Update 59 Telemedicine

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					HST UPDATE Issue No. 59       February 2001




Telemedicine
                          1
HST UPDATE Issue No. 59                                                                                February 2001




      Table of Contents                                                                                        6
  Editorial                                                                       3


  Month in Review                                                                 5


  Overview                                                                        6
                                                                                      Doctors Khotu and Mandil

  Telemedicine in South Africa                                                    6

  Case study: the Northern Cape

  Case study: Kimberley Hospital
                                                                                  8

                                                                                  8
                                                                                                               8
  Case study: the Eastern Cape                                                    9

  Is telemedicine really working?                                                 9


  HST News                                                                       12

  Peoples Health Assembly                                                        12       Tele-ultrasound


  e-News                                                                         14

  Using Electronic discussion lists                                              14
                                                                                                               9
  Book Launch                                                                    16

  South African Health Review 2000



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                                                                                      People’s Health Assembly



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HST UPDATE Issue No. 59                                                                                     February 2001




                                              Editorial
                                          Fatima Suleman, Health Systems Trust




    One of the first South African telemedicine initiatives involving UNITRA and AFIP (See page 9 for more information)



We all remember stories by our grandparents and                 supplemented the use of face-to-face consultations
elders in the community, referring to “things to come”          with the additional use of the spoken and written word.
or the future. Most often these tales foretold of great         The computer came into use over the last decade,
advancements in the use of technology. One that stays           mainly in the form of email (electronic messaging),
in my memory is my grandmother talking of the greater           electronic discussion lists and the Internet.
use of the television in the future, as a means of
                                                                With the rapid advancements made by technology over
communication to others, for the purposes of work,
                                                                the last few decades, and as a result of globalisation,
social interaction or education. And I am equally sure
                                                                surely health can benefit from international support to
that most of us laughed off these stories as too “space
                                                                address the challenges it faces? Almost all countries
aged”.
                                                                have been facing health care reforms recently, with
But, there have been great strides in technological             the most pressing issue being how to balance
developments. The early 1900s saw strides in the                increasing health care costs, with scarce resources
development of the radio. Then followed develop-                and increasing population demands.
ments in television between the 1930s and 1950s.
The early 1940s saw the advent of computers, with               Good quality and well-distributed telecommunication
the use of personal computers becoming popular in               services can have a tremendous impact on the health
the last few decades. We have indeed developed into             services. Increasingly, countries are beginning to use
a “global village”. This is no more evident than in the         telecommunications to deliver health care. The most
fields of trade, industry and economics. However, what          recent health care initiative, called “Telemedicine”, is
about health?                                                   being experimented with.

The Health Sector has always sought to make use of              According to Dr. Salah H. Mandil, of the World Health
new technology in delivering better health services.            Organisation, “Telemedicine is the practice of medical
The telephone, and much later, the use of facsimile,            care using audio, visual and data communications: this



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HST UPDATE Issue No. 59                                                                                February 2001


includes medical care delivery, consultation, diagnosis,       Telemedicine has also led to links being established
treatment, education and the transfer of medical data.         between developing countries and the industrialised
Education covers both the education of the patient and         countries. One of the earliest examples in Africa was
the ‘continuing education’ of the health-care staff”.          in 1986, with Tanzania and Uganda linking up with
                                                               Canada.
Telemedicine is not meant to replace strategies
implemented to overcome poverty, access to water,              However, communication infrastructure remains the
nutrition promotion and sanitation. It is merely a             greatest challenge to implementation of Telemedicine
response to scarce resources that are available to deal        initiatives in Africa. South Africa had embarked on its
with health problems. However, the additional                  telemedicine project in April 1999, and one of the
challenge to Africa as a whole is the lack of                  objectives of the project is to find alternative
vital infrastructure. This is by no means “mission             communication infrastructures.
impossible”, though.
                                                               There are other aspects that would need to be
The best example of the use of telemedicine and its            considered before telemedicine would be able to be
success is the river blindness or Onchocerciasis               implemented nationally:
Control Programme (OCP) involving 11 African                   •   Is telemedicine likely to provide increased revenue
countries. The programme relied on teams walking,
                                                                   for urban and specialist centres, rather than rural
cycling, driving, and flying in helicopters; and the use           and remote centres?
of face-to-face communication together with the use
of old-fashioned but reliable radio transmitters/              •   Do standards exist for medical equipment used in
receivers for reporting between teams and the 5                    telemedicine services?
centres. Data were collected by means of sensors               •   What are the costs associated with these services?
placed along river streams taking real-time readings
                                                               •   Are tariffs for services going to be imposed?
and automatically transmitting this data to a satellite
that bounced the data to the main collecting station in        •   What are the ethical and legal implications of this
Ouagadougou, Burkina Faso. This station was linked                 form of health care delivery?
to a desktop computer for storage, processing and              The message here is to advance with caution and
computing the optimal spraying by the team in the              deliberation. In the famous words of Captain Kirk, “to
helicopter.                                                    boldly go where no man has gone before”, and to add
                                                               to this, “place one foot in front of the other”.




