Hi4D_Telemedicine solution for Displaced populations

The Northwest and Southwest regions of Cameroon are the two English-speaking regions of the ten regions in the country, with a population of almost five million inhabitants (20% of Cameroon's population). These regions have experienced an armed conflict since 2017 with over 4000 people killed, over 400,000 internally displaced and at least 80,000 externally displaced into neighbouring Nigeria. This has resulted in disruption and massive closure of health facilities, poor access to health services for the displaced rural populations, and health providers fleeing the conflict zone. The displaced population has moved into very remote informal settlements, which are considered safe from warring parties of the crisis. Unfortunately, in these informal settings, there are no basic amenities like housing, water, sanitation, health care services or schools. Access to these informal settlements is exceedingly difficult and there are no established economic activities for the displaced women to make a living and support their families. This displaced population is subject to poverty, lack, and poor health and this has significantly increased the morbidity and mortality rate of this population, especially maternal, infant and childhood mortalities from common preventable, infectious diseases and injuries. The displaced population is also living in a very fragile security situation because they are often involved in the crossfire and constant attacks by the warring parties, especially in their efforts to travel and seek basic healthcare in health facilities in neighbouring towns. With the increasing severity of the armed crisis and the progressive deterioration of health services for this displaced population, there is an urgent need to structure a solution to improve the health status of this population through preventive, health promotion, curative, palliative and rehabilitative services.

Following lessons learnt from the COVID-19 pandemic, there is increasing evidence that quality health care can be provided to individuals, families and communities remotely through telehealth/telemedicine programs. Additionally, evidence from the Extension for Community Health Outcome (ECHO) project implemented by the University of New Mexico and the AIDS Educational Training Centers (AETC) in the NW of the USA, has shown that capacity can be transferred from more specialized complex health settings to very remote, resource-limited settings using Community Health workers (CHWs) to obtain high-quality health outcomes for the community.

Based on both models (Telemedicine and ECHO), Hi4D plan to implement a telemedicine and ECHO solution, to provide continuous and good quality health care to over 250,000 displaced population in informal settings, resulting from the armed crisis in Cameroon, especially targeting women and children. This model will identify community health workers (CHWs) living within the displaced population, train, and mentor them through the ECHO model and use them to provide health promotion and preventive medical services to the population. Hi4D has an established partnership agreement with the ECHO project of the University of New Mexico.

In addition, the solution will also use a telemedicine model with the FHL Medical Center hub to provide specialized medical care to individuals and families in informal settings using the hub and spoke model. The CHWs will be guided to set up spoke sites in these informal settlements with basic telephone and mobile internet connection to link up with specialists' medical providers in the FHL hub to guide targeted individualized medical care to members of the displaced settlement. 

The population that this solution will serve are a sizable proportion of the over 400,000 displaced people from the armed crisis who are now living in informal settlements. Specifically, women and children in this population will be targeted for preventive and curative medical services. This population is currently living in extremely poor hygienic conditions with congestion and poor sewage disposal, no portable water supply, poor environmental conditions, and no economic activities to improve their nutrition and environmental conditions. They are exposed to both environmental and nutritional predictors of poor health and injuries. This solution will seek to reduce their environmental exposure through health promotion, health education and prevention intervention through the Extension for Community Health Outcomes (ECHO) model. Prevention of disease interventions like proper waste disposal, treatment of water, immunization for children, malaria prevention with insecticide-treated nets, condom distribution and antenatal care for pregnant women will be capital in this solution through health education and working with the local Department of Health to supply basic commodities. Prevention will also focus on screening for TB, and multi-disease screening for chronic conditions like hypertension, diabetes, and HIV, using trained and mentored community health workers. Key community stakeholders (traditional healers, and community leaders) will be engaged in these health promotion and prevention activities.
For persons in this population who are already suffering from any disease condition, the telemedicine solution will help to provide diagnosis, treatment and follow-up of these patients, using the FHL Medical Centre telemedicine unit as the hub and CHWs setting up and coordinating a satellite health post in the communities as spokes. Hi4D will help with the identification and setting up of satellite telehealth posts in five informal settlements hosting the most displaced populations.

