

Final Report - Assessment Telemedicine Service in Pandemic Situation in Indonesia.pdf3.75 MB

4. What were the biggest wins and the biggest challenges in implementing the telehealth solution?

WINS: With the existence of Telemedicine services that have been carried out in Indonesia, both from the government and the private sector, it gives hope that these services will develop further, where this is supported by various conditions such as developments in information technology including increasingly even network infrastructure, population demographics dominated by productive age and understanding Digital-based health services, challenging geographical conditions, and increasingly conducive legal regulations and following the development of digital services.

Challenges: Some of the challenges in the implementation of Telemedicine services in Indonesia were immature organization and lack of financial support where most of the payment method is out-of-pocket. The payment model used is fee for service, and only a small proportion of them collaborate with insurance partners.

The majority of telemedicine operators in Indonesia consider their current human resources to be insufficient. This shows that telemedicine administering organizations are on average still in their early stages and moving towards maturity. There is lack of training for doctors to improve their skills in providing telemedicine services which for some doctors is a new form of service to patients.

In general, some Indonesians can enjoy telemedicine services, although they are still limited in big cities where internet access is easier to obtain. It could cause inequality and people who were in poor situation with little to no access to internet cannot utilize this services. further efforts are still needed to equalize access from low-income and disadvantaged education groups.

5. How has UNDP supported the introduction and scale-up of telehealth services?

During the COVID-19 pandemic, the use of telehealth has increased and supported to improve patient health outcomes. Many professional medical societies endorse telehealth services and guide medical practice in this evolving landscape not only for COVID-19 services but also for other diseases such as AIDS, tuberculosis, diabetes, etc.

UNDP Indonesia collaborating with Indonesian Telemedicine Alliance (ATENSI) to strengthen telemedicine services for Doctors to Patients conducted by Private Companies based on Smartphone applications and websites, organized by Alliance Telemedicine Indonesia (ATENSI). This cooperation agreed on several activities, such as:

• Evidence-based practices through Assessment to analyze the telemedicine service in pandemic situations and university network development on telemedicine research to provide recommendations to government regarding working areas of telemedicine services to improve their services and as part of the public health service system;
• Advocacy on development of national framework and governance on telemedicine; and
• Support to promote South-South learning, exchange, and capacity building.

In addition, UNDP has the initiative to implement an assessment to measure the extent to which this telemedicine service can provide benefits to the people of Indonesia, what types of services are accessed by patients through this telemedicine service, the quality of health services, how much is the cost raised through this telemedicine service. UNDP Indonesia engaged with the Ministry of Health Republic Indonesia and ATENSI to conduct this assessment and aim the objective where the Government received a valuable recommendation and became evidence for policy improvement related to telemedicine services in Indonesia. The objectives of this assessment are:

• The extent to which the telemedicine service can provide benefits to the people in Indonesia
• Provides recommendations to the government regarding working areas of telemedicine services to improve services and as part of the public health service system in addition to hospital, clinic, and Puskesmas health services.

This assessment report has been presented to ATENSI members and we are planning to disseminate the assessment result to the Ministry of Health and provide recommendations on improving the telemedicine services and regulation.

source: www.atensi.or.id

6. Besides that, Are there opportunities to expand the use of telehealth in your country? If so, which telehealth solutions and/or health challenges should be prioritized?

There are a lot of opportunities in expanding the use of telehealth in Indonesia. Through STRATEGIC project, UNDP Indonesia aimed to develop telemedicine platform scheme during pandemic and post-pandemic such as ethical standard, emergency decree, code of conduct (in practical do and don’t) material with MoH, ATENSI, and beneficiaries and establish a national multi-stakeholder platform to promote engagement, coordination and collaboration between government agencies, public and private health providers, telemedicine developers, and CSOs.

Besides telehealth, UNDP Indonesia will assist the Ministry of Health in developing the Digital Health Strategy. Ministry of Health through Data Information Centre and Digital Transformation Office has been developing health digitalization priority 2021-2024. Therefore, this digital health strategy will be supporting digital health transformation from the policy framework, institution strengthening in central and district level, human resource capacity, infrastructure readiness, and feasible and measurable implementation strategy.

Here's an example of a digital psychosocial intervention from Ghana (illustrated in the background paper): 

MindIT, founded in 2017, provides free mental health services through mobile technology for people in Ghana where an estimated 650,000 people live with a severe mental health disorder and over two million live with moderate to mild mental health condition. There are less than 20 psychiatrists and around 1,000 registered mental health nurses in the country, and many people in Ghana are not aware of mental health conditions and do not know where to access affordable services.

MindIT uses a toll-free “quick code” (USSD, or unstructured supplementary service data) that enables screening for symptoms that are suggestive of mental health conditions. Responses are sent to a government-funded call centre where trained personnel analyse the data and refer people to the nearest community psychiatric unit, where patients can access either free or subsidised services from the National Health Insurance Scheme in Ghana. In 2021, the short code was incorporated into the Ghana Mental Health Services authority and is free of charge. In the last two years, more than 8,000 people have accessed the service and many of those received attention and treatment provided by clinical staff.

Dr. Wisdom Atiwoto do you have any reflections about the success of this intervention? What would need to happen to scale this service up in Ghana?

Week 1 Discussion Summary, 23 - 27 August 

Dear All,

Happy to kindly share a brief summary and some reflections from our discussions last week.

Many thanks!

• Several countries have introduced different telehealth interventions in recent times to improve health outcomes.
• In Ghana, a telehealth intervention aimed at strengthening the capacity of community health workers has empowered health care workers and improved   access, efficiency, and quality of care. In Pakistan, a telemedicine platform has been used to train about 5,000 doctors and medical staff and provide virtual consultations for thousands of patients. In Indonesia, an e- health application and other channels such as web chat and WhatsApp are being utilized to support patients and provide health information. In Kenya, a free low-tech solution that uses short code or USSD is being used to strengthen disease surveillance whilst in Bhutan a digital system has supported the country’s very successful COVID 19 vaccination efforts
• Telehealth services have been beneficial in addressing human resource deficits in the health sector by strengthening capacity of health personnel and connecting health personnel with patients. During this pandemic, telemedicine interventions have also been used for surveillance, screening, monitoring of patients and the delivery of medicines.
• Despite all these benefits, numerous challenges impede the expansion and quality of telehealth services. These include lack of financial support, uneven /unequal internet connectivity, inadequate human resource, and low uptake of telehealth interventions in certain populations. Promoting behavior change to encourage uptake and ensuring that telehealth interventions are context specific and sustainable, will be critical for the scale up of telehealth interventions
• Collaborations and partnerships are proving to be critical ingredients for the initiation and scale up of telemedicine interventions as evidenced by partnerships between UNDP Indonesia and Indonesia telemedicine alliance (ATENSI) and collaborations with Safaricom, Kenyan Ministry of health and Korea telecom. Harnessing public private partnerships and developing broader multi stakeholder platforms for engagement, coordination etc. will also be instrumental in scaling up interventions
• Providing technical support for the development of the telehealth infrastructure as well as supporting the institutionalization of the interventions through broader policy and legislative support could be a winning formula as highlighted by work done by  UNDP Indonesia and UNDP Pakistan

Hi everybody, WELCOME to week 2 of the e-discussion. Thanks very much Belynda Amankwa for your brilliant moderation last week and for getting Room 1 off to a cracking start! My name is Les Ong and I will be your moderator for Room 1 this coming week.