                                      Useful Telemedicine Web Sites

 •   International Society for TeleMedicine: (http://isft.org/). The Society’s goal is to promote the
     development of telemedicine, telecare and telehealth around the world. The Society acts as a
     forum for the exchange of information and ideas among all those interested in the telemedicine
     field

 •   European Health Telematics Observatory: (http://www.ehto.org/). It aims to collect and to
     disseminate most valuable information on all relevant issues relating to health telematics,
     including European standards, regulatory and ethical issues. Moreover, it offers a space for
     displaying interactive news, and a space for on-line virtual electronic demonstrations, available
     to users, industry and service providers

 •   TeleHealth/E-Health: (http://strategis.ic.gc.ca/SSG/it05551e.html). Find out more about Canadian
     capabilities and how Industry Canada works to promote the growth of the Canadian ICT industry

 •   Virtual Medical Worlds: (http://www.hoise.com/vmw/01/articles/index.html). Virtual Medical
     Worlds is a monthly Virtual Magazine on Telemedicine and High Performance Computing and
     Networking for readers interested in computer applications in medical environments

 •   Health-wa.net is an internet-based university: (http://www.health-wa.netfirms.com/pages/
     telemedicine.htm). Provides links to international telemedicine sites.


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HST UPDATE Issue No. 59                                                                                      February 2001




                                Month in Review
The Budget announcement last month held the most                   the increase in defence spending.” The Health
important implications for the health sector, with most            Department’s expenditure on hospital services is to
analysts responding that the allocation for health did             grow by only 1,8% a year over the medium term - a
not meet the country’s challenges.                                 decline in real terms.
The 9% nominal increase in health expenditure to just              Finance Minister Trevor Manuel stressed in his Budget
under R30bn and government’s commitment to                         speech that it was time government focused not just
increase health spending by more than 7% over the                  on spending but on improving service delivery and
next three years was not nearly enough to insulate                 obtaining better value for the money it spent.
the health services against the impact of AIDS. Only               He drew special attention to the health sector, saying
R261m is to be spent this year on fighting the disease.            that improving service delivery meant “reinforcing an
“The funding for AIDS is an appallingly low figure,” says          ethic of care and compassion in our clinics and hospital
Democratic Alliance (DA) AIDS spokesman Sandy                      wards, combating theft of medicines and imposing a
Kalyan. “It’s as though the Minister, Manto Tshabalala-            cost-effective laundry or building maintenance regime”.
Msimang, hasn’t come to grips with the scale of the
epidemic.”                                                         The other items in the news were that senior national
                                                                   Health Department official, Joel Mokonoto, appeared
AIDS funding will come from three main sources:                    in court on charges of fraudulently milking the state’s
•   The Poverty Relief Fund, which will make a single              medical aid scheme of R1,9-million. The assistant
    allocation of R25m this year                                   director at the tuberculosis (TB) laboratory in the Health
•   The Health Department’s budget, which will provide             Department is alleged to have set up a fictitious
    R111m this year, R116m next year and R119m in                  laboratory and submitted claims to Medscheme for
    2003/2004 for government’s AIDS Action Plan; and               people who had not been his patients.
•   The integrated programme introduced last year                  During the month of February, the cholera epidemic in
    involving the Education, Health and Welfar e                   KwaZulu-Natal reached its worst level in 20 years. More
    departments. It will receive R125m this year,                  than a thousand new cholera cases have been
    R300m in 2002/2003 and R313m in 2003/2004 for                  reported every day in the province that month, and
    four programmes: life skills training, voluntary               the health department warned that the infection rate
    testing and counselling, home-based care, and                  could double.
    community outreach and mobilisation.
                                                                   The number of cholera infected people in the province
Supplementary allocations made by the minister were                was close to 35 000, while more deaths were
R120-million in 2001/02 for short-term poverty relief              confirmed, bringing the death toll to 107.
measures, including interventions in response to
                                                                   The department also warned that the spread of the
cholera outbreaks. R580-million will also go to water
                                                                   cholera epidemic to other rural areas where there was
supply and sanitation projects, particularly in areas
                                                                   little infrastructure could not be ruled out. The epidemic
affected by cholera.
                                                                   had already spread to areas of Ladysmith and
Di McIntyre, Director at the University of Cape Town’s             Newcastle, while more and more cases were being
Health Economics Unit, pointed out that the increase               reported in the Pietermaritzburg area.
in health over the next three years would average
                                                                   Positive news was that the Medicines Control Council
7,3 % per year - which would just keep up with inflation.
                                                                   gave Pfizer the go-ahead to begin the supply of its
“It’s on a par with other social services but, overall, it’s       antifungal agent, fluconazole, to the country as part of
less than the consolidated national expenditure, which             an agreement with government.
will increase by 8,1% per year over the next three years.
                                                                   The council was required to assess the product that
This means that spending on health is falling behind,”
                                                                   has been on the market and registered for many years,
McIntyre said.
                                                                   as it would be supplied in a new form to avoid it
“I don’t feel health is getting the kind of policy priority        appearing on the black market.
as before. Prior to 1998/99, it was keeping up with
                                                                   The six-month delay in the approval was criticised by
inflation, and was receiving higher increases than the
                                                                   Zackie Achmat of the Treatment Action Campaign, who
norm.”
                                                                   said the delay had cost lives. “People are dying while
“In fact, what we’re seeing is quite a drop. I do think            Helen Rees (the council’s chairwoman) and the council
the arms deal has contributed to this - it’s clear from            delay registration.”



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HST UPDATE Issue No. 59                                                                                     February 2001




                                             Overview
                            Telemedicine in South Africa
                                                     Kathryn Strachan

Sitting in an office in Pretoria and locating the beating         community or district hospitals which are linked to
heart of a foetus in a Free State hospital through a TV           larger central hospitals - and amongst the services on
screen, a remote control and tele-ultrasound brings               offer are radiology, pathology, opthamology, ultrasound
home the magic of telemedicine - the latest project of            and antenatal screening. The technology also plays
the health services in their drive to bring health care           an important part in conducting research, in collecting
closer to people.                                                 statistical data, and in training.

