Telemedicine For Maternal-Newborn Health

The aim of this project to to reduce neonatal and maternal mortality while addressing the gap between urban and rural refugee camp maternal-newborn health care services.There is persistent low quality and poor accessibility of maternal and newborn health care services, health professional on duty has little or no access to expert help, no specialists e.g. pediatrician and obstetrician, access to tertiary care is often impossible,leading to increased number of referrals and associated costs,time and stress to an already economically burdened refugees. Patients monitoring and screening is of low quality .The health professionals in these camps have a high rate of staff turnover.

We will implement a telemedicine support  system to promote maternal and newborn health.Scaling this solution globally would result into improved quality and accessibility of medical care by allowing distant providers to evaluate, diagnose, treat, and provide follow-up care to patients in less-economically developed countries . 

There is unacceptable high mortality and morbidity rates of maternal and newborn patients in Nakivale refugee resettlement,Kyaka 11 and Rwamwanja refugee camps. 2% of women die from delivery associated complications while 5% of newborns  die from preventable illness. 

Globally, every day in 2017, approximately 810 women died from preventable causes related to pregnancy and childbirth while 375 women died in Uganda from similar causes.Globally, 2.5 million children died in the first month of life in 2018 from preventable diseases.

Factors related to solution: lack of access to quality health services(e.g.lack of general doctors and specialists obstetrician  and pediatrician (absolute lack ) leading to wrong diagnosis and therapeutic choices). This is compounded by inconsistency in care and access to  reliable information. 

Nakivale refugee resettlement, Rwamwanja and Kyaka 11 camps are in rural south western Uganda. Total population is about 250,000, 70% are women of child bearing age.Majority are from Rwanda, Congo and south Sudan and speak Kiswahil, Kinyarwanda and French languages. These are victims of forced displacement, internal conflicts, human rights violation and wars from their countries.Tele-medicine links rural and hard to reach health centres in the 3 refugee camps in south western Uganda.

Solution 

Using a simple mobile telephone the midwives are able to call the 4 general  doctors and 1 consultant obstetrician in real time about about cases of pre-eclampsia and eclampsia.

Midwives can get correct diagnosis, treatment,and followup of patients.

Technology champions in each camps will link with the patients in their camp residence to ensure they continue to take their medications in time, followup blood pressures and community reviews with assistance from the doctors. 

These refugees are poor and live in rural communities without running water, electricity, sanitation facilities are poor and have no secondary and tertiary health care systems. Families sustain themselves through donations for basic needs from humanitarian agencies. Illiteracy rate among these women is 75% and don’t not have income or lacks the ability to pay for medical care or ever transportation to the available primary health centre. Tertiary hospital is inaccessible. Compared to other Ugandan villages, there are no community first responder known village health teams (VHT) the health workers are Midwives who receive 2 years of training in caring for women around childbirth and Clinical Officers who receive 2½ years of training in general medical practice. By continuing to provide telemedicine support and reinforcing their knowledge of maternal and new-born health, it will allow these professionals to both execute a high standard of care in their own practice and to in turn educate their patients.

Telemedicine has proven potential to improve the quality and accessibility of medical care by allowing distant providers to evaluate, diagnose, treat, and provide follow-up care to patients in less-economically developed countries  and marginalized communities.It will provide efficient means for accessing tertiary care advice in these camps both directly to the patients and supporting the health workers. By increasing the accessibility of medical care telemedicine can enable patients to seek treatment earlier and adhere better to their prescribed treatments, and improve the quality of life for women, new mothers, and newborns

1. The midwives and the teams have the support, interest and the skills to use this approach. We will identify active, interested midwives/clinicians and we will provide them with telemedicine support and they will act as champions gradually infecting other midwifes with enthusiasm.as such this telemedicine will enhance and improve existing health sciences.
2. The telemedicine champions  have been  involved in all the stages of developing this proposal to ensure ownership and effectiveness of the project
3. To follow best practice business principles, there will be no other layers of management involved to avoid making it look special.
4. Our approach is user-friendly, no special telemedicine rooms which are threatening and often inconvenient to midwives and often locked, inaccessible or depend on the presence of clinician to operate them. The system is integrated into, normal work environments on the mobile phone. The system is easy to use since we are using the phones that the midwives are already familiar with.
5. We ensure “Train, train and train again”, e.g. meetings and education sessions using telemedicine will be introduced early on in the implementation to allow the midwives used with operating with videoconferencing in their health care environment. And to avoid training anxiety the training will continue at their pace.
6. This application will be evaluated and sustained in a clinically appropriate and user friendly manner. Implementation will be done in way to make it sustainable over time, as it will ensure necessary equipment, staff costs and technical support are properly funded