Thank you to those of you who kindly shared several examples of telehealth solutions across a broad range of health system functions. We heard about good practices, key challenges and lessons learned in introducing and scaling up these solutions, and the policy, regulatory and strategic framework that enable their sustainable use. Several UNDP colleagues also highlighted the support that they provided in helping to rollout telehealth solutions.

For Week 2, we would like to continue pretty much in the same vein as last week. We hope that you are able to build on the discussion that has already taken place. Please feel free to react/respond to the questions or points raised by other discussants, and tag relevant individuals (either those who are already part of the e-discussion or those yet to join) so that they are aware of your posts. Please also share any relevant literature / resources in your interventions (either as a hyperlink or as an attachment to your post).

Apart from the guiding questions listed in the introduction, please also consider addressing some of the questions that discussants raised last week:

• How can we best change the behaviour of health professionals in adopting the use of telehealth?
• Are there any examples where existing digital solutions have been repurposed  for the COVID-19 response?
• How can we quickly build the capacity of primary healthcare workers to enable the transition from paper-based to digital M&E and reporting? Some examples of successful, evaluated training of HCP to use digital reporting systems would be helpful.
• What support is needed by national governments in upgrading their digital infrastructure to delivery broadband data at affordable prices? Any examples of support to strengthen internet coverage?
• What examples do we have of strong frameworks that ensure patient confidentiality, and strengthen data security for government, CSOs and the individual client?

Looking forward to our discussion this week!

Telemedicine Practice Guidelines from Government of India

Until March 25, 2020, India did not have legislation or guidelines on the practice of telemedicine, through video, phone, Internet based platforms (web/chat/apps etc). The existing regulations that used to be applicable were those primarily governing the practice of medicine and information technology. Lack of clear guidelines resulted in ambiguity on the practice of telemedicine. Considering that gaps in legislation and the uncertainty of rules pose a risk for both the doctors and their patients as well as potential of tele-consultations in meeting the needs of citizens during the Covid pandemic the Government of India released telemedicine practice guidelines. Available online @ https://www.mohfw.gov.in/pdf/Telemedicine.pdf

Related references:

Frequently Asked Questions (FAQs) on Telemedicine Practice Guidelines 

Modification in Medicine List in Telemedicine Practice Guidelines 

Purpose:

The purpose of these guidelines is to give practical advice to doctors so that all services and models of care used by doctors and health workers are encouraged to consider the use of telemedicine as a part of normal practice. Also these guidelines were to be used in conjunction with the other national clinical standards, protocols, policies.

Catalytic effect of the guidelines on the virtual care ecosystem in the country:

The practice guidelines releases by the Government had a catalytic effect on the virtual care ecosystem in India. Here is an attempt to sum-up the key developments in a chronological fashion following their release. 

March 25, 2020: Board of Governors in supersession of the Medical Council of India (MCI) released “Telemedicine Practice Guidelines: Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine”

April 7, 2020: Telemedicine Practice Guidelines for Ayurveda, Siddha & Unani practitioners

April 10, 2020: Telemedicine Practice Guidelines for Homeopathy practitioners

May 12, 2020: Gov amends “Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002” 

•New regulation: “Indian Medical Council (Professional Conduct, Etiquette and Ethics) (Amendment) Regulations, 2020” 

May 14, 2020: Gov notified the regulation and published them in the Gazette of India (Deemed to have been effective from March 25, 2020)

June 11, 2020: Insurance Regulatory and Development Authority of India (IRDAI) issued directive

•To allow claim settlement for telemedicine consultation wherever normal consultation with a medical practitioner is allowed in the terms and conditions of the policy contract. 

•Telemedicine offered shall be in compliance with the Telemedicine Practice Guidelines and amendments if any from time to time

October 1, 2020: Telemedicine consultations will be covered under health insurance policies 

•Health policies covering consultations through physical visits will include consultations over telemedicine as well

October 15, 2020: The National Health Authority (NHA) issued invitation to conduct Proof of Concept (PoC) for ‘Telemedicine Building Block’ under "National Digital Health Mission”

Scope: 

•Meant for Registered Medical Practitioner (RMP) enrolled in the State Medical Register or the Indian Medical Register, RMP is a person enrolled and entitled to practice under the Indian Medical Council Act 1956.

•Covers norms and standards of the RMP to consult patients via telemedicine 

•Includes all channels of communication with the patient that leverage IT platforms, including voice, audio, text & digital data exchange

Exclusions: 

•Specifications for hardware or software, infrastructure building & maintenance

•Data management systems involved; standards and interoperability 

•Use of digital technology to conduct surgical or invasive procedures remotely 

•Research, evaluation and continuing education of health-care workers 

•Does not provide for consultations outside the jurisdiction of India 

The seven elements 

1.Context: Is telemedicine appropriate and sufficient in the given situation?

2.Identification of Dr and Patient: Consultation should not be anonymous

3.Mode of Communication: Video, audio or text

4.Consent: Implied (when patient initiates) or explicit (when initiated by health worker, Dr or a caregiver)

5.Type of Consultation: First consult or the follow-up consult

6.Patient Evaluation: Professional discretion to gather the type and extent of patient information required to be able to exercise proper clinical judgement

7.Patient Management: Provide health education as appropriate in the case; and/or provide counselling related to specific clinical condition; and/or prescribe medicines (specific restrictions apply as per guidelines)

‘Train to Practice Telemedicine’ Certificate Course

•Launched by Telemedicine Society of India on 4th April 2020 (within 10 days of release of Telemedicine Practice Guidelines)

•To train doctors on the basics of telemedicine practice as per the notified practice guidelines

•Eligibility: All doctors registered and practicing in India can to enrol for the online course

•Four modules of 20-30 minutes each, followed by Q & A. 

•Conducted on weekends (Saturdays and Sundays)

•Covers introduction to telemedicine, tele-triage, legal aspects of practice guidelines and setting up telemedicine practice (a DIY approach)

The Course Flow

     1. Registration
2. Pre-course quiz
3. The course
      a. Introduction to Telemedicine
      b. Introduction to Tele-triage
      c. Legal aspects of the Telemedicine Practice Guidelines
      d. Setting up your telemedicine practice - A DIY approach
4. Question and Answer Session
5. Post-course quiz
6. Certificate of completion of course.

•Course completion certificate: Provided for those who pass online assessment with a score of 80% or above

Alliance for Telemedicine Registry and Evaluation

•Lead by Digital Health India Association with partners - Consortium of Accredited Healthcare Organisations, College of Healthcare Information Management Executives (India), Healthcare Information and Management Systems Society and supported by National Resource Centre for EHR Standards.

•Survey targets four broad categories of telemedicine solutions

•Primary survey: Output is the registry of telemedicine solution providers 

•Evaluation: By panel of experts from participating associations and preparation of a curated list of providers meeting the requirements of healthcare providers and conformance with telemedicine practice guidelines

While there are lot more developments that have happened/happening in India on virtual care front this post is to highlight the relevance of regulations and their impact in the overall ecosystem that evolves over time. 
 