While still in its pilot phase, the nationwide telemedicine
project is promising to have far-reaching effects in
improving access to specialist services for rural
communities and in improving the quality of health
care.

Although South Africa has been one of the late starters
in the telecommunications game, in just a few years it
has caught up and become a world leader among
developing countries, says Dr Salah Mandil, the World
Health Organisation’s Director on Health Information
and Telematics. South Africa is now ahead of many
other countries in terms of the number of sites
connected up and in the range of medical procedures
being applied. But South Africa does have the
advantage of being able to learn from the lessons of                       Dr Shaheen Khotu and Dr Salah Mandil
other countries, the most important being that the
                                                                  The first phase of the project has cost R10 million to
space-age technology has to be woven into the threads
                                                                  set up, with most of the funds being spent on the
of everyday routine and made a part of the system
                                                                  medical equipment at each end such as the scanner
instead of being set aside as a special project.
                                                                  and the microscope rather than on the computer link.
The main hurdle the project has encountered is the                Phase two of the project, which will begin next month,
unreliable telephone system in remote areas, but its              involves extending the same technology to a further
planners are exploring ways of using radio frequencies            71 sites, mostly clinics, across the country and to
and satellite systems instead.                                    linking up with other medical centres in the SADC
                                                                  region. This phase is expected to cost a further R20
“Information communication is the great divider or the
                                                                  million.
great leveller,” says Mandil, citing the fact that there
are more phones in New York city than there are on                “Despite the distance between the patient and the
the whole of the African continent. “In 1996 sub                  specialist, the service is as good as if the specialist
Saharan Africa had only five phone lines and 142                  was sitting next to the patient,” says Khotu. Other great
radios per 1 000 population and the question that is              advantages are that telemedicine saves the patient the
asked is how can we take hi-tech into Africa when we              inconvenience and cost of travelling all the way to the
don’t even have simple phones,” he says. “The answer              specialist centre and that a diagnosis and treatment
lies in skipping a level of technology - the phone lines          can be given straight away.
- and going straight to digital networks and to find
                                                                  The new technology bridges the gap between the
temporary solutions to overcome the problems of
                                                                  highly specialised and curative services located in
infrastructure.”
                                                                  urban areas and the poor health services in rural areas.
At present, says Shaheen Khotu, Director of the South             It provides a way of sharing skills and cutting through
African Health Depar tment’s National Health                      the problems caused by geographic isolation, scarcity
Information System, there are 30 sites - almost all               of doctors and poor transport systems, says Khotu.




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HST UPDATE Issue No. 59                                                                                    February 2001


The focus of the telemedicine project is on supporting          conveniently, close to their homes. As Shaheen Khotu
primary health care services, particularly for women            says, it is the people and not the technology that
and children. Specialists located at major medical              determine the success of the system.
centres can supervise routine pre-natal care and
sonogram examinations which are carried out by
midwives, thus reducing perinatal and neonatal                   Box 1:
mortality rates. Surgeons can obtain frozen section
                                                                 The National Telemedicine project is being
results of pathological tissue specimens while the
patient is still under anesthesia and complete the               implemented in 3 phases over a period of five
treatment without having to bring the patient back to            years.
theatre for a second operation. Internal medicine
                                                                 PHASE I:    April 1999 to March 2001 - 28 pilot
specialists can make use of high resolution cameras
                                                                             sites over 6 Provinces involving
to study skin and mucosal lesions and assist in the
diagnosis and control and sexually transmitted                               Teleradiology, Tele-ultrasound
diseases and HIV/AIDS. Radiologists can provide                              Ante-natal services, Telepathology,
immediate diagnosis to victims of trauma and patients                        Tele-ophthalmology and the
requiring emergency medical attention, and for all of                        establishment of the National
these, early diagnosis and intervention enables them                         Telemedicine Research Center.
to catch the diseases while they are still at a
preventable or curable stage.                                    PHASE II:   April 2001 to March 2002 - Involves
                                                                             the development of an effective
                                                                             Telemedicine connection between
                                                                             75-sites divided into various
                                                                             Provincial networks for management
                                                                             purposes.

                                                                 PHASE III: April 2002 to 2004, Additional sites as
                                                                            required to meet the rural healthcare
                                                                            needs. Transformation from pilot
                                                                            stage to clinical and operational
                                                                            stage.




              An example of Tele-pathology

In order to deliver these services, the telemedicine
system conducts regularly scheduled electronic clinics
which means that doctors in designated centres are
available at regularly scheduled times to provide
consultations. However, the carrying capacity or
bandwidth needed to transmit a given amount of
information within a fixed period of time still serves as
a practical limit to the size, cost and capability of the
telemedicine system. The South African project is
working with international groups including British and
Italian aerospace to overcome these problems.
But as the technology is used more and more, and as
                                                                              Tele-education in progress
these obstacles are overcome, patients will begin to
use cost-effective primary health care services at
community centres rather than to seek treatment at
tertiary hospitals. And that is the whole aim of the
system – that people can be treated effectively and




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HST UPDATE Issue No. 59                                                                                   February 2001