The informal settlement will promote risky sexual behaviors and also favor sexual exploitation as a means of livelihood, this solution will also provide family planning education and services and support the implementation of contraceptive methods within this population to prevent unwanted pregnancies and ensure the birth spacing

With these coordinated interventions this solution will reduce infection, promote health and also treat basic diseases and overall improve the health outcomes of these displaced populations. 

Our solution team will be made up of local stakeholders, trained CHWs, the Hi4D ECHO team, the FHL Medical Centre telemedicine unit and other developmental partners.
We will identify key community stakeholders to use in implementing the solution. Our community stakeholders are the community leaders and religious leaders who are trusted in these communities and have a say in the decisions of the communities. They will be responsible for sensitizing and mobilizing the community for services to be provided. The local department of health also has community actors who will be used to mobilize the communities while the department will supply primary health care services and commodities for these communities' health activities.
Community Health workers who have been displaced to live in these informal settlements will be identified, trained and mentored on primary health care services, the ECHO model and telemedicine services. They will be used as the intermediaries between the Hi4D ECHO team and the FHL telemedicine unit to deliver services to these populations.
HI4D has an ECHO team that has a partnership agreement with the University Of New Mexico ECHO project and will use this model to deliver health promotion and prevention activities. Hi4D will also leverage resources from the UNM ECHO worldwide project to provide evidence-based community health services and community interventions.
FHL Medical Center has a well-trained telemedicine unit with a team of specialists consisting of:

 Dr Tumasang Florence is a Specialist in Obstetrics and Gynecology, Former Director of the Department of Family Health in the Ministry of Health. She will be one of the leading specialists in Maternal, Child and Reproductive Health. She is passionate about family planning interventions and will lead the scaling up of family planning interventions.

Dr Gilbert Tene is a specialist Pediatrician and a former Pediatric Care and treatment lead for the Centers for Disease Control in Cameroon. He will lead the pediatric telemedicine services and childhood disease prevention interventions.

 Dr Tshimwanga Edouard, an infectious disease specialist will be the infectious disease specialist for management of infections and also leading infection control measures

Mrs Gladys Ghogomu, MPH, is a state registered nurse who will lead the nursing services 

 Dr. Bakor Albert, MBBS, MPH, PG Dip. Project Management, MSc Health Economics, and Pharmacoeconomics is the CEO and will provide global oversight and coordination of the Project. Dr Bakor has been the Country Director of Health Alliance International Cote d’Ivoire, I-TECH South Africa, EGPAF Cameroon.

Other local development partners will include UNICEF, the World food program, and Doctors without borders will be collaborating to provide other services to these populations.

 This solution will train the identified 10 CHWs in each of the targeted five informal settlements (a total of 50 trained CHWs) on ECHO and telemedicine fundamentals and primary healthcare approaches.

The solution will also target to train over 100 community stakeholders on health promotion and prevention activities, considering that they will be champions in these interventions

This solution will target to reach out to 50,000 displaced population, primarily women and children with quality preventive, health promotion, and health education messages per year through the ECHO model. This activity will reach about 250,000 individuals in 5 years.

The solution will provide curative, chronic care and rehabilitative healthcare services to 5,000 patients per year (25,000 patients in 5 years) through telemedicine.

With these solutions proposed to provide comprehensive health care for the displaced population, HI4D and FHL Medical Centre already have constituted ECHO teams and the telemedicine Unite. While HI4D is a registered local not-for-profit organization operating in the regions, FHL Medical Center is an independent Medical Care centre affiliated which has a signed agreement with Hi4D and will provide curative health care to the displaced population at a very subsidized rate. FHL Medical Centre has a functional telemedicine unit that is ready to provide free consultations to the displaced population in Cameroon through the telemedicine program and subsidized specialist care for complicated cases.