FAQs on Telemedicine Practice Guidelines_MoHFW_Gov of India_April 2020.pdf151.86 KB

Telemedicine Practice Guidelines_MoHFW_Gov of India_25 March 2020_0.pdf1.36 MB

Hi again, just responding somewhat late to Les's point on behaviour change of doctors towards using telehealth solutions. After consultation with our telemedicine partner Sehat Kahani, we can share the following challenges they faced during the implementation of the UNDP funded telehealth initiative in Pakistan and how Sehat Kahani has tried to respond to these challenges: 

• The mode of health care delivery has always been physical hence the first barrier was to convince the doctor that virtual consultation can be as effective for the patient as a physical consultation. The doctors often have issues navigating technology, become conscious of their appearance and are resistant to do detailed conversation to the patient as they are very used to skimming patients quickly as it is in physicals hospitals due long waiting lines.
  • How we mitigate this is by doing training with doctors on usage of the telemedicine platform, communication and soft skills, taking a detailed history and exercising increased empathy towards the patient. These are four training sessions done within a month of recruitment and are mandatory for all doctors to attend. 
• The doctors somehow fear that they would earn less in a telemedicine consultation than in a physical consultation or will not get as many patients coming to them as there in a physical consultation. 
  • How we mitigate this is creating a business model that gives them a 70% to 80% cut of the revenue earned from the consultation. We also make them understand that they are saving travel and time cost that they would in physical consultation. We also help them market themselves through digital marketing campaigns to increase patient flow. 
• Sometimes doctors consciously or unconsciously behave or address the patient casually on a telemedicine platform. This reflects in their clothing or place of consultation or noise management in the room they are practicing in. 
  • We have created a SOP for client management for the doctors that helps them communicate/display themselves in a professional manner for clothing to room setup to solitude within the room they are practicing in with no distractions. 
• Doctors often face internet disruptions as they may be based in diverse settings as they work from home rather than one physical setup. 
  • We provide internet connectivity packages to doctors along with random speed tests to make sure their internet coverage is smooth.

Greetings from Dominican Republic! 

Telemedicine for remote areas in the Dominican Republic

In the Dominican Republic, we are accelerating and pivoting a teleconsultation system with the Private Sector Unit and the Accelerator Lab.  In Previous years, some specialized centers consulted online., however, after the COVID 19 pandemic and the drastic physical distance measures, the eHealth has become most needed. Some doctors avoid getting infected by doing their own online consultations without having an official platform, system medical policy, and the security of the data shared by patients.

As a result of all the above, a team of innovators in conjunction with one of the most recognized universities in the country began to iterate and test an online hospital platform, where you could not only consult with a specialist to treat covid symptoms but to treat the psychological sequelae that the confinement was leaving in the people, this platform called eHospital has been scaling and implemented to rural environments, where people of limited resources, facing different geographical barriers can save costs and time and have quality health through monitoring and prevention of their comorbidities.

Also, at the country level, some digital gaps could be understood as one of the biggest barriers or detractors to be able to realize the efforts related to telemedicine. We are aware of the impossibilities for everyone to access existing platforms and understand them, both as a medical body and as patients. However, the UNDP in the Dominican Republic through the Digital X initiative has been selected to accompany and accelerate this telemedicine project called eHospital, this platform seeks to reduce the gaps and barriers that the population in rural areas faces, bringing medical specialists closer to patients.

The main feature of the platform it doesn’t enhance the digital gap for the users and the medical staffs by being installed in rural clinics, which are first-level care centers where patients from remote areas usually generate confidence with the central doctor, however, patients visit the center only to treat emergencies and seek medication, without being able to make use of it for it was conceived, monitoring and prevention of serious consequences to already known diseases; this is why the UNDP Dominican Republic seeks to pilot with this platform that can ensure health and prevention in remote areas saving costs and time to patients while reducing the digital divide.

Also, the platform will support the creation of a unique medical record of beneficiaries that is necessary at the country level, it will also allow us to have inputs and data to build public policies that support telemedicine, to know how the systems work in vulnerable areas.

You can read more about the launch here.

Ghana's digital health space is a very busy space right now with many entities aggressively implementing one digital health solution or the other. Telehealth with all it's potential, appears on surface, to be just one of the many digital health interventions, just like the others and as result faces many sustainability risks and even decline in uptake, as demonstrated by the existing implementations.

The Ghana Telemedicine Project funded by the Novartis foundation was scaled up with the establishment of teleconsultation centers (TCC) in six (6) regions in Ghana; and it clearly demonstrated, through an evaluation, the many benefits that are worthy scale up.

Years down the line, the story is evolving. Currently only the implementation in the national capital have seen substantial numbers in service uptake due to reconfiguration of the teleconsultation center to serve COVID-19 patients . All the other regions have decline in uptake; and even two of the regions have stopped operating their teleconsultation. Nevertheless because the current COVID-19 pandemic, a review of the model of telemedicine is being undertaken by the Ghana Health Service.

To curtail the challenges above, a different approach in concept design, borne out of the challenges experienced and lessons learnt from the six region scale up, have been adopted to refine the model of telemedicine to be implemented in the review and scale up of the Ghana Telemedicine project. The approaches include:

1. Integration at both the service level and the the technology level. Telehealth is not being redesigned as a standalone innovation, but rather a comprehensive technology platform that is focused to serve as the backbone for service delivery. This is informing our approach to the conceptualisation, design and branding.   Creating a home for telehealth in one of the key service delivery efforts, we believe, will enhance its sustainability rather when it run as a standalone. We want to see telehealth as a service delivery solution rather a technology solution.

2. Establishing key linkages with service delivery innovation and Primary Health Care initiatives that are aimed at addressing the many challenges that confront the Ghana Health Service. In this regard telehealth concept redesign and implementation planning is focusing at using telehealth as the technology backbone to support the implementation of the new Network of Practice initiative defined in Ghana's roadmap to Universal Health Coverage.  The Networks of Practice is an initiative to reorganise Primary Health Care service delivery around what is described as Model Health Centers to ensure there is the provision of quality to 24- hour clinical services at the sub-district (rural areas). The new telehealth implementation s includes 4 key components

   1. Provider to Provider Telehealth

   2. Provider to Client Telehealth

   3. Health System Strengthening  such referral management, coaching, supportive supervision, service reorganisation. etc etc

   4. eLearning and capacity building

Since 2018, Jan Vikas Samiti (JVS), Varanasi (India) is implementing Telerehabilitation project in the North India in collaboration with 19 partner organisations. Our focus area is physical rehabilitation and school readiness. Through this project, rehabilitation of children with disabilities managed by experts from remote location and CBR facilitators through technology for door-step delivery of services.

Using technology and digital penetration even in resource-poor settings, an integral platform of telerehabilitation is built using Mobile phone and Web portal. CBR facilitators are guided to conduct physical assessment and prepare a rehabilitation plan by qualified team operating from remote location. CBR facilitators even with basic knowledge can drive entire process using this platform. Direct transfer to pictures, videos, checklists and standardized tests conducted through application   helps developing a robust rehabilitation plan immediately.

Rehabilitation cost reduced by 50%; no wage loss and transportation cost for parents as no travel required; immediate services for children and on-job training  for CBR facilitators-entire process is optimised  for delivering efficient, cost-effective and quality services. At present 703 children with disabilities (mainly children with Cerebral Palsy) are getting benefits of the programme. Even during COVID crisis, parents and children were in direct contact with us.