                                                                There were also problems with personnel as the
          Case study:                                           people who had been trained left after a few months
                                                                and the province had to start training all over again.
       the Northern Cape                                        The community doctors sent to Kuruman were not
                                                                properly orientated and were reluctant to use the
                    Kathryn Strachan
                                                                equipment, which meant that the system was not used
                                                                for the last six months of last year. However an
                                                                undertaking has been reached with Kimberley Hospital
The vast stretches of land and the sparse population
                                                                that all community doctors will be briefed and will
in the Northern Cape made it the ideal site for
                                                                receive hands on training before being deployed to
implementing telemedicine, whose main aim is to link
                                                                Kuruman Hospital.
people and facilities over vast distances and difficult
terrains.                                                       There are a number of ways that the project can be
                                                                taken forward in the Northern Cape, says Hunter. Since
Jeanette Hunter, who runs the service for the provincial
                                                                the numbers involved in antenatal, obstetric and
health department in the Northern Cape, says the
                                                                gynaecological consultations are so small, the
decision to implement tele-ultrasound specifically
                                                                equipment would be more cost effectively applied if
between Kimberley and Kuruman was triggered by
                                                                consultations were extended to other specialities like
the fact that a large proportion of maternal deaths in
                                                                mental health, ENT, radiology and dermatology, she
Kimberley Hospital were made up of women who were
                                                                says. The equipment could also be more actively
transferred from the Kuruman area. There were also
                                                                applied to interactive video conferencing as a teaching
no medical specialists employed at Kuruman Hospital.
                                                                medium, and a link should be established between
The initiative, which began in May last year, involves          Kimberley Hospital and a tertiary institution like
the head of obstetrics and gynaecology from the                 Universitas in Bloemfontein for medical consultations,
receive site, and community doctors and a primary               she says.
health care sister at the send site. So far, she says, 12
cases have been discussed over the telemedicine
system and only four high risk patients were eventually
transferred to Kimberley Hospital - a definite decrease
in the number of cases referred. Telemedicine also
provided an opportunity for community doctors in the                     Case study:
district hospitals to learn the basic elements of
ultrasonography.                                                      Kimberley Hospital
The problems encountered have been mainly                                           Kathryn Strachan
technical. The link was supposed to be set up in 1999,
                                                                Dr Eleno Napoles Urgelles, who was the medical
but it only became operational last year because the
                                                                doctor working with the telemedicine system in
incorrect lines had been installed. Telkom corrected
                                                                Kimberley Hospital, sees great potential for the system
the mistake and the proper bandwidth ISDN lines were
                                                                in the Northern Cape. Costs of referrals from district
installed. The initial modem also had to be replaced
                                                                hospitals to Kimberley Hospital, the only provincial
and problems are still being experienced with the store
                                                                hospital, can be greatly reduced and telemedicine can
and forward function.
                                                                be used to improve primary health care services
                                                                without necessarily having a doctor in each centre.
                                                                The country can definitely benefit from telemedicine
                                                                by using it as a vehicle for taking specialist services to
                                                                the most remote areas, he says.

                                                                At Kimberley Hospital he used the technology for
                                                                ultrasound scanning in high risk pregnant women and
                                                                in assessing patients with gynaecological problems.
                                                                His training consisted of an ultrasound course at the
                                                                University of the Free State and a short course on how
                                                                to operate telemedicine equipment. He did not
                                                                experience many problems with the equipment
                                                                because the ultrasound machine and the computer
                                                                were part of the whole unit.

         An example of the Tele-ultrasound image                Consultations are done once daily and a weekly



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HST UPDATE Issue No. 59                                                                                       February 2001


programme is drawn up and consultants rotate to
attend to telemedicine consultations. The telemedicine                       Is telemedicine
system means that the community doctors are
exposed to the basic elements of obstetric and
                                                                             really working?
gynaecological ultrasonography, and these need to be                                   Kathryn Strachan
built into their training programme.
A lack of understanding on the part of doctors and
                                                                   Dr Sam Gulube, who works at the Medical Research
nurses leads to reluctance to use telemedicine in some
cases, he says, but this can be overcome with regular              Council, has been given the task of evaluating the
                                                                   national telemedicine system. “The future of
use and training. Once the benefits are clear to
everyone, the acceptability of the system will improve,            telemedicine in South Africa seems to be in good
he says.                                                           hands because the first phase of the National
                                                                   Telemedicine system has been welcomed by the
                                                                   young doctors doing their community services in the
                                                                   remote parts of the country,” he says. The young
                                                                   clinicians described telemedicine as an effective
            Case study:                                            information communications technology that improved
                                                                   their ability to diagnose and manage difficult medical
         the Eastern Cape                                          conditions and reduced feelings of professional
                                                                   isolation.
                     Kathryn Strachan


Dr Lech Banach, director of the telemedicine unit at
the University of Transkei (Unitra), was one of the first
to start using the new technology. Unitra began working
with telemedicine about five years ago, sending their
pathology samples off to the Armed Forces Institute
of Pathology (AFIP) in Washington for special
investigations and second opinions. The reason for
choosing the AFIP service, which is given free of
charge to developing countries, was their secure web
server, next-day results and the excellent service, says
Banach.