Type of information

 we will share documents , We will also exchange audios over the phone call. No still images and videos and electronic medical records will be applied.

Using a phone camera, static medical records will be digitized using a camera and then transmitted as still images. For follow-up and non-emergence reviews, copies of written records will be sent as still images to the general doctors and a copy posted to the consultant for advise prior to telemedicine session.

Low cost and legal appropriate images of a case scenario will be taken by mobile phone camera

 Audio: voice will be transmitted by telephone.      

Video: real time  compressed video image transmission  in emergence situation.We will us a 4G enabled airtel  modem  for transmitting the video signals and technical assistance including software upgrades and  fault finding. To minimise the costs of high video equipment, we will use video conferencing.

The telephone is cost effective means of transmission method with good coverage in the refugee camp, with of compromising reliability of the service   .We will procure phones that can send text information in seconds to the participating links

Telephones that we will use have a good bandwidth 1200bits/s enough to carry the required video conferencing and audio signals      

 where real-time transfer is not needed we will use Mobile phones

Information will be displayed by phone screens for sound we will use the mobile speakers no extra gadgets are required.

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 (4, 13). In particular, 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
(4). Further, evidence points to important socioeconomic benefits to patients, families, health
practitioners and the health system, including enhanced patient-provider communication and
educational opportunities (15)

We have impacted over 1000 pregnant women in the rural communities and 250 newborn.we also directly offer clinical support to  20 health workers in the catchment area of our hospital.

We will directly impact 20000 pregnant refugee women and 1000 newborn babies in the first year.

We will target to impact 100,000 pregnant refugee women and 10000 newborn in the five years.

Goal; To provide telemedicine support to more than 5 millions of marginalized and undeserved pregnant women and newborn worldwide

To achieve this, we hope to open cross boarder consultations and partnerships to reach more people in this context.

We will increase our physician capacity and make them available to offer more services. We target to multiply or number to 500 licenced physicians by five years who will be working remotely.

We will create an online platform including an application that can be accessed anywhere in the world provided one has internet, it will increases access to physicians.

One such challenge is a complex of human and cultural factors. Some patients and health careworkers resist adopting service models that differ from traditional approaches or indigenous
practices, while others lack ICT literacy to use telemedicine approaches effectively. Most challenging of all are linguistic and cultural differences between patients (particularly those underserved)
and service providers (4, 6, 13).
A shortage of studies documenting economic benefits and cost-effectiveness of telemedicine
applications is also a challenge. Demonstrating solid business cases to convince policy-makers
to embrace and invest in telemedicine has contributed to shortcomings in infrastructure and
underfunding of programmes (4).
Legal considerations are a major obstacle to telemedicine uptake. These include an absence of
an international legal framework to allow health professionals to deliver services in different
jurisdictions and countries; a lack of policies that govern patient privacy and confidentiality visà-vis data transfer, storage, and sharing between health professionals and jurisdictions (16–18);
health professional authentication, in particular in e-mail applications (17, 19); and the risk of
medical liability for the health professionals offering telemedicine services (20).
Related to legal considerations are technological challenges. The systems being used are complex,
and there is the potential for malfunction, which could trigger 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 over come these challenges telemedicine must be regulated by definitive and comprehensive guidelines, which are applied widely, ideally worldwide (21). Concurrently, legislation
governing confidentiality, privacy, access, and liability needs to be instituted (22). As public and
private sectors engage in closer collaboration and become increasingly interdependent in eHealth
applications, care must be taken to ensure that telemedicine will be deployed intelligently to
maximize health services and optimal quality and guarantee that for-profit endeavours do not
deprive citizens access to fundamental public health services (22).
In all countries, issues pertaining to confidentiality, dignity, and privacy are of ethical concern
with respect to the use of ICTs in telemedicine. It is imperative that telemedicine be implemented
equitably and to the highest ethical standards, to maintain the dignity of all individuals and ensure
that differences in education, language, geographic location, physical and mental ability, age,
and sex will not lead to marginalization of care (22). 