There are many cases of telehealth projects. Possibly, not too many emerged from African grassroots and have been considered by Ministries of Health for national implementation. Here in Zimbabwe, triggered by the demand for access to health care during the COVID-19 pandemic, in the outlying province of Masvingo, the community built together with the Ministry of Health a telehealth solution: the Digital Information and Consultation Platform for COVID-19 information. Attached, a report describing the context, content and observations for your perusal. 

20210903, DICP Zimbabwe, report to UNDP on Country Experience in Implementing Telehealth Services.pdf563.65 KB

Hi all,

This is a great discussion. We have been working with VillageReach in creating a toolkit for governments and service providers to create national-scale telemedicine and health hotline systems. VillageReach has experience in several countries implementing these systems. We are finishing these two reports and hope to have them available in the next 2-3 months. If anyone is interested in receiving one, they can email me at jblaya@worldbank.org.

SUMMARY OF WEEK 2

Thank you to all your insightful discussion last week! We heard about the interesting and innovative work that is going on in the Dominican Republic, Ghana, India, Indonesia, Pakistan and Zimbabwe. Here are some highlights for me:

Introducing policies, regulations and processes

Several countries are in the process of developing or implementing national guidelines, policies and regulations to create an enabling framework for effective and sustainable telehealth sector. India recently launched its “Telemedicine Practice Guidelines” to help facilitate the mainstreaming of telemedicine into national clinical standards and protocols, and to provide the framework for quality and ethical telemedicine practice. This has led to the introduction of a raft of new regulations, policies and processes that aim to improve ethical and professional conduct, clinical practice and standardization of the telehealth sector.

Indonesia is also currently in the process of developing ethical standards, emergency decrees, and code of conduct for telemedicine services. While Ghana is re-conceptualizing its overall approach to telehealth - they realise that an effective, sustainable telehealth service needs to be fully integrated into the entire system for health service delivery.

It would be important to understand the successes (and failures) when formalizing and enforcing these policies, regulations and processes, particularly in a sector (health) that is already heavily regulated, and the need for buy-in from professional bodies and patient/consumer groups. Joaquin Blaya Wisdom Atiwoto Jenniffer Taveras Laura Sheridan Jai Ganesh Udayasankaran Nora Nindi Arista  what are your reflections on the development and implementation of these guidelines / policies / strategies? A toolkit created by the World Bank and VillageReach provides governments and service providers with guidance on establishing national-scale telemedicine and health hotline systems, may also be a useful resource to help navigate this process.

Importance of fostering partnerships

It is evident that public-private partnerships are critical in facilitating the introduction and scale up of telehealth services. In India and Indonesia, peak public bodies are working closely with industry groups on creating the policy, regulatory and capacity strengthening frameworks; while in the Dominica Republic, UNDP is facilitating the collaboration between technology innovators and academia to develop and scale an online hospital platform. We need to learn more about how these partnerships can be fostered, and what role should development partners, such as UNDP, be playing.

Promoting sustainability

In many of our countries, the telehealth landscape is typically crowded and fragmented, and pose a significant challenge to quality and sustainability for many of these solutions. Some lessons learned in overcoming these challenges include:

• improving the broad acceptance among health professionals by providing guidance on how to engage with patients virtually and building their capacity in using the technology;
• introduce regulations that ensure adequate health insurance coverage of telehealth services and minimization of out-of-pocket payments for patients;
• Implement a business model that can sustainably incentivize health professionals - through revenue-sharing arrangements, making it easier to engage with patients and expanding service reach, or other approaches. We need to learn from successful telehealth models that are financially self-sustaining, that can ensure retention and motivation of health providers, and which also take into consideration issues of affordability and satisfaction of clients and patients. Ranjeet Jenniffer Taveras Joaquin Blaya do you have any lessons to share?

Finally, with a multitude of telehealth services springing up during COVID-19, an interesting question that was raised by Clara Aranda is the sustainability of these services ‘post-pandemic’ (if that time ever arrives!). Will the momentum of rapid telehealth adoption continue post-pandemic? Is the proven value-proposition of telehealth enough to continue its expansion among a broader group of health professionals / clients, but also across other areas of the health system?

Thanking you all for making this discussion a pleasure to moderate! Please feel free to offer your own summary of the discussion so far. I Iook forward to another week of conversation. Over to you, Nithima Ducrocq 

Hi,

We are a digital health and electronic medical platform that is currently most active across Africa and Asia. We have had quite a few experiences trying to integrate and work with telehealth. One of the big problems we have encountered is lack of interoperability, and lack of secure patient management systems that can be accessible for more stakeholders. Most of the work is on paper, patients don't have their medical history or doctors aren't able to pass on pertinent information to other health practitioners as patients move through the health systems. The lack of information and follow-up leads to significant waste, increased cost and decreased quality of care, and often worse compliance. Being able to ensure that patients records and telemedical visits transfer over to in-person points of care is extremely important and also improves resiliency of health systems.

This is a problem we are actively overcoming with our platform.

Best,

Mark

@LesOng - re the sustainability model, Sehat Kahani is currently managing the business model of the Tele- ICU model in private hospitals is based on annual subscription or retainer by the hospital. This retainer will cover management cost, tech cost, support cost and doctors cost based on an assumption as to how many consultations will be done per month per ICU. These assumptions are build on market research and existing patient flow in the ICU. The doctors providing services via the teleICU platform are paid on a revenue share basis of total consultations that they have done on a monthly basis. The net profit margin is 30 % which is invested further in business expansion and cross subsidising services in low income hospitals. As for government hospitals, Sehat Kahani is currently applying to government procurement tenders that can help provide services in public (and under-resourced private) teleICUs.  

At present, JVS Telerehabilitation  " Sambhav" is providing guidance for the physical rehabilitation service to selected 19 Partner Organisations (POs) in Uttar Pradesh, Bihar, Uttarakhand, Jharkhand, Madhya Pradesh, Odisha, Chhattisgarh, Rajasthan, Manipur and Meghalaya under this project.

JVS Tele Rehab.pdf3.13 MB

Hello everyone, I'm Dr. Nguyen Thanh Ha from UNDP Viet Nam. On behalf of the team, I would like to share experience and post the responses for question 1, 4 and 5 as below:

1. Describe the telehealth solutions that have been introduced in your country/region. If available, please share a link to relevant literature.

In the context of the COVID-19 pandemic and the Industrial Revolution 4.0, UNDP Viet Nam CO places strong importance on supporting ’s national digital transformation roadmap to 2025 and vision to 2030, including digital transformation of health. Also, in many areas of Viet Nam, people have been facing geographical, physical, cultural, and climate change related barriers (droughts, floods, storms, landslides, etc.). It is even more severe in the context of social distancing and/or lock down due to COVID-19 pandemic. Given that situation, UNDP is closely cooperating with the Electronic Health Administration/ Ministry of Health (EHA/MoH) to develop the Bác Sĩ Xã (“Commune Doctor”) – a web-based digital platform and smartphone application for connecting health staff at commune health stations with local people to provide health information and remote consultation services in mountainous and remote areas, including ethnic minorities and people with disabilities, with a focus on leaving no-one behind. This digital solution includes a secure video conferencing platform enabling commune health staff to seek consultation from medical staff at district hospitals/health centres and higher levels of the healthcare system.