Pathology samples and x-rays are sent to his Unitra
centre from the rural Eastern Cape hospitals of
                                                                          Case presentations using telemedicine set-up
Lusikisiki and Rietvlei for diagnosis via the telemedicine
link, and his centre sends the results back usually
within 30 minutes - which saves the patient having to
                                                                   In a nutshell, telemedicine can be an important strategic
travel 300km for a five minute consultation. They also
                                                                   tool in delivering equitable health care and educational
use the technology for continuing medical education
                                                                   services irrespective of distance and the availability of
and for video conferencing, and many doctors in rural
                                                                   specialised expertise particularly in rural areas.
hospitals have expressed an interest in further services.
                                                                   The initial idea in 1998 was to implement the
The main problem facing telemedicine in the area is
                                                                   telemedicine system in three phases over a period of
the phone lines which can be down for months at a
                                                                   five years. Since then, there have been concerns raised
time or simply suspended for six months for no reason
                                                                   about various technical problems and project
at all. The CSIR is working on developing a microwave
                                                                   management, but overall the response has been
or radio frequency, which if successful, will end the
                                                                   positive. Doctors doing their community service in the
dependence on Telkom lines. The radio frequency link
                                                                   remote health facilities of the Free State reported that
would have a narrow radius and would be used only
                                                                   the telemedicine system enhances their confidence in
to connect former Transkei clinics with Umtata.
                                                                   diagnosing and managing various medical conditions
Hi-tech equipment is not necessary, he says, and the               particularly those related to trauma and chest diseases
technology is more likely to be accepted if it is simple           and they felt that the system was able to reduce the
and easy to use. If it is too complicated it is difficult to       number of transfers. In the North West Province the
integrate into the hospital system.                                community service doctors noted that the system



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HST UPDATE Issue No. 59                                                                                    February 2001


enabled them to differentiate between chronic TB                community health facilities without having to transfer
lesions and occupational lung diseases such as                  the patient to urban tertiary centres. One case of a
asbestosis and lung cancers. A number of transfers              walk-in traumatic cervical spine dislocation was
were avoided by enabling the doctor to correctly                diagnosed within few minutes using the system and
diagnose the lung disease rather than transfer the              the patient was immediately immobilised and
patient to a higher level of care because of uncertainty        transferred thereby avoiding further injury. Some
about the diagnosis. The system was noted to be                 trauma patients had cervical abnormalities that were
useful in detecting bone tumours from symptomatic               not initially recognised at the remote sites. The
patients. Some of the symptoms that were thought to             diagnosis was made by the specialist radiologist by
be from arthritis were found to be from bone tumours            teleradiology and appropriate management was
requiring a drastic change in management.                       instituted. Because of all these successes, the
                                                                provincial tertiary institution has requested that, for the
Some doctors said that before the introduction of
                                                                time being, all trauma spine x-rays from the
telemedicine in their facilities, many trauma patients
                                                                telemedicine site must be read by the specialist
complaining of neck pain were transferred
                                                                radiologist through the teleradiology system. The
unnecessarily because primary care providers were
                                                                current practice is that the primary doctor in charge
not able to read cervical spine x-rays. Now with the
                                                                reads the x-rays and specialist consult is requested as
teleradiology system, primary care providers are able
                                                                needed.
to institute appropriate management in their
                                                                The tele-ultrasound antenatal application for the first
                                                                phase of the National Telemedicine system was
                                                                designed to move the pre-natal ultrasound services
                                                                from the provincial referral centre to the remote and
                                                                rural community health centres. The purpose of tele-
                                                                ultrasound is to:

                                                                •   Train health care providers in the use of ultrasound
                                                                    service for pre-natal care

                                                                •   Provide tele-consultations for pre-natal care

                                                                •   Provide diagnostic and management services for
                                                                    complicated pregnancies.

                                                                Antenatal tele-ultrasound consultation has primarily
                                                                been used to train primary care providers and to
                                                                consult with an obstetrician about complicated
                                                                pregnancies. A number of cases that would have been
                                                                transferred for further investigation have been
                                                                managed locally without transferring the patient to the
                                                                tertiary site because primary care providers have been
   X-ray images transmitted via one telemedicine system         able to seek the advice of specialists using this system.
                                                                In evaluating the project, Dr Gulube has looked at:

                                                                •   How it has improved access to care for dis-
                                                                    advantaged communities
                                                                •   How it has improved quality of care

                                                                •   Whether it is cost-effective or not.

                                                                His evaluation confirms many issues identified by other
                                                                international telemedicine projects. Almost all of the
                                                                South African sites had operated for less than 9 months
                                                                at the time of his evaluation, and five of 28 sites were
                                                                still experiencing serious technical problems 9 months
                                                                into the operational stage. Most of the time the
                                                                outcomes are not quantifiable and can not really be
                                                                converted into Rands and Cents. The comparison in
                                                                the evaluation study was between the telemedicine



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HST UPDATE Issue No. 59                                                                    February 2001


system and the system in the absence of telemedicine.
In some parts of the country, the telemedicine pilot
was undertaken without a comparable system,
because telemedicine was used to provide a service
that was not available before, while in other parts
telemedicine was used to improve the quality of care,
he says.

An important take home message from Dr Gulube is
that telemedicine is not a substitute for face-to-face
medical practice, but rather it is a tool to compliment
the current health care delivery in South Africa.