Due to the nature of this model, the maximum time expected for this project per week per person will be 12 hours, However they will be fultime teammates working remotely as per link placed from the participating sites.

2 Full time obstetricians

2 Full time pediatricians

4 Full time general medical doctors

12 volunteer medical doctors that will be recruited when the project starts. we have also secured their letters of support (attached)

We recognize that telemedicine does not require experience in practice but rather interest in offering medical services in  this model. My teammates are all interested and have a great courage to working with telemedicine which is the key.

DR TAYEBWA BEKSON

Has a bachelors degree in medicine and surgery and a masters degree in Obstetrics and gynecology. He has 2 years working experience. 

DR.OTIM SIMON

Has a bachelors degree in medicine and surgery and a masters degree in Obstetrics and gynecology. He has 7 years working experience. 

DR MUNANURA TURYASIMA

Has a bachelors degree in medicine and surgery and a masters degree in pediatrics. she has five years working experience. 

DR. GERALDINE BAINESHANYU

Has a bachelors degree in medicine and surgery and a masters degree in pediatrics. she has five years working experience. 

DR ATUHAIRE JUSTUS(CEO and team leader)

is a practicing medical officer  St.Francis hospital Naggalama, holds triple  degrees:bachelors of information technology,bachelors of medicine and surgery and masters of health information technology. has experience in implementing basic health projects especially in marginalized communities. i have five years experience in health informatics project with particular interest in marginalized communities. http://www.mathnakivale.com/. i have already been taking part in developing telemedicine content for basic health e.g.(https://youtu.be/ooUh7tmaXSQ).Currently am the cordinator telemedicine services at Naggalama hospital. 

DR.ALLAN SENTONGO, DR.SSENDAGIRE and ATUHURA JOSEPH 

Are practicing medical officers at St.Francis hospital Naggalama, have bachelors degree of medicine and surgery.

AITEL Uganda :Provides us with the technology include internet connections and technical support

Ministry of Health:Provides us with clinical guidelines and guidance. Also will be responsible for paying the health workers we will be working with

Camp UNHCR;The United Nations High Commissioner for refugees; will offer permission to carry out the activities in the camp(see letter of support)  as well will financially support the medical personnel both financially and socially as related to this project

We will be providing remote telemedicine support services to the patients and health care workers.

specifically we will support diagnosis ,treatment,and followup of the cases . Health workers will as well gain from continuous medical education. our focus will be obstetrics and newborn health.

This will overall result in better and efficient quality of care of patients in the refugee camps. 

We acknowledge that currently in developing countries, costing telemedicine services still posses a great challenge because of absolute lack of health insurance. Our approach uses low cost technology while preserving the quality of our services so that we are able to run our services on donations for extended period of time. In addition we are serving the refugee community who are extremely poor and cannot manage the costs associated with the services provided.We will continue to enhance the existing partnership and create new partnership with the ministry of health t#and the UNHCR  for running  and maintenance costs moving forward and beyond the this fund. We will also continue to extend our work since we are already paid by the government of Uganda as civil servants.

We are applying to get financial support so that we can offset the costs of technology since the refugee population cannot afford this technology.

As already stated in previous section, the financing and costing of telemedicine still posses a challenge in developing countries and yet we are the people who need it most. This is partly because we have no health insurance policies and that the diffusion of these applications is still low, therefore revenue and funding would be difficult and yet possible, we would therefore request mentorship in this parameter as it will also help us in sustainability. 

MIT faculty ; We would expect to partner with them in enhancing cross boarder telemedicine  is possible especially in similar context .

We are also interested in getting support from MIT faculty in enrolling modern telemedicine technology that are cost effective and yet reach majority in rural and marginalized communities.