The technology platform

The grassroots digital health platform utilizes a fully open-source software stack with underlying technologies such as the Database Management System (PostgreSQL), Server Operating System (Linux CentOS) and programming language of web application as recommended by the Ministry of Information and Communications (MIC) for purchase and use by government authorities according to Circular No. 20/2014/TT-BTTTT dated December 5, 2014. This helps to optimize long-term investment and operating costs (without additional costs for platform software licenses). The video conference uses the open-source Jitsi Meet platform which is also recommended by MIC for wide application as an alternative to online platforms like Zoom due to its commitment to security and information safety. This platform has also been used by MIC for online video conferencing during the COVID-19 pandemic.

4. What were the biggest wins and the biggest challenges in implementing the telehealth solution?

The biggest wins in implementing the telehealth solution:

UNDP and EHA/MoH supported Provincial Departments of Health Services in Ha Giang, Bac Kan and Lang Son provinces from December 2020 to March 2021 to pilot the grassroots digital solution (Commune Doctor) including installation, training of district and commune personnel and field testing of the system in three remote and mountainous districts. Training was provided for IT staff of the Provincial Departments of Health and district hospitals and health centers to support and operate the system. A total of 153 health workers including 38 from district health facilities, 105 from commune health stations and 10 village health workers from three provinces were trained on using the web-based software and the smart phone application. Training materials and user manuals were compiled and provided to each training participant. The working team also directly went to commune health stations to guide the installation, check the connection and set up a direct call to the higher-level hospital/health centers in three communes (one per pilot district).

The results of this initial pilot show that the system has very good potential for contributing to the national programme for digital transformation of health in the context of the COVID-19 pandemic and the Industrial Revolution 4.0 by improving people’s access to high quality health information, diagnosis and treatment in remote areas while saving time and costs for travel, supporting social distancing during the COVID-19 pandemic, and reducing overcrowding of higher-level facilities. This could be an additional option for the commune health station to rapidly expanding scope of the Tele-health project hosted by Ministry of Health (the Telehealth – 1,000-point connection), as Viet Nam has more than 11,000 commune health stations and very few of them have been equipped with this telehealth set.

The biggest challenges in implementing the telehealth solution:

Given the information technology (IT) infrastructure including both IT devices and internet signal is quite poor in the remote and mountainous provinces, more investment to set up the grassroots telehealth functioning rooms at commune health stations to make the program be implemented.

The IT capacities of health staff at the grassroots health facilities are also low. Training and continuous technical assistance need to be provided.

5. How has UNDP supported the introduction and scale up of telehealth services?

UNDP and EHA/MoH supported Provincial Departments of Health Services in Ha Giang, Bac Kan and Lang Son provinces from December 2020 to March 2021 to pilot the grassroots digital solution (Commune Doctor) including installation, training of district and commune personnel and field testing of the system in three remote and mountainous districts including Hoang Su Phi district of Ha Giang, Ba Be district of Bac Kan and Cao Loc district of Lang Son.

Building on the initial success of the pilot period, UNDP continues cooperating with EHA/MoH to implement the scaling-up phase from April 2021 to June 2022. The grassroots telehealth software will be upgraded to meet the requirement of program expansion to full three provinces (Ha Giang, Bac Kan and Lang Son). The launching conference and Training of Trainers (ToT) for health representatives of all 63 provinces will be organized by UNDP and EHA/MoH as a preparation step for nationwide expansion.

Hi everyone,

My name is Nithima and I'll be your moderator for this week. I've been following the discussion in both rooms, and I'm excited to keep hearing more about your experiences and engagement with such an important topic.

I'm currently working with the Chief Digital Office at UNDP, focusing on the CDO Country offices support . Prior to joining UNDP, I've worked as an innovation and digital consultant IOM and WFP, working on various project from nutrition educational app in schools to using AI for disaster response.

I was also the founder of a mobile health company for Thai women focusing on sexual and reproductive health. I've been passionate about e-health and its potential to provide healthcare and information directly to the patient. The topic became even more relevant since the start of the pandemic.

As a reminder, here are the questions that we are trying to address in this room:

1. Describe the telehealth solutions that have been introduced in your country/region. If available, please share a link to relevant literature.

2. What health system challenges/priorities do these telehealth services aim to address? What health outcomes have been achieved?

3. Describe the technical support that was needed for expanding the coverage and quality of telehealth services.

4. What were the biggest wins and the biggest challenges in implementing the telehealth solution?

5. How has UNDP supported the introduction and scale up of telehealth services?

6. Are there opportunities to expand the use of telehealth in your country? If so, which telehealth solutions and/or health challenges should be prioritized?

I'm looking forward to hearing (and learning!) from your experiences. Feel free to message me on here if you have any questions about the consultation.

On behalf of UNDP Somalia:

As part of a joint program on youth led by UNFPA, five youth centres will be established across Somalia with a view to expanding access to decent jobs, supporting youth civic and political engagement and the YPS agenda, as well as increasing use of youth-friendly health services. In partnership with a local telehealth startup, Ogow Health, UNDP Somalia will be unrolling a telemedicine pilot across the youth centres, focused on sexual and reproductive health services. Clinics within the youth centres, serviced by nurses, will be connected through telemedicine equipment to volunteer medical students and doctors in the diaspora, with the aim of enhancing the clinics’ diagnostic capacities. Nurses will be trained to refer suitable cases for telemedicine consultations. The model is informed by work previously conducted by UNDP Egypt. To the extent possible, design thinking and behavioural science principles are being drawn on to anticipate possible behavioural barriers to the solution's adoption.

With the rapid evolution of digital technology seen as an opportunity to improve rehabilitation services in remote parts of the country, Jan Vikas Samiti has introduced the telerehabilitation project “Sambhav” with a motto reaching the unreached using the web portal and the mobile app for a better individual rehabilitation plan and service delivery. The project “Sambhav” aims to capacitate CBR facilitators on rehabilitation diagnosis, making custom made treatment/rehabilitation plans and providing appropriate therapies to the children and youth with disabilities who are most in need in the rural parts of India using recent technology. The main purpose and focus of the project Sambhav is the application of the web portal and mobile app for purpose of assessment and rehabilitation plan, progress and outcomes.  Currently JVS Telerehabilitation unit is providing guidance for the physical rehabilitation service to selected 19 Partner Organisations (POs) in Uttar Pradesh, Bihar, Uttarakhand, Jharkhand, Madhya Pradesh, Odisha, Chhattisgarh, Rajasthan, Manipur and Meghalaya under this project.

https://janvikassamiti.org/tele-rehabilitation-2/#1627462648229-e71defc7-1ac2

What health system challenges/priorities do these telehealth services aim to address? What health outcomes have been achieved?

Our Priorities:

On the role of telemedicine in health care service delivery, a patient survey predicts that 75% of all patients expect to use digital services in future. 75% of the country’s healthcare infrastructure is concentrated in urban areas while more than 75% of the population lives in rural areas. The majority (69%) of persons with disabilities reside in rural areas. 71 % of children with disabilities live in rural India and facing a range of barriers. E- Rehabilitation technology will thus provide an opportunity to serve the poorer and marginalized sections of the community.

