Abstract
Telemedicine started in Madagascar in 2005. The work was led by the government in partnership with the United Nations and the World Bank. Since then, there has been increasing telemedicine activity. This is one of the first reports on the topic of telemedicine in Madagascar.
According to the World Health Organization (WHO), Africa suffers from a critical shortage of health-care professionals especially in remote areas. 1 Outside the major cities, doctors have only limited access to specialist consultations or to continuous medical education (CME). Madagascar is no exception to these problems: it has a population of 18 million, most of whom (78%) live in rural areas with the remainder in six major cities. 2 Most specialists practise in these six cities.
Madagascar is the fourth largest island in the world. Since 1960 it has been an independent country and the language of medical instruction is French. It is divided into six provinces, each with its own regional administration. Each province has one regional hospital which is supplemented by local hospitals and dispensaries. The physician/population ratio is 1 per 8300, compared to 1 per 500 in the USA. The majority of doctors are general practitioners working in remote areas. Specialists, who represent 10% of the workforce, practice in the major cities. This maldistribution of physicians is an important problem for the health-care system. Also, two-thirds of the population live at least 8 km from a medical centre, and due to the poor telecommunication infrastructure, there is limited access to health-care services for the majority of the population. 3
The core benefits of telemedicine are connecting health professionals in remote areas through distance education (tele-education), the ability to request second opinions (teleconsultation) and better coordination of public health activities through timely information for decision makers. 4 Madagascar is currently participating in three telemedicine programmes: two are government sponsored (the e-Health Telemedicine Programme and the Pan-African e-Network) and one is university-run (the RAFT Network).
E-Health Telemedicine Programme
The e-Health Telemedicine Programme is sponsored by the Malagasy government with the collaboration of the United Nations and the World Bank. It began in 2005. 5 It is designed to connect the country's health-care facilities from remote villages to the regional and provincial hospitals. It is part of the government's long term strategy published in the Madagascar Action Plan (MAP) to reduce poverty and improve the quality of health care. The objectives of the telemedicine programme are to increase the delivery of public health, provide in-service training (tele-education) of primary care providers in remote areas and promote professional growth by providing specialist consultations (teleconsultation). The telemedicine programme has gained support from the Malagasy government, the private international sector (USAID) and national professional societies, who have pledged their commitment by providing monetary and human resources for the programme.
Pan-African e-Network
In January 2009, the Malagasy government created a special agency called the Medical Institute of Madagascar as part of the Pan-African e-Network grouping of 53 African countries. It involves the coordination of two government ministries: the Ministry of Health and the Ministry of Telecommunication. The Institute uses videoconferencing (tele-education) by medical specialists (cardiologists, radiologists) who share their knowledge with medical practitioners in the main cities and in remote areas. This project will also connect the 53 countries via satellite and should reduce the number of costly transfers of patients to regional hospitals and overseas. Madagascar will benefit not only from tele-education but also from teleconsultation with national and international specialists such as cardiac surgery and neurosurgery.
RAFT Network
In 2006, the University of Antananarivo (Madagascar) joined the RAFT Network (Réseau en Afrique Francophone pour la Télémédicine), which is sponsored by Geneva University Hospitals in collaboration with the WHO. The network includes 15 French-speaking African countries. 6 Its main goals are to provide distance CME sessions (tele-education) and teleconsultation for doctors in remote areas, thus helping them to make better diagnostic and therapeutic decisions locally. The network also provides timely transmission of epidemiological data to the Ministry of Health, thus improving epidemiological surveillance. Finally, telemedicine reduces the social isolation of patients by connecting family members and friends.
The RAFT Network is based on a decentralized model involving national coordination teams in each participating country. Each team is responsible for coordinating all telemedicine activities at the national level, organizing training sessions for participating health-care facilities and overseeing the technical aspects of telemedicine. Typically, each team contains three people:
The national coordinator, or ‘focal point’, is a recognized medical authority who liaises with government officials and is in charge of overseeing the operation at the national level. In Madagascar, the focal point is Professor Rabenja Rapelanoro from the University of Antananarivo. The medical coordinator is a junior doctor in charge of training and liaising with local health professionals. The technical coordinator is in charge of the technical aspects of telemedicine. Currently, the network is expanding from the capital Antananarivo to the other cities.
The future
The future of telemedicine in Madagascar appears promising and involves expansion of the three existing programmes over the next 10 years:
E-Health Telemedicine Programme. The telemedicine programme represents a three-phase approach to national development which aims to fight poverty, improve the quality of the health-care system and promote economic development through the deployment of services such as e-learning, telemedicine and e-governance. An evaluation of the pilot programme is being performed and replication in other local communities is under consideration.
Pan-African e-Network. The Malagasy government has invested US $130 million (US $1 ≈ £0.6) in financial and human resources to support the e-network. Its future plan is to expand the tele-education programme to reach the entire country and to expand teleconsultations to involve many specialties at the national and international levels, including cardiac surgery, invasive radiology, neurosurgery and dermatology.
RAFT Network. The RAFT Network is expanding its teleconsultations which enable a virtual community of experts to collaborate in solving patient specific diagnostic problems and plan medical evacuations. Teleconsultations in dermatology, radiology, infectious diseases and ophthalmology are planned. 7 Other teleconsultation tools are being developed such as low-cost ultrasound devices in remote hospitals to improve the decision-making capability of doctors and to reduce the cost of unnecessary transfers to regional hospitals. Also, the RAFT Network is developing Dudal (distance education environment), using low bandwidth connections (25 kbit/s) to enable remote users to participate. The educational courses are free, and are produced in Africa for national and local health professionals.
Telemedicine is a reality in Madagascar. Although recently introduced to the island, its use has been rapidly expanding and it already plays an important role in health care, and in the economic and social development of the country. This could serve as a model for other countries in Africa. The Malagasy government is committed to expanding the use of telemedicine by participating in international networks such as RAFT and the Pan-African e-Network, by setting up a special agency dedicated to its expansion, and by investing substantial financial and human resources.