Thursday, June 15, 2017

Distance Matters - Problems in Telemedicine

With Patan hospital as the hub, the government of Nepal has started telemedicine service in 25 Himalayan districts including Acchham, Sindhuli and Khotang. Without doubt, telemedicine will prove to be useful in increasing public’s access to health facilities. Lack of road connectivity and poor infrastructures in general, and lack of good hospitals and trained doctors in particular, will be addressed by telemedicine. However, with the example of Nangi clinic, this article will point out the problems that telemedicine might have to face in Nepal. I assume Nangi clinic in Ramche VDC of Myagdi is more or less representative of other clinics with telemedicine service in the hilly and mountainous districts of Nepal. 

The Nangi Clinic

Nangi private clinic, which is under the management of Himanchal Education Foundation (HEF) is an initiative of Mahabir Pun, a Roman Magasaysay winner for the community leadership he demonstrated in Nangi. Telemedicine service started in Nangi clinic nearly a decade ago, and the clinic provides the facility to this day. The register maintained by the clinic shows that 80 patients have benefited from the facility until January 2013. Nanda Bahadur Phagami of Nangi developed a pain in his knee, which was diagnosed to be a pilo by Dr Saroj Dhital of Kathmandu Model Hospital via telemedicine. It was successfully operated in the clinic by health workers with supervision from the doctor. Phagami is happy to have saved time and money. Similar is the case of Uddima Tirada who was successfully treated for itching. According to Rupa Pun, a health worker in the Nangi clinic, in addition to benefiting the locals, the presence of telemedicine has also increased the confidence of the health workers. They feel backed-up by qualified doctors available to guide them when necessary. 
Telemedicine Center in Nangi Clinic

However, according to Raman Pun, the principal of Himachal Higher Secondary School (HHSS), “the flow of patients in the clinic asking for telemedicine service was particularly high in the initial days, but it has decreased now.” Not a single entry in the register since September 2012 proves Pun’s claim. “It has become a showpiece, the performance has not been satisfactory as expected,” Dev Kumari Garbuj, a primary teacher of HHSS, expressed her disappointment. 

The Problems

There can be several reasons for the decreased flow of patients requesting telemedicine service in Nangi clinic. Lack of infrastructure is still the most important setback, while constant power cuts and unreliable internet connection are the other hindrances. According to Lila Pun, a health worker in Nangi clinic, battery back-up has solved the problem of electricity, but the problem of internet connection still exists. There are several cases where patients had to be turned back from the clinic because of error in internet connection. 

The other reason behind the underperformance of telemedicine is the lack of trained professionals to operate the service. There is a dearth of health workers who are familiar with telemedicine hardware and can work with computer and internet connections. The internet connection in Ramche Health Post (a government health post) didn’t work for almost eight months between 2011 to 2012 until Kishan Pun, a computer teacher at a local school, repaired it. 
Similarly, lack of awareness among the people about the working of telemedicine creates lack of faith in the new technology, leading to reluctance in availing of the service. “I don’t know how telemedicine works and how the quality of treatment is maintained by the use of telemedicine, even though I am a teacher” says Rama Pun, a teacher of Shree Deurali Lower Secondary School in Ramche. She pointed out the need for an awareness campaign about the advantages and effectiveness of telemedicine.

Finally, “the lack of medical and communication skills in low-ranking health workers, due to which they are unable to communicate with doctors in the hub, has also been a problem,” stresses Elsa Sallenave, a nurse from France volunteering in the clinic.

Ways Ahead

The problems discussed above are relevant to all the telemedicine centers in Nepal. Problems in internet connection in Pyuthan are already in the news. Similarly, services were obstructed in Khotang, Jajarkot, Sankhuwashabha, etc because of lack of trained personnel who can operate telemedicine. Likewise, the decreasing number of patients who request telemedicine will soon raise the question of patients’ faith in the system. Also, since telemedicine is available only at district hospitals, people living in rural parts of the hilly and mountainous districts will find it difficult to make it to telemedicine centers, which will also hinder the effective implementation of the service.
In order to achieve the desired level of success in telemedicine in mountainous districts, the government should immediately supply technicians to operate the service. Similarly, problems related to electricity and internet should be solved. Moreover, the people should be made aware of the benefits of telemedicine. The most important aspect of the awareness campaign should focus on generating faith in the people regarding the service. Finally, in order to ensure good service, heath works in the districts should be given medical and communication training. 

Published in Republica (25 June, 2013). Available in

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