Telemedicine reaching rural Kenya but barriers abound

At the Suba Sub-County Hospital, patients of disparate health conditions line up at corresponding treatment sections. However, parents whose children are ailing are seated inside a newly refurbished segment of the hospital, where telemedicine services are being delivered.

In a separate room in this section, doctors and clinicians are busy diagnosing a student in live consultation with a specialist at Gertrude’s Children’s Hospital in Nairobi through video conferencing.

Jared Ogutu’s daughter, Akinyi, has been experiencing persistent pain in her abdomen in the last 15 years, and today she is being examined by doctors at the telemedicine centre. In a virtual session, she is asked to open her mouth and stick out her tongue to check for oral thrush by Dr Eman Kamal, a specialist at Gertrude’s, Nairobi who is constantly speaking to Mark Muchache, the clinical officer in charge of the hospital and Maurice Ogalo, the clinician in charge of telemedicine, some 400 kilometres away.

The whole service is running on a web-based software called Agnes Interactive that connects the clinicians at the Suba hospital to the medical specialists in Muthaiga, while medical devices such as a camera, an electrocardiograph, a cardiogram, an ophthalmoscope, a stethoscope, an ultrasound machine, a thermometer and an otoscope ensure real-time transmission of patient data for fast and seamless decisions on diagnosis and prescription.

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Electrocardiographs measure the electrical activity of the heart, cardiograms record muscle activity within the heart while ophthalmoscopes allow a physician to see into the fundus — the part of the eyeball opposite the pupil — of a patient’s eye.

Stethoscopes are used to listen to heart sounds, the lungs and even blood flow in the arteries and veins while sphygmomanometers are used to diagnose diabetes, high and low blood pressure, artery plaque and hypotension.

After clinical assessment, Jared is given a printed paper containing all diagnosis and prescription information for his daughter.

“I have been trying herbal medicine to cure her because hospital expenses are too high for me,” 46-year-old Jared tells Healthy Nation. But since the launch of the Daktari Smart initiative by the M-Pesa Foundation and Gertrude’s Children’s Hospital, he has not paid a cent.

It is the same case for Martin Ojuondo* who has brought his five-year-old son for a specialised diagnosis at the same hospital. “Without this service, I would have struggled to raise money to travel to Nairobi to get treatment for my son’s eyes,” he says.

Eighteen patients ailing from various diseases, including epilepsy, cerebral palsy and hypertension, had been treated through videoconferencing before we visited, and while the hospital would initially offer the services three times a week, it now offers them daily.

At the Samburu Sub-County Hospital, Joyce Lolmeweti’s three-year-old son is undergoing diagnosis at a newly opened hospital wing specially for telemedicine services. He is asked to take a deep breath to establish if her mother’s worries of a cardiovascular problem are valid.

All medical devices attached to the patient’s body are connected to a computer through which the software sends real-time data to a specialist at Gertrude’s Hospital in Nairobi. “The child has only mild chest pain, not a thing to be worried about. No cardiovascular condition confirmed,” says Jackie Lenges, the hospital telemedicine clinician, after a live consultation with Dr Renson Mukhwana, a paediatric endocrinologist at Gertrude’s.

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In this centre, 42 patients had been diagnosed and treated when we visited, with only two cases being referred to Nairobi for surgery. The three cases are part of the more than 32,000 patients in Homa Bay, Samburu, Lamu and Baringo counties benefiting from a Sh200 million telemedicine programme dubbed Daktari Smart which has seen their medical expenses cut from hundreds of thousands of shillings to zero.

While the initiative at first focused on children under the age of five, older children are now getting treatment at the centres, which has come as a big relief to many parents.

“It brings specialised treatment closer to the rural areas. We no longer have to travel. It is cost-effective,” Joyce tells Healthy Nation.

The programme, which kicked off last November, will run for three years. It has already trained 1,200 healthy workers and 1,400 community health volunteers who are now sensitising residents about virtual treatment.

For Nairobi doctors who do not understand the vernacular languages, translation is done to ensure a smooth and direct flow of information from doctor to patient.

“Technology will change everything in medical care,” says Dr Brian Akuom, a general practitioner at the Suba Sub County Hospital, who says the Sh4,500 consultation fee that Nairobi’s specialist doctors ask for is a big turn-off for many ailing citizens.

“Considering the transport, the cost of lab tests, the crowding in hospitals and the time it takes to get a specialist consultant, this telemedicine centre is a huge relief for many residents,” he says.

However, he notes that hurdles exist in the delivery of the service, as intermittent internet connection hinders them from achieving the required software uptime.

“Were the Internet stable we would have this service in every sub-county,” he says, adding that residents from all eight sub-counties and the 18 islands of Homa Bay County have to rely on one telemedicine centre.

Another hiccup is the lack of enough specialized medical staff to co-ordinate the service.

“Every Level Four hospital must have 20 medical officers and 50 clinicians. I’m alone here... with a few clinicians,” he notes.

 While a telemedicine centre helps a great deal in helping patients access medical services, personalised services from a patient’s smartphone in the remote areas to a doctor in the city remains a dream in Homa Bay County, which has 78 per cent of smartphone penetration, according to the 2019 Census data.

“We have a long way to go in reaching the government’s universal health coverage dream,” Homa Bay County Director of Health Dr Gordon Okumu says.

“The ratio in this county is one doctor per 3,000 residents. Telemedicine helps us reach underserved regions but allowing patients to do follow-ups with their doctors is the ultimate dream.”

Patients in Samburu County have had to deal with issues of poor infrastructure, leading to late arrivals in hospitals, which contributes to deaths.