This solution will be privileged to benefit from SOLVE's expertise in technical assistance and SOLVE's network to mobilize financial resources to support this initiative. SOLVE's technical expertise and its extensive network of partners will be important to provide evidence-based and innovative strategies to tailor the ECHO and telemedicine interventions to the specific needs of these displaced populations. SOLVE will also guide the implementation of this model based on its experience of a similar model elsewhere. SOLVE and its network will also support financial solutions for the training of CHWs, stipends of selected CHWs intermediaries and for setting up and running of community satellite ECHO and telemedicine post. Most importantly, this solution will depend on the experience and technical support of the connected SOLVER network/ teams with partners who can help advance our solutions

The Northwest(NW) and the Southwest (SW) regions of Cameroon, with a population of five million inhabitants (20% of Cameroon's population) have experienced an armed conflict since 2017 with over 4000 people killed, over 400,000 internally displaced and at least 80,000 externally displaced (

https://www.un.org/africarenew...).  This has resulted in the disruption of economic and health activities, closure of hospitals, fleeing of health providers from the crisis, and population displaced to informal settlements with no access to health services. The most affected populations are women and children because their families have been killed in the crisis or have joined the militia leaving them to flee to safe havens. These women have lost their source of livelihood, are forced to become head of the household, have no economic activities in these new settlements and have no basic amenities for health, water, and sanitation services. Consequently, they have engaged in trading sex or other illegal acts as a means of sustaining their families. 

The government has no means of reaching these populations due to poor transport, and insecurity and no basic services are planned for these informal settlements. 

With the insecurity/poor access, we plan to implement an ECHO and telemedicine solution to provide continuous and quality healthcare to the displaced population targeting women and children. This model will identify community health workers (CHWs) living within these settlements, train and use them to implement and monitor preventive, curative, chronic care and rehabilitative health services in five selected displaced communities hosting most of the internally displaced women and children. Hi4D has an affiliated FHL Medical Centre with a pool of general and specialist clinicians that provide holistic medical care in the SW region and has a fully developed and functional telemedicine unit. Leveraging the widespread mobile phone/ internet network access in the country, this technology will be exploited to implement the telemedicine solution. Community stakeholders (community leaders and religious leaders with decision-making authorities in the communities) will be used to sensitize and mobilize the population within these settlements. Trained CHWs will set up megaphones at community venues where public health specialists can broadcast health promotion messages. Meanwhile, clients identified within the settlement with specific disease conditions will be consulted and offered expert treatment using the telemedicine model by the clinical/specialist team. 

The solution will coordinate with the local Health Departments for basic public health services (immunization, hygiene, water, and sanitation), provision of medical supplies, and essential medications through an established route using local bikers. Local and international developmental partners (UNICEF, World Food Program) will be contacted to provide basic supplies to these displaced populations.

Telemedicine had been proven to be highly effective in providing quality health care remotely and this approach became widespread during the COVID-19 pandemic. This approach is poorly developed in Cameroon, but FHL Medical Center has an established and functional telemedicine team that has completed the Fundamentals of Telemedicine Operations with the Harvard University Telemedicine Unit

Hi4D has a partnership agreement with the University of New Mexico ECHO project.

Hi4D in collaboration with local stakeholders and the local department of health will map out the most populated informal settlements housing the most population (especially women and children), and informal settlements hosting more than 30,000 population will be targeted.

 Community stakeholders (community leaders and religious leaders) with decision-making authorities in the communities will be used to sensitize and mobilize the population within these settlements and link them through ECHO for the provision of health education, health promotion and preventive messages by a team of public health experts. Identified and trained CHWs will be used to set up megaphones at community venues where the mobilized population will gather for the broadcast of health messages. This activity will target to reach out to 50,000 displaced population with quality preventive, health promotion, and health education messages per year. This activity will reach about 250,000 individuals in 5 years.

The FHL medical Center telemedicine team will train the identified 10 CHWs in each of the targeted communities (a total of 50 trained CHWs)  on telemedicine fundamentals and an additional 100 community stakeholders on primary healthcare approaches. These CHWs will select a health post within the informal settings (church or a tent) where basic and confidential medical consultation could take place and work with FHL to set up the basic telemedicine equipment (smart TV, Video conferencing and audio outlets, internet and mobile telephone set up). These satellite posts will be linked to the FHL telemedicine unit where the specialist will connect for individual confidential patient consultation and offer a line of management. The CHWs will be mentored on patient nursing and improvement follow-up according to an agreed management plan by the clinician. The clinical team will connect with the remote sites regularly to monitor the clinical improvement of the clients. The solution will provide curative, chronic care and rehabilitative healthcare services to 5000 patients per year (25,000 patients in 5 years) through telemedicine.