Outcomes:

• Reached to 714– Children with Disabilities
• For physical rehabilitation services 75% - Parent Satisfaction Rate Parents reported a high level of satisfaction with the telerehabilitation service due to saving time and money.
• 46% Children achieved mobility Progress reports shows at nearly half the children with disabilities achieved mobility.
• 30 Staff Trained Staff trained and gained confidence to able to render quality services in the community

Describe the technical support that was needed for expanding the coverage and quality of telehealth services.

A protocol for the physical rehabilitation diagnosis/planning of children with developmental disabilities is made at JVS to help the selected partner organizations to develop their capacities in terms of providing quality physical rehabilitation service.

To provide better Telerehabilitation service delivery, regular training programs are conducted for selected CBR workers from the Partner Organisations (POs) on video filming and the use of rehabilitation protocol. Web portal and Mobile app on Telerehabilitation is developed by JVS and the same is shared with the selected CBR workers. Store and Forward (in which after video shooting, it can be stored and at the time of need can be forwarded to the JVS headquarter for intervention planning) method of technology which is quite practical and suites well to the concept of telerehabilitation and as per need real-time interaction and guidance have been provided to the parents/caregivers and field staffs as well. Rehabilitation professional/expert at JVS Telerehabilitation unit regularly receives videos of children with disabilities and assesses the case and provides treatment protocol/rehabilitation plan to the POs and periodically monitors the progress of cases.

What were the biggest wins and the biggest challenges in implementing the telehealth solution?

Wins:

Telerehabilitation service delivery will give the best benefit to the end-user (i.e., an individual with a disability) within their environment. It optimizes the timing, intensity and duration of therapy that is often not possible within the constraints of face-to-face treatment protocols in current health systems. From the inception of the program in mid-2018 to till date more than 700 children with disabilities are assessed and their rehabilitation plan has been made in the pilot phase. Partner Organisations heads and field staff have shared that they are now able to provide quality intervention in remote areas as per the physical rehabilitation protocol through tele-rehabilitation.

Challenges:

The challenges in this project are very minimal but some risk factors are observed during the project implementation as mentioned below-

• Retention and attrition of the CBR staff.
• Poor technological skills among CBR staff.
• The vast project area is covered by less human resources in the field.
• CBR staff are engaged in almost every activity of the organisations.
• Poor understanding and lack of interest in the project at the higher level of some organisations.

Hi everyone! My name is Clara Aranda and I only joined the discussions late last week, but I have read some contributions to the conversations and they have been so interesting and insightful. I was wondering if someone has experience with (successful) funding and financing mechanisms for telehealth. There are two areas that I think might be interesting to discuss (but please, do share other thoughts).

• Startups or individual organisations are developing many telehealth solutions, and these are then piloted in one or several healthcare facilities. In these cases, it seems like there is often an external organisation (international aid/development organisation or private sector) supporting the initial pilot and development of the solution. It seems that after this stage, there are many challenges experienced scaling up and ensuring the sustainability of the solution. Could someone share your experiences on this?
• Secondly, a smaller number of solutions have been government-funded. Some of these are part of research institutions or funding provided to research-level solutions to evaluate a solution or prove a concept. In these cases, if the government adopts the solution, the institutionalisation of the solution seems to provide a mechanism for long-term funding. In HICs, an example of this would be the NHS apps. Does anyone have experiences to share around government-led/funded telehealth solutions in LMICs?

Good morning, afternoon or evening everyone,

My name is Claudia, and I am honored to act as your moderator for this 4th and last week of the e-consultation Scaling Up Telehealth to Promote Equitable Access to Essential Health Services. In Room 1, we´ve been learning about country experiences in implementing telehealth services, in an effort to understand its benefits in expanding health access but also its particular challenges regarding financing, articulation, quality, connectivity and uptake. 

As COVID-19 spread, telehealth relevance surged as a solution to protect both patients and staff. Virtual healthcare did not only made possible remote COVID-19 screening and monitoring, but also, it has facilitated access to other medical services in contexts that are deemed too risky for patients with pre-existing conditions, or complicated due to lockdowns or limited transportation. Telehealth holds the potential to forever change how health practitioners work, many of whom are now using digital tools to work remotely, but also to increase health access to vulnerable communities such as senior citizens and those living with disabilities; telehealth can also help institutions manage resources and space more efficiently by keeping low-risk patients at home, preventing medical systems saturation and an overwhelmed staff. Still, discussing and evaluating its potential limitations due to regulatory issues, cultural barriers and access to technological devices, to name a few, its essential to harness its true telehealth true potential.

This discussion room constitutes a space to share experiences and reflect on past learnings in the implementation of telehealth solutions. It will be inspiring to read your ideas and insights  during this wrap-up week. You can share your thoughts in English, however, the platform can translate the text on pages into over 100 languages (use the “Select your Language” option at the top right of SparkBlue). Use this feature to translate comments into your preferred language, as well as to translate the comments of others. Also, feel free to comment in the language you´re most comfortable with.

A kind reminder to answer one or more of the following questions, and indicate which question you are responding to in your post:

1. Describe the telehealth solutions that have been introduced in your country/region. If available, please share a link to relevant literature.

2. What health system challenges/priorities do these telehealth services aim to address? What health outcomes have been achieved?

3. Describe the technical support that was needed for expanding the coverage and quality of telehealth services.

4. What were the biggest wins and the biggest challenges in implementing the telehealth solution?

5. How has UNDP supported the introduction and scale up of telehealth services?

6. Are there opportunities to expand the use of telehealth in your country? If so, which telehealth solutions and/or health challenges should be prioritized?

At the end of this week´s consultation we will pin a summary to the top of the page. Take some time to read and contribute with your insights, ideas and learnings, engage with other commenters and do reach out if you encounter any issues posting. Looking forward to share this space with you!

Hello everyone, I am Hira Nand from India working as a project officer for the telerehabilitation project Sambhav (possible). The project is being implemented in the 10 states in India by the 19 collaborating organisations.  The project Sambhav with its motto ‘the reaching the unreached' has been started in 2018. From its inception, more than 700 children with disabilities are getting benefits of physical rehabilitation in their environment.

Please find the our response on above questions-

1. Describe the telehealth solutions that have been introduced in your country/region. If available, please share a link to relevant literature.

With the rapid evolution of digital technology seen as an opportunity to improve rehabilitation services in remote parts of the country, Jan Vikas Samiti has introduced the telerehabilitation project “Sambhav” with a motto reaching the unreached using the web portal and the mobile app for a better individual rehabilitation plan and service delivery. The project “Sambhav” aims to capacitate CBR facilitators on rehabilitation diagnosis, making custom made treatment/rehabilitation plans and providing appropriate therapies to the children and youth with disabilities who are most in need in the rural parts of India using recent technology. The main purpose and focus of the project Sambhav is the application of the web portal and mobile app for purpose of assessment and rehabilitation plan, progress and outcomes.  Currently JVS Telerehabilitation unit is providing guidance for the physical rehabilitation service to selected 19 Partner Organisations (POs) in Uttar Pradesh, Bihar, Uttarakhand, Jharkhand, Madhya Pradesh, Odisha, Chhattisgarh, Rajasthan, Manipur and Meghalaya under this project.

https://janvikassamiti.org/tele-rehabilitation-2/#1627462648229-e71defc7-1ac2

2. What health system challenges/priorities do these telehealth services aim to address? What health outcomes have been achieved?