 Box 2: TELEMEDICINE SITES AND APPLICATIONS

 PROVINCE                                                        MODULE
 Eastern Cape 2 sites
     Umtata Hospital                  Lusikisiki                 Tele-pathology
 Free State 4 sites
     Universitas Hospital             Harrismith Hospital        Tele-radiology
     Zastron Hospital                 Senegal Hospital

 Kwazulu Natal 11 sites
     Edendale Hospital                Madadeni Hospital          Tele-ophthalmology
     Ixopo                            King Edward VIII           Ante-natal Tele-ultrasound Services
     GJ Crooks Hospital               Stanger Hospital
     Gandhi Hospital                  Kwadabeka Clinic
     Osindisweni Hospital             Port Shepstone Hospital
     Phoenix Clinic
 Northern Cape 2 sites
     Kimberly Hospital                Kuruman Hospital           Ante-natal Tele-ultrasound Services

 Mpumalanga 5 sites
     Pretoria Academic Hospital       Witbank Hospital           Tele-radiology and Research Centre
     Themba Hospital                  Ermelo Hospital
     Philadelphia Hospital

 North West 4 sites
     Klerksdorp Hospital              Bophelong Hospital         Tele-radiology
     Taung Hospital                   Lehurutshe Hospital

 Pretoria National DoH Site                                      Project Management Centre




                                                            11
HST UPDATE Issue No. 59                                                                                   February 2001




                                          HST News
                              Peoples Health Assembly
                                      Bangladesh - December 2000
                                                    Carmen Baez

With the aim of strengthening the movement towards              From the Third World Network came a plea for
long-term sustainable solutions to global health                enhancement of worldwide networking and co-
problems and to ensure “Health for all”, a Peoples              operative action, especially in regard to poverty
Health Assembly (PHA) – a grass root level organisation         eradication. It was, indeed, a time of sharing worldwide!
– took place in Bangladesh during 4 th to 8th December          The media were prominent in recording this event.
2000.

Over 1 800 delegates from 93 countries gathered at
Gonoshasthaya Kendra (GK) campus at Savar, about
one hour’s drive from Dhaka. Although the 300+ Indian
contingent was by far the largest, there was good
representation from South/Southeast Asia, Latin
America, and Africa, and smaller contingents from
elsewhere (including Europe, North America and
China). South Africa’s delegation comprised 12
delegates representing NGO’s, students and other
projects.

On 3rd December a “Global March for Health” took place
in the afternoon. The formal meeting then took place
over the following five days. Each day had a different
theme – Health, Life and Well-being; Inequality, Poverty                 Carmen Baez with participants from the
and Health; Health Care and Health Services;                                  People’s Health Assembly
Environment and Survival; The Ways Forward.
                                                                The afternoons and evenings were filled with more
Relevant speakers included Dr.Halfdan Mahler – ex
                                                                special interest sessions, organised both by topic and
Director-General of the World Health Organisation (and
                                                                by geographic regions. Artistic performances from the
chief architect of the original primary health care             different regions of the world and stalls and exhibitions
model), Mr.Richard Skolnik – regional World Bank                welcomed many visitors. Although the days were full
representative for South Asia, Dr. Mira Shiva – social          there was still time for community and sharing of meals
activist from India, Mr. David Werner of “Where There           by participants. A daily newsletter was produced every
Is No Doctor” fame, Dr. Zafrullah Chowdhury, founder/           night to highlight the most salient events. The local
director of the host institution, and many others               organisation by Gonoshasthaya Kendra, our
provided vibrant inputs during the conference.                  Bangladeshi host NGO in their beautiful campus
Most plenary sessions took the form of stories from             outside Dhaka, was commendable and the support
the grassroots level narrated by people involved with           by the local community inspiring; their women
panels consisting of representatives from across the            prepared and served our meals as an income
world, responding to those stories. A survivor of the           generating exercise.
Bhopal, India disaster, where chemicals killed 10 000           After a laborious and participatory process of
and injured 20 000 more, told a story of community              consultation, participants adopted the PEOPLE’S
mobilisation and aggressive action calling for more             CHARTER FOR HEALTH. This groundbr eaking
corporate responsibility. From the Philippines a story          manifesto, together with PHA’s Framework Paper and
was presented of community action around the theme,             four topical Background Papers which clearly spell out
“maybe no medicine is better than bad medicine”,                what PHA stands for can be found on PHA’s website
opposing the privatised control of essential drugs.             at www.pha2000.org.



                                                           12
HST UPDATE Issue No. 59                                                                                    February 2001


Central to all of this was the development of a plan on
the way forward. The last day of the Assembly was
totally devoted to this. The voices of over 100
participants were heard and some of the suggestions
included:

•    Wide dissemination of the Peoples’ Charter for
     Health

•    The organisation of a solid network and sub-
     networks on specific issues
•    Using the website, mailing lists and email list-
     servers,
•    The translation of PHA documents into many                            Panel at one of the sessions at the
     languages including simple language versions                             People’s Health Assembly
•    Challenging local health decision-makers to a
     dialogue on people’s health issues

•    Holding annual PHA meetings at national level by
     monitoring the implementation of pro-people health
     initiatives.
                                                                  Publication of interest
    The South African delegation included the following
    people:

    Prof. David Sanders, Director of the Public Health
    Programme, UWC                                                  The National Primary Health Care
                                                                         Facilities Survey 2000
    Prof Sazi Nyathikazi, Commnunity Committee
    Member, Niche (Natal Institute for Community                            Commissioned and published by
    Health Education)                                                         the Health Systems Trust
    Sybil Bongiwe Shawuka, Proffessional Nurse,
    Halley Stott Health Centre
                                                                 Notable moves, either towards or away from equity
    Robin Joubert, Member of Executive,Niche (Natal              in Primary Health Care (PHC) provision in South
    Institute for Community Health Education)                    Africa, are observed when comparing the 1997/
                                                                 98 and the 2000 PHC Facility Surveys. Significant
    Mrs Bongiwe Mhlauli, PN, Mntwana Clinic, Mt Frere
                                                                 strides towards improvement have undoubtedly
    Health District
                                                                 been accomplished. Sadly there are also areas in
    Mrs Busisiwe Sikrweqe, Community Health Worker,              which inequity has increased. Given the supposed
    Mntwana Clinic, Mt Frere                                     increased prioritisation of and budgetary allocation
                                                                 to PHC in South Africa in recent years,
    Dr. Boshi Mohlala, Director, Rural Support Network
                                                                 improvement across the spectrum of indicators
    Johan Montsioa, Rhoda Sinela, Victoria Manzini and           measured in this survey could have been
    Dr Carmen Baez from SAHSSO - Gauteng.                        expected. Sadly many areas of PHC remain in dire
    Mpefe Ketlhapile, researcher, Women’s Health                 straits. Undoubtedly there have been marked
    Project                                                      changes for the better in PHC provision; equally
                                                                 true is that such improvements seem to come at
    1 TAC representative                                         the expense of other areas of PHC.
    2 students                                                   Authors: Dingie van Rensburg, Renier Viljoen,
                                                                 Christo Heunis, Ega Janse van Rensburg, Annalize
It is never too late to join the People’s Health Assembly        Fourie, Centre for Health Systems Research &
movement either as individuals or as organizations.              Development, University of the Free State
Just drop a line to phasec@pha2000.org or
gksavar@citechco.net and regularly visit the website.
                                                                 Copies can be ordered from HST or email:
(With thanks to Professor David Sanders in putting this          Cynthia@hst.org.za
report together).



                                                            13
HST UPDATE Issue No. 59                                                                                     February 2001




                                                e-News
                        Using Electronic discussion lists
                                                      Rakshika Bhana

Many institutions are turning to the use of electronic             From a more technical perspective, these programmes
discussion groups to conduct their business, whether               are set up so that a message can be sent to a central
it be as a tool for information dissemination, for group           address (eg, lyris, listserv, majordomo), which then
discussion and announcements, for advertising, or for              takes over the task to process the message and to
general interest. Mailing lists can be further classified          send it out to all subscribers on the list. This central
into a number of categories, depending on whether                  computer programme also handles the job of adding
they are used for discussion or for the one-way                    and removing subscribers. Mailing lists generally have
dissemination of information and whether they are                  two distinct addresses, the first being the “listname”
open to the public or closed to serve particular interest          address that is used to send a message to subscribers
groups. These lists are characterised by the fact that             on the list. The second important address is the
people who are members of the list automatically                   “command processor” and this is used to send
receive an e-mail message when a message is posted                 administrative requests such as “subscribe” and
to the list.                                                       “unsubscribe” to the server.

There are various Listservers (computer programmes)                The exact form of a command varies slightly between
that are used to run electronic mailing lists and all these        the various mailing list programmes. Below is a table
servers operate on the same basic principle and                    outlining the basic commands for subscribing and
purpose but differ in the set of commands that are                 unsubscribing to the most common mailing list
used to communicate with the server. Often users are               programmes. To use these commands a message
confused because a command that works for one list                 must be sent to the mailing list command processor.
may not necessarily work for another. Some of the
familiar “brand names” for computer programmes used
to run mailing lists include: Listserv, Listproc,
Majordomo, Mailbase and Lyris.


  Programme                Subscribing                                             Unsubscribing

  Listserv / Lyris         SUBCRIBE [listname] Firstname Lastname                  SIGNOFF [listname]
                           e.g. SUBSCRIBE localgov John Smith                      or
                                                                                   UNSUBSCRIBE [listname]

  Majordomo                SUBSCRIBE [listname]                                    UNSUBSCRIBE [listname]
                           (e.g. SUBSCRIBE localgov)                               (UNSUBSCRIBE [listname] [address]
                                                                                   if you subscribed under a
                                                                                   different e-mail address.)

  Listproc                 SUBSCRIBE [listname] Firstname Lastname
                           (e.g. SUBSCRIBE localgov John Smith)                    UNSUBSCRIBE [listname]

  A more detailed list of mailing list commands can be viewed at the following web address:
  http://www.wesleyan.edu/libr/infokey/mailser.htm

  Other relevant health related information / discussion lists / news alerts can be found at the following websites:
  http://www.healthnet.org
  http://www.health-e.org.za
  http://www.kaisernetwork.org/email_alert/email.cfm

  http://www.hdnet.org



                                                              14
HST UPDATE Issue No. 59                                                                                       February 2001