Local stakeholders and local transporters, especially bikers who have understood the dynamics of the crisis and can navigate their way to towns and to these displaced settlements will be engaged to set up a channel to facilitate the transport of essential medicines and medical supplies.
The local Ministry of health department will be engaged to facilitate the delivery of vaccines, essential medications (antimalarials, antiparasitic and antibiotics) and medical supplies. Local and international development partners will be engaged in the delivery of food and medical supplies. 

Lessons learnt from this telehealth solution (which is still very poorly developed in Cameroon), will be shared with local and national stakeholders, and can set the pace for the MOH to serve the remote and inaccessible communities in Cameroon, even in the other 8 regions that do not have an armed crisis, considering that 60% of the country is rural and inaccessible in many aspects. This will also provide evidence for the development of telemedicine in the country.

The project will collect routine hospital and public health data for service offices to patients and displaced populations in the informal settlement through telemedicine and ECHO services. Standard clinical registers and Primary health care data collection tools from the local department of health (hospital and community outreach tools) will be used. The indicators of interest collected in routine tools will be customized into a data software called DAMA. DAMA is an electronic version of hospital data found in hospital registers, which will integrate community indicators which will be used to aggregate and summarize the data for specific indicators for reporting to stakeholders. The indicators of importance in this solution address SDG 3: Ensure healthy lives and promote well-being at all ages for the displaced population in Cameroon due to the armed conflict. 

The indicators will target:

SDG 3.1 Reduced Maternal mortality by recording 

• The proportion of births attended by skilled health personnel (supervised by CHWs and Telemedicine)

SDG 3.2 The under-5 mortality rate from preventable deaths of newborns and children under 5 years of age by documenting the

• Under 5 mortality rates in the informal settlements
• Neonatal mortality rate in the informal settlements

SDG 3.3 To end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases by reporting the

• HIV prevention, diagnosis, and referral for treatment
• TB contact tracing and diagnosis and referral for treatment
• Malaria prevention and treatment

SDG 3.4 To reduce premature mortality from non-communicable diseases and improve well-being through documenting the reduction in  

• Mortality from HPT, Diabetes and respiratory diseases

SDG 3.5 To strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol by tracking the 

• reduction of substance and alcohol abuse in these settlements

SDG 3.7 To ensure universal access to sexual and reproductive healthcare services, including family planning, information and education through

• The proportion of women of reproductive age (aged 15-49 years) who have their need for family planning satisfied with modern methods

SDG 3.8 To access quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all through documentation of

• Coverage of essential health services

The goal (Impact) of this solution is: To ensure healthy lives & promote the well-being of all ages for the displaced population in Cameroon due to the armed crisis.

This will be achieved through the following objectives(outcomes)

1. Reduced maternal mortality

Inputs:  Training session for CHWs; ECHO sessions; Telemedicine sessions

Activities: Telehealth for antenatal consultations; Trained CHWs to follow up ANC/labour/delivery, Supervised labour/delivery at the health post

Outputs: # of PW attending ANC/Postnatal care; # CHW trained for ANC/PNC; # PW delivered at a health post

2.  Reduced < 5 mortality rates

Inputs: ECHO session; Telemedicine sessions; CHWs

Activities: Mentoring CHWs on ECHO; Identification of children < 5 for immunization; ECHO follow-up for infant immunization completion

Outputs: # children < 5 identified and immunized; # infants completing routine immunization

3. Reduced HIV /TB/Malaria transmission and care /treatment

Inputs: Supplies (condoms, mosquito nets, HIV self-test kits); ECHO sessions; Telemedicine sessions

Activities: Distribution of supplies; HIV screening and testing, TB screening and contact tracing; Distribution of insecticide-impregnated nets

Outputs: # HIV cases identified; # condoms/HIVST kits distributed; # suspected TB cases identified; # presumptive TB cases referred 

4. Reduced mortality from non-communicable diseases

Inputs: BP machines; Glucometers; Telemedicine. ECHO; CHWs

Activities: Weekly monitoring of BP and blood sugar; Weekly screening for hypertension/Diabetes; Chronic care model for hypertension and diabetes 

Outputs: # new cases of Diabetes & hypertension; # of persons with BP & blood sugar controlled; # persons adherent to chronic care model.