Priorities:

On the role of telemedicine in health care service delivery, a patient survey predicts that 75% of all patients expect to use digital services in future. 75% of the country’s healthcare infrastructure is concentrated in urban areas while more than 75% of the population lives in rural areas. The majority (69%) of persons with disabilities reside in rural areas. 71 % of children with disabilities live in rural India and facing a range of barriers. E- Rehabilitation technology will thus provide an opportunity to serve the poorer and marginalized sections of the community.

Outcomes:

• Reached to 714– Children with Disabilities
• For physical rehabilitation services, 75% - Parent Satisfaction Rate Parents reported a high level of satisfaction with the telerehabilitation service due to saving time and money.
• 46% of Children achieved mobility Progress reports shows at nearly half the children with disabilities achieved mobility.
• 30 Staff Trained and gained the confidence to able to render quality services in the community

3. Describe the technical support that was needed for expanding the coverage and quality of telehealth services.

A protocol for the physical rehabilitation diagnosis/planning of children with developmental disabilities is made at JVS to help the selected partner organizations to develop their capacities in terms of providing quality physical rehabilitation service.

To provide better Telerehabilitation service delivery, regular training programs are conducted for selected CBR workers from the Partner Organisations (POs) on video filming and the use of rehabilitation protocol. Web portal and Mobile app on Telerehabilitation is developed by JVS and the same is shared with the selected CBR workers. Store and Forward (in which after video shooting, it can be stored and at the time of need can be forwarded to the JVS headquarter for intervention planning) method of technology which is quite practical and suites well to the concept of telerehabilitation and as per need real-time interaction and guidance have been provided to the parents/caregivers and field staffs as well. Rehabilitation professional/expert at JVS Telerehabilitation unit regularly receives videos of children with disabilities and assesses the case and provides treatment protocol/rehabilitation plan to the POs and periodically monitors the progress of cases.

4. What were the biggest wins and the biggest challenges in implementing the telehealth solution?

Wins:

Telerehabilitation service delivery will give the best benefit to the end-user (i.e., an individual with a disability) within their environment. It optimizes the timing, intensity and duration of therapy that is often not possible within the constraints of face-to-face treatment protocols in current health systems. From the inception of the program in mid-2018 to till now more than 700 children with disabilities are assessed and their rehabilitation plan has been made in the pilot phase. Partner Organisations heads and field staff have shared that they are now able to provide quality intervention in remote areas as per the physical rehabilitation protocol through tele-rehabilitation.

Challenges:

The challenges in this project are very minimal but some risk factors are observed during the project implementation as mentioned below-

• Retention and attrition of the CBR staff.
• Poor technological skills among CBR staff.
• The vast project area is covered by less human resources in the field.
• CBR staff are engaged in almost every activity of the organisations.
• Poor understanding and lack of interest in the project at the higher level of some organisations.

5. How has UNDP supported the introduction and scale-up of telehealth services?

                       There is no support for this project from UNDP

6. Are there opportunities to expand the use of telehealth in your country? If so, which telehealth solutions and/or health challenges should be prioritized?

This innovative initiative is easy to access and quite practical to service users.  There is a huge scope for replication in the country. Here it is important to mention that the JVS telerehabilitation project “Sambhav” has won the best rural health initiative award and is shortlisted for Zero Project Award 21-22. Moreover, this project is selected for Zero Project Impact Transfer Program as the most impactful and replicable initiative. Of course, the COVID -19 pandemic situations put telehealth in the frontline service delivery system. It is high time to prioritize the telehealth solution to every health care delivery system from top to bottom whenever and wherever possible.

JVS Tele Rehab_0.pdf3.13 MB

UNDP Philippines - Tele-psychotherapy

Hi everyone! My name is Cecil Behino from UNDP Philippines and we would like to share with you our free tele-psychotherapy project in 2020 aimed to support the psychosocial needs of PLHIV and Key Populations during the lockdown periods due to the pandemic. 

1. Describe the telehealth solutions that have been introduced in your country/region. If available, please share a link to relevant literature. 

UNDP Philippines provided free online psychosocial support services to people living with HIV (PLHIV) and key populations (KP) in 2020 during the height of lockdowns in the Philippines due to the COVID-19 pandemic.  

2. What health system challenges/priorities do these telehealth services aim to address? What health outcomes have been achieved? 

In 2020, UNDP Philippines and UNAIDS conducted a survey on the treatment and care concerns of PLHIV, and the result showed that 20% of the participants said that they need psychosocial support as some of them experienced anxiety and depression (UNDP, 2020). A total of sixty (60) clients were catered from May-December 2020. 68% or 41 clients are still active or are continuing their free telepsychotherapy sessions with their assigned psychosocial support specialist (PSS), two have been discharged, while 17 have terminated their sessions to discontinue receiving the offered services. 

3. Describe the technical support that was needed for expanding the coverage and quality of telehealth services. 

Technical expertise in clinical psychology and support from the local government units, academic institutions, and community-based organizations were needed to implement this program. The collaboration and close working relationship among these organizations contributed to the success of the program.  

4. What were the biggest wins and the biggest challenges in implementing the telehealth solution? 

Biggest wins: The psychosocial needs of some of the PLHIV and KP were addressed, and this raised awareness of the need for psychosocial support, especially during lockdowns and uncertainties 

Biggest challenges: Few people signed up for the first few months of running the project, even with the help of the referral system. In addition, there were instances of no-shows or no-response from the clients. Lastly, some clients expressed the need to back out of the telepsychotherapy programs for reasons related to changes in their schedule with work or school as they adapted to a new normal and offices started opening.  

5. How has UNDP supported the introduction and scale-up of telehealth services? 

Under the UBRAF project, UNDP and local government units and academic institutions initiated the project and contracted the technical expert on Clinical Psychology. 

6. Are there opportunities to expand the use of telehealth in your country? If so, which telehealth solutions and/or health challenges should be prioritized? 

Yes. However, funding is needed to contract clinical psychotherapists and a good telemarketing solution to spread the news of free telepsychotherapy, especially those in rural areas.  

Greeting, everyone.

My first experience with telemedicine was in 2019 during the COVID-19 pandemic, when I was on a detail assignment in Kazakhstan. I developed an eye infection and could not visit an ophthalmologist due to the lockdown. My U.S. eye doctor examined me through Google meet and prescribed medicine that I was able to buy from a pharmacy. Ever since I have been following different projects related to telemedicine and would like to share some interesting recent innovations. My apologies if these come across as too technical, or focused on "gadgets" - but geographical distances, lack of equipment and emergency situations show how important these technical solutions can be.

https://echonous.com/en_us/  -   The first AI-assisted handheld ultrasound tool to increase diagnostic confidence at the bedside. A clinician can perform heart, lung and abdominal assessments in minutes.

https://www.patchai.io/ - A cognitive platform focusing on patient engagement. The platform is embedding an intelligent virtual assistant with conversational frameworks for patient engagement and real-time data collection. It bridges patients and doctors during clinical trials. Obviously, there are some privacy concerns and some ethical data use questions that have to be addressed.

https://www.smarttab.co/ - a personalized wireless medicines delivery platform comprised of an ingestible capsule with a microprocessor, proprietary smart polymer actuator, and active ingredients.

https://vocalishealth.com/ - using voice as a biomarker to check health status. Developed because of the COVID-19 pandemic and obviously associated with some concerns about privacy and accuracy. Technology is experimental and not yet approved for use.