One of the key objectives of the HealthLink programme              Usage guidelines differ from list to list, but some
of the Health Systems Trust (HST) is the effective and             general points about list usage can be made:
appropriate dissemination of information for the health            •   Keep the welcome message you are sent when
services through the establishment of a                                you first subscribe to the list. It generally contains
communication infrastructure. One of the ways in                       important     technical       information       about
which this objective has been successfully achieved                    unsubscribing from the list or changing your
over the past few years is through the implementation                  subscription options, as well as information about
and management of the Lyris listserver. By hosting                     the purpose of the list
open and closed e-mail discussion lists, Lyris serves
both the programmatic needs of the HST as well as                  •   Make sure that you direct your messages to and
the communication needs of organisations working                       reply to the correct addresses, viz. the list name
closely with the HST. The number of lists hosted by                    address, command processor address or individual
the HST has steadily grown over the past years and at                  poster as the case may be. Sending administrative
present the following open discussion lists are                        requests to the list name is just annoying for other
available.                                                             list members; sending what you intended to be a
                                                                       private response to an individual to five hundred
localgov:       Local Government Discussions
                                                                       people can be very, very embarrassing
repro-l :       Reproductive Health Discussion list
                                                                   •   Don’t set your e-mail programme to acknowledge
dhs-l:          District Health Systems                                receipt or delivery of messages, or set up “automatic
mailadoc:       Doctor’s Dialogue                                      replies”. In the case of unmoderated lists, these
                                                                       messages will go to everyone on the list. In the case
druginfo:       Drug Information and Policy
                                                                       of moderated lists they will create unnecessary
mchmail:        Maternal and Child Health                              work for the moderator
fam-doc-l:      Family Medicine Discussion List                    •   Unsubscribe from lists if you are going to be without
hlinfo-l        HealthLink Bulletin: The bulletin is                   e-mail access for an extended period, or suspend
                distributed weekly and aims to update                  your mail if the list gives you this option
                subscribers on developments in the                 •   Familiarise yourself with the tone and “culture” of
                health system in South Africa.                         the list
Please note that these lists are targeted at health workers        •   If you are asking for assistance, formulate your
and those involved in policy/planning or research in                   question carefully so as to elicit meaningful
health in South Africa, and are not intended to provide                responses
health information to the general public.
                                                                   •   Use the subject line intelligently. For example, if
                                                                       you’re looking for a book on the Boer War don’t just
To SUBSCRIBE to any of these lists will require the
                                                                       title your message “Help wanted”. Rather head it
following:
                                                                       along the lines of “Boer War reference needed”
  Send an e-mail to:                                               •   DON’T WRITE ALL IN CAPITALS – it looks as though
            lyris@healthlink.org.za                                    you’re SHOUTING

  with the following command in the body of the message:           •   Don’t attach files to messages you send to lists

            subscribe listname Firstname Surname                   •   Don’t include the entire body of a long previous
                                                                       message in your response – edit it so that only the
                                                                       essentials are included in your message
A description as well as subscription instructions for
                                                                   •   Don’t forward chain letters or virus warnings. If you
the abovementioned lists can be found at the following                 receive a virus warning which you suspect may be
HST website: http://www.hst.org.za/info/hllists.htm
                                                                       true, forward it to your IT support section for
Any queries can be directed to:                                        verification, or take the time to check it out yourself
listadmin@healthlink.org.za                                            at a reputable anti-virus site such as Symantec:
                                                                       http://www.symantec.com/avcenter
Mailing list usage guidelines                                      •   Turn off html/RTF encoding in your e-mail software.
The following guidelines are taken from an article titled              Rootsweb provides an explanation of how to do
“Using mailing lists”, by Ann Tothill. The full article is             this in a variety of e-mail packages:
available for your perusal at: http://www.nrf.ac.za/                   http://www.rootsweb.com/rootsweb/listowners/
yenza/internet/maillist.htm                                            html-off.htm



                                                              15
HST UPDATE Issue No. 59                                                                                       February 2001




                                        Book Launch
                      South African Health Review 2000


The Health Systems Trust                                                            The HIV/AIDS epidemic does not only
launched the South African                                                           affect those with living with HIV, their
Health Review 2000 on the                                                             families and carers, it also places a
1st of March 2001. This is an                                                          huge burden on staff in clinics and
annual publication that                                                                 hospitals who are providing care,
provides an annual and longer-                                                           often in less than ideal
term review of health policy                                                              circumstances, and on health
developments in South Africa.                                                              service planners and managers
The foreword best describes this                                                            faced with competing demands
Health Review: “The year 2000                                                                for resources. The successes
                                                                                              identified in this Review are
was a significant one in terms of
developments affecting the health                                                              testament to the commitment,
                                                                                                dedication and hard work of
sector. Local Government elections
in December heralded the beginning                                                               health service staff.”
of the final stage of the transformation
of Local Government, paving the way
for the full implementation of the                                                                     The image used on the
District Health System.                                                                                   cover is a beadwork
The National Health Accounts were                                                                            design created by
undertaken, providing an overview of                                                                Khulangani Khomo of the
financing and expenditure in both private                                                             Sinikithemba HIV/AIDS
and public sector care. And, as can be                                                  Centre at McCord’s Hospital, Durban.
evidenced by the frequent references to                                            The beadwork map of South Africa is based
HIV/AIDS in many chapters of this Review,                                                 on a design by Vedant Nanakchand.
the impact of the epidemic began to be felt
in almost every aspect of the health system. This first
South African Health Review of the millennium aims
to provide a combination of detailed information on                 Anyone who wishes to view the contents of the
health status and health care coupled with in-depth                 South African Health Review 2000 can visit:
analysis of policies and practices affecting the                    http://www.hst.org.za/sahr/2000/
provision of health services in South Africa.
                                                                    Orders can be obtained from
Recent Reviews have been characterised by a
                                                                    cynthia@hst.org.za. Please include full postal details.
particular focus on policy implementation and this is
                                                                    The prices are as follows:
maintained, as is an emphasis on equity, especially in
regards to financing and expenditure.                               South Africa (Public Sector/NGO): R200ea (book);
                                                                    R65ea (CD); R250ea (Book and CD)
In 1997, again in 1998, and most recently in 2000, the
Health Systems Trust commissioned a survey of                       South Africa (Others): R250ea (Book); R65ea (CD);
primary health care facilities. The survey forms part of            R300ea (Book and CD)
an ongoing monitoring of progress in implementing
                                                                    Other countries: US$80ea (Book); $20ea (CD); $90ea
Primary Health Care. Key findings from the Survey are
                                                                    (Book and CD)
provided in the Review, and they provide a unique
insight to quality of care in public sector clinics in South        A 10% discount is offered for orders of 10 or more
Africa.                                                             books and CDs (Bulk orders).


                                                               16

				
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