5. Reduced alcohol and substance abuse

Inputs: ECHO sessions; Stakeholders

Activities: Counselling sessions for adolescents on alcohol and other substance abuse; Advocacy with religious and community leaders on substance sensitization; Health education sessions

Output: # adolescents/persons who stop illegal drug intake; # stakeholders involved in community sensitization

6. Improved Sexual and reproductive health / Family planning services

Inputs: ECHO sessions; Telemedicine

Activities: Health education sessions for reproductive health; Advocacy and sensitization against GBV; Post rape management

Outputs: # post rape cases managed; # adolescents/leaders engage in GBV advocacy.

7. Improved quality of health care services & essential medications
Inputs: ECHO sessions; Stakeholders; CHWs; Bikers for transport

Activities: Community health education (HE); Health promotion; hygiene and sanitation campaigns; Supply of essential drugs and medical supplies

Outputs: # persons reach with HE messages; # persons provided with essential drugs

The solution will leverage the wide availability of mobile telephone networks and mobile internet coverage even in the most remote parts of this country. Every household and almost every adolescent has a mobile telephone and are using the smartphone for internet and social media communication

The ECHO model implemented by the University of New Mexico and the NW AETC has been shown in the US to provide quality and specialist health services even to the most remote communities in the US.

Telemedicine in any form has been shown to provide health care to individuals, families, and communities remotely. During the COVID-19 pandemic and the shutdown, telemedicine was the best means to provide critical care synchronously and asynchronously to individuals and families for critical care, chronic care, and cuts across all specialties of medical practice. This innovative way of providing medical care is expanding widely across the West.

FHL telemedicine unite has completed the ECHO immersion training with the University of New Mexico and has an ECHO contract with the University to implement ECHO activities in Cameroon and will leverage the ECHO network across xx countries to tap resources (human and learning resources) to improve community health outcomes in the displaced population in Cameroon

 FHL medical centre has a fully developed telemedicine unit and will connect both local specialists and the extensive network of specialists in its telemedicine program to provide general and specialist healthcare delivery services to this displaced population 

The team has a diverse membership with women making up over 45% of the executive board, members and providers.

We involve all races, nationalities and in our project and leadership team. We have a small representation of people living with a disability. We do not have any sexual orientation in our composition.

Our code of conduct ensures a welcoming, non-discriminatory environment.

Our business model is not profit-making, as Hi4D is a registered not-for-profit organization which has the following objectives:

1. To promote Health Education on common and preventable health conditions.
2. To engage in systematic and regular Disease surveillance.
3. To design, develop and implement the Chronic Care model for chronic conditions.
4. To promote Health Communication to raise health awareness of the population.
5. Promotion of the Family care model
6. To promote equality and advance the rights of women, youth, children, and other disenfranchised populations at all levels of society.
7. To promote access to Health Education/Promotion, Sexual and Reproductive Health (SRH), HIV/AIDS, Hygiene, Water and Sanitation 

In this model, Hi4D and FHL have reached an agreement that medical consultation that will be provided to the population in informal settlements through telemedicine will be free of charge to the beneficiaries and specialized medical care will have a highly subsidized rate

Our model is free to the beneficiaries, but the model needs resources for set up, running and maintenance.

We are depending on donor funding for the setup and maintenance of both ECHO and Telemedicine in these informal settings.

We believe that the capacitated community stakeholders and trained CHWs will remain as constant resources in the community making this service provision more sustainable. Engagement of the Ministry of Health and the local Department of Health will ensure ownership and guarantee sustainability even after the end of donor funding.

No experience to share for now