Dear colleagues,

Thank you for this thoughtful discussion on telehealth.

We are responding to Question 1) Describe the telehealth solutions that have been introduced in your country/region. If available, please share a link to relevant literature.

From the perspective of the HIV and Health Team at HQ, we wanted to share some country examples from the Japanese Supplementary Budget (JSB). In May 2020, the Japanese government announced its supplementary budget for COVID-19 emergency response and prevention, which includes $63,635,654 for 29 countries of priority for UNDP and Japan (Bangladesh, Bhutan, Burkina Faso, Egypt, Ethiopia, Fiji, India, Indonesia, Iran, Iraq, Kenya, Kyrgyzstan, Libya, Maldives, Mali, Mauritius, Mongolia, Myanmar, Nigeria, Palestine, Philippines, Rwanda, Somalia, South Africa, Sudan, Thailand, Turkey, Uzbekistan, Vietnam). Implementation of this programme started in June 2020 and will continue through December 2021. It highlights Japan’s interest to help realize human security and focuses on three areas:  1) Health Systems Support; 2) Inclusive and Integrated Crisis Management and Response; and 3) Social and Economic Impact Needs Assessment and Response. Telehealth, or digital solutions that enhance or enable self-management of healthcare, facilitate remote support from healthcare providers, and support any components and activities in the health system in the provision of care – are a crucial component of a digital approach. With funding from the JSB, countries are implementing digital approaches that enable health systems strengthening, disease monitoring, and preventive and diagnostic efforts.

This e-discussion has already highlighted select examples from JSB countries such as Bhutan, Indonesia, India and Vietnam. Other select examples are below.

In Mauritius, UNDP is digitizing the COVID-19 response. Similar to the cloud-based digital systems introduced in India (Electronic Vaccine Intelligence Network; eVIN) and Indonesia (Sistem Monitoring Imunisasi Dan Logistik Secara Elektronik; SMILE), UNDP Mauritius has partnered with the Central Health Laboratory to adopt an Electronic Laboratory Information Management System (OpenELIS Global). ​Following a successful rollout, the government partnered with UNDP to further scale-up the system at the airport.

In Burkina Faso, digitalization has been instrumental in addressing the need for official/verified, reliable and accessible information. In partnership with the Ministry for the Digital Economy, the Ministry of Health and the Ministry of Science and Research, UNDP developed a unified COVID-19 web platform, which includes public health information, health records as well as a COVID-19 database.

http://surveillance-sante.bf/.

In Libya, UNDP, in partnership with the Ministry of Health, the Government of Japan and a private sector start-up company, Speetar, launched the country’s first telemedicine initiative. The app connects Libyans with physicians in diaspora communities who speak their language and understand the local context. It also reduces the burden of travel and mobility for people suffering from chronic diseases who require constant monitoring. This Telemedicine Initiative engages around 6,000 patients and 1,000 specialists and will process 10,000 virtual consultations and e-prescriptions. The Libyan National Centre for Diseases Control used the app to provide information and consultations during the COVID-19 pandemic.

In Vietnam, Rwanda and Kenya, UNDP has procured smart anti-epidemic robotic solutions to aid the health response and management of the COVID-19 pandemic. Compelling evidence has shown that the use of technology can accelerate the development of COVID-19 diagnostics, therapeutics and vaccines, including through the use of robots, which minimizes transmission of a highly infectious disease.

For more info:

Kenya: https://www.ke.undp.org/content/kenya/en/home/presscenter/pressreleases/2021/undp-in-collaboration-with-the-ministry-of-health-to-pilot-smart.html

Rwanda: https://www.rw.undp.org/content/rwanda/en/home/presscenter/articles/2021/News0/News.html  

Vietnam: https://www.vn.undp.org/content/vietnam/en/home/presscenter/pressreleases/15Robot.html

(More information can be provided by Doug Webb, Deena Patel, Simisosenkosi Mloyi)

Dear Colleagues, very delighted to come across this rich discussion (and sorry for being (very) late to the party). Thanks to Nithima Ducrocq, Les Ong, Belynda Amankwa for the incredibly helpful summaries!

I will briefly share our overall experience in Libya and then specifically focus on Nithima's question: Are there opportunities to expand the use of telehealth in your country? If so, which telehealth solutions and/or health challenges should be prioritized?

Our social enterprise, Speetar, has partnered closely with UNDP Libya (incl. UNDP Digital X and extending to stakeholder support with the MoH and wider comms support) to provide telehealth services in Libya and, through partnerships, in the wider MENA region. Speetar’s platform integrates a patient mobile app, doctor web-based app, and an on-ground patient site, offering a wide range of telehealth services and access to GPs/specialist doctors/psychosocial support to the organization’s constituents - none of which are otherwise accessible to them in Libya’s current healthcare crisis. Next to general health services, we partnered with UNDP, MoH, and CDC, to integrate a national COVID19 triage, testing, tracing (and are pursuing to launch a vaccination platform) (https://www.forbes.com/sites/andrewwight/2020/04/02/how-did-a-libyan-doctor-give-back-a-covid-19-fighting-app).

While the benefits of telemedicine in Libya are very straightforward (healthcare infrastructure was consistently and systemically targeted during the civil war, affordability and geographic distances/insecurity prevent equitable access), adoption of digital health solutions by care providers and receivers remains a key challenge. Speetar has made progress in this area through strategies, similar to those mentioned by laurasheridan. Furthermore, we have identified a narrowed focus on particular patient populations (ie diabetic, elderly homes, mental health) and corresponding corporations with key stakeholders as a successful entry point. Despite the adoption challenges, one clear win has been the consistently enthusiastic feedback we receive from users. 

Next to this, our priority remains to reach remote, rural, and other ethnically marginalised populations in the south of Libya (key challenge: last-mile outreach; internet access; exploring to expand telehealth service points and partnerships with network companies) and to serve the many displaced communities in Libya. We work closely with local youth, women’s rights and migrant organizations to reach young women, IDPs/refugees/migrants and we are exploring how Speetar could also provide employment opportunities for health care providers from displaced communities. A key blocker for this remains the vetting of doctors' qualifications and associated liability issues (something that, in general, we now made progress through supporting the Libyan government in the adoption of medical liability insurance policy for telemedicine providers). Together with other UNDP country offices and the RSC, it would be interesting to explore how cross-border cooperation could provide better health support to mobile populations entering Libya from Sudan/Chad/Niger/Algeria, for whom we really see a unique benefit that telemedicine and central patient registries could provide.

Outside of Libya, we partnered with Egyptian company Smart Doc to launch “Yashfi” telehealth platform, which was recognized as one of the top 3 companies at the Egypt TechHack. Yashii is currently scaling to combat COVID in Egypt.  In Syria, we initiated a COVID19 related project in partnership with the Syrian Expatriate Medical Association to create a basic tool designed to function in low-connectivity areas (offline-first capabilities allowing workers to screen their patients at the point of care, and securely share the data with organizers of the local response).