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M-Pesa Foundation’s head of social impact Karen Basiye says they seek to reduce the number of referrals of sick children by allowing county health facilities to access specialists to attend to sick children.

“No child should die. We want to optimise the capacity and reach of healthcare delivery systems by easing access to healthcare services for all children,” Ms Basiye says.

With many medical specialists avoiding work in marginalised counties, she challenges the private sector to play a role in helping bring rural citizens at par with their urban counterparts in terms of access to specialised treatment.

“It cannot always be the role of the government to bridge these gaps. We cannot thrive where communities are suffering,” she adds.

Gertrude’s Hospital Foundation chairperson Les Baillie said their mission is to transform local communities by improving access to quality healthcare services for needy and disadvantaged children in the country.

“The Daktari Smart programme will enable us to provide much needed specialist care to children in far-flung regions and develop appropriate data and information to support paediatric healthcare in the country,” Mr Baillie noted.

So what happens when the 36-month funding period is over?

“By that time, these county governments will have learnt how it works and consider allocating budgets to keep the telemedicine services up and running,” Ms Basiye hopes.

According to the Kenya Medical Practitioners and Dentists Board (KMPDB), the doctor-to-patient ratio in the country stands at about one doctor for every 6,355 patients, which makes it difficult to access qualified medical professionals.

The ratio, KMPDB says, increases when it comes to specialists. The counties in the programme have either one or no paediatricians.

Daktari Smart will also see community health volunteers, social workers and health workers in Samburu benefit from video conferencing training to build their skills and capacity.

But the collaboration between the two organisations will have to ensure that the low internet bandwidth requirement for the equipment, which ranges from 512Kbps to 2Mbps, covers the targeted areas so that the platform can be installed in underserved areas that do not have network and fibre connectivity.

Samburu County Governor Moses Lenolkulal signed a community health services Bill into law to ensure community health volunteers are trained on basic health skills to enable them to administer services at the household level with the intention of responding faster to emergencies.

Samburu County Deputy Governor Julius Leseeto says the health volunteers will help achieve the targets of the Daktari initiative in the county.

“We have doubled the number of health volunteers and they will assist in linking patients for referrals,” Mr Leseeto says.

While noting that the provision of ambulances and tuk tuks in Suguta had complemented the work of the county government, and having seen internet connectivity rise from 10 per cent to 70 per cent over the years, he revealed that a more stable internet connectivity is needed.

“We have had 2G and 3G internet for a long time. Having fast 4G internet across the county means residents can access health information and teleconference from their phones faster.”

And although the programme has also helped medical students in the county get practical education on the future of medicine, residents in remote zones of the county such as Baragoi still have to make long trips to Maralal town to access health services.

“These residents need a 4G internet connection so they can get treated from their smartphones straight from the villages,” remarked Angata Nanyekie MCA Paul Leshimpiro during the launch of the initiative on February 28.

According to the Kenya Healthcare Federation, the telemedicine field consists of 41 registered e-Health providers who offer diagnostics, prescription, surgery pre-assessments, ultrasound, crowd funding, pharmaceutical e-commerce, health insurance, doctor-to-doctor consultation and medicine e-learning. But their focus has been the city counties of Nairobi, Mombasa, Kisumu and Nakuru, cutting off 70 per cent of Kenyans who live in the rural areas from their services.

Last year, KMPDC approved 20 hospitals to roll out telemedicine services amid Covid-19 containment measures but all of them operate from urban centres where internet connectivity is strong enough to allow clear videoconferencing.

According to the World Health Organisation (WHO), telemedicine holds great potential for reducing the variability of diagnoses as well as improving clinical management and delivery of health care services worldwide by enhancing access, quality, efficiency, and cost-effectiveness.

“Telemedicine can aid communities traditionally underserved – those in remote or rural areas with few health services and staff – because it overcomes distance and time barriers between health-care providers and patients.”

Despite the promise, WHO says, telemedicine applications have achieved varying levels of success due to challenges of human and cultural factors. Some patients and healthcare workers resist adopting service models that differ from traditional approaches or indigenous practices, while others lack ICT literacy to use telemedicine approaches effectively, it says.

Most challenging of all are linguistic and cultural differences between patients and service providers. Legal considerations are also a major obstacle.

Although Kenya has a Data Protection Act to protect patient data privacy, confidentiality of such data is still a challenge due to vulnerable methods of data transfer, storage, and sharing between health professionals.

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WHO notes that related to legal considerations are technological challenges as the systems being used are complex, and can oftentimes malfunction due to software or hardware failure.

This could increase the morbidity or mortality of patients and the liability of health-care providers as well. In order to overcome these challenges telemedicine must be regulated by definitive and comprehensive guidelines.

Despite the fact that Kenya is one of the African countries making progressive steps in e-health, patients still suffer from inadequate access to sustained telemedicine services due the instability of electric power supplies and expensive mobile internet connectivity.

Even on telemedicine platforms that have achieved substantial success, the threat of cyber attackers is existential.

Most patients still do not trust apps with their data, and keep suspecting that platform owners may share their private medical information with third parties without their consent.

The Kenya National e-Health Policy document of 2016-2030 lists some of the challenges facing telemedicine as inadequate technical expertise, unreliable power supply, limited funding and lack of government involvement.

But despite all these, Kenyan experts believe the country is on the right path towards using the service to achieve Universal Health Coverage.

“We only need to keep innovating and improving the internet services in rural Kenya. It is a learning process,” says Mr Ogalo.

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