Remote Patient Monitoring: Drawbacks and Its Importance in Africa

1. Introduction

Did you know that Remote Patient Monitoring (RPM) has been around  for almost 150 years? In 1948, the concept of telehealth was put into test when physicians in West Chester sent radiology images 24 miles over a telephone line when doing a consultation with another physician in Philadelphia, USA. This subsequently became a norm for other medical practitioners such as the doctors, psychiatrists etc to make consultations relying on telehealth (the 1876’s Graham Bell’s invention, the telephone, becoming the channel through which to communicate to anyone anywhere).

In the 1980’s, certain African countries had started telemedicine projects; Nigeria, Ghana and Gambia became part of the HealthNet project in 1980. Kenya and Uganda also introduced a telemedicine project in cooperation with several international organizations around the same time. Between 2000 – 2001, a successful attempt to use telemedicine services was achieved in South Africa and Mozambique for teleconsultation and distance learning. RPM was also used in some parts of Africa to effectively fight the Ebola virus.

The adoption and development of remote patient monitoring (RPM) has been influenced by several significant global health trends. Advances in healthcare have improved diagnosis, treatment, and prevention of diseases. Access to interventions like vaccinations and antibiotics has reduced the impact of infectious diseases. Medical technology and therapies manage chronic illnesses, extending lifespans. These advancements have reduced mortality rates and improved population well-being. But as life expectancy rises and the elderly population grows (in different parts of the world – not just industrialized nations), a key concern is whether this ageing demographic will experience good health and quality of life. This is because the rise in the ageing population has been accompanied  by an increased prevalence of chronic illnessesdisability which have put a strain on socioeconomic and health systems globally.

Without a doubt, the COVID-19 pandemic has played a pivotal role in cementing the use of RPM as an essential healthcare practice. The unprecedented global health crisis necessitated innovative solutions to monitor and manage patients while minimizing the risk of viral transmission. RPM emerged as a crucial tool in this regard, allowing healthcare providers to remotely monitor patients’ vital signs, symptoms, and health data. It enabled timely identification of COVID-19-related complications, facilitated early intervention, and helped prevent the overwhelming of healthcare systems.

Whereas there might be risks associated with the transfer/sharing of sensitive patient data, it is argued in this piece that RPM is a crucial aspect of modern healthcare. Further, that the pandemic acted as a catalyst, accelerating the adoption of RPM as a mainstream healthcare approach.

2. Is RPM vital for healthcare systems in Africa? 

2.1 Making the case for RPM in Africa

RPM to the medical practitioners has become indispensable in some cases because when diagnosis is made at the right time and accurately, a patient has a higher potential for a positive health outcome. This is because decision making is tailored to a correct understanding of the patient’s conditions. Tools such as wearable devices are able to track activity levels, heart rate, and other vital information about patients.

The doctor to patient ratio in Africa remains worrisome (as of 2022 estimated to be 1:10,000). RPM could more broadly reduce the burden on healthcare systems – through reduced queues, reduced patient visits/admissions; and in some cases some of these tools ease the work of  medical practitioners by providing analytics that help in interpreting the data.

RPM holds several advantages for healthcare in African countries. Firstly, it addresses the challenge of limited healthcare access in remote areas. RPM enables healthcare providers to remotely monitor patients’ health conditions, allowing individuals in rural or underserved regions to receive timely care and interventions without the need for long and costly travel. Secondly, RPM enhances disease management and prevention in African countries. With the prevalence of chronic diseases such as cancer, hypertension and diabetes, RPM enables continuous monitoring of patients’ vital signs, medication adherence, and disease progression. This proactive approach enables early detection of complications, timely intervention, and improved management of chronic conditions, ultimately reducing morbidity and mortality rates.

Below is a summary of some positive use cases from Africa.

Some impactful use cases for RPM in Africa
Disease management – 
In Nigeria noncommunicable diseases account for 24% of the deaths. These diseases include heart diseases, stroke, cancer and type 2 diabetes. According to WHO, these diseases are preventable through regular physical activity and maintaining a proper diet, and using remote patient monitoring. With existence of self-monitoring devices, healthcare providers can monitor a patient’s progress.

Infectious disease control – Overcrowding especially in the healthcare centers was a very easy way to transmit infectious diseases. Covid-19 known for being a world-wide pandemic for its highly infectious nature, was known to have triggered the use of digital health technologies. To reduce Covid-19 transmission but still effectively deliver healthcare, crowding in the healthcare centers was to be stopped and integration of emerging technologies took the upper hand to support delivery of virtual healthcare. These emerging technologies included telemedicine and smart wearable devices that were used to track the patient’s condition without needing to physically visit the healthcare centers.

Patient awareness –  with the RPM tools, the patient is able to track their healing process. For example, for overweight persons trying to lose weight, with the help of RPM tools like smart watches, they are able to see how many calories they have burned due to their physical activities. With this information, healthcare providers and caregivers can help by advising the patients accordingly. A study concluded that smartwatches helped improve glycemic control among diabetic patients in Kenya.

Reducing burden on the healthcare systems – A lot of preventable hospital admissions can be avoided in healthcare centers that have integrated telemedicine to their systems. This ensures that caregivers and medical professionals are able to notice abnormalities in the patient’s health conditions and work with the patients towards finding the reasons why and how to control the health condition back to normal. For example if the sugar levels are not tracked and they go up or below the normal, that usually leads to hospital admissions which are preventable if noticed early enough.In Nigeria, a study found that RPM tools reduced hospital readmissions among patients with obstructive pulmonary disease by at least 50 %. Below are actual examples.

Baobab circle – This is a RPM solution that exists in seven African countries but registered in the UK. It was initially a provider of personalized chronic disease management known as Afya Pap that used AI and behavioral science to improve management of chronic conditions by providing personalized patient monitoring using SMS and their application.Clinitouch – It is a solution that provides RPM in South Africa, Namibia and Nigeria. It provides a very user friendly interface for both the patients to update their health metrics and clinician dashboards to have a quick look into their patients and assess where and when interventions are required.

2.2 Challenges facing RPM in Africa

Still, RPM in the African setup could be different because of a number of reasons including low network/internet connectivity, limited access to technology (described as a high digital divide currently being experienced in low-and-middle-income countries), low levels of mobile and digital skills, and low income to afford these new technologies. Many regions in Africa still lack reliable internet connectivity, electricity, and access to smartphones or wearable devices. This has meant that communities/individuals are still largely left behind when it comes to access to RPM.

Further, rolling out an RPM also comes with other extra costs which include software costs, technical staff to manage the systems and costs on training the staff to use the new technology; the software may also come with other licensing costs that raise the total cost of ownership.

Integrating RPM to existing healthcare systems is a big challenge as different healthcare providers use different healthcare software, standards and infrastructure. Some healthcare systems use outdated software technology stacks;  ensuring interoperability between modern and legacy systems accurately and securely becomes very challenging.

Another significant consideration is the potential for risks to personal and sensitive data privacy and other data governance related risks. RPM involves the collection and transmission of sensitive patient health data, which must be protected to maintain patient confidentiality and prevent data breaches. This may pose challenges in implementing and enforcing robust data protection measures. Addressing these challenges requires heavy investments in infrastructure, technology, capacity, and data governance frameworks to ensure the secure and ethical use of patient data.

3. The question of personal and sensitive data and RPM in Africa

If proper security measures are not in place, such as encryption protocols and secure data storage systems, personal and sensitive information can be intercepted, leading to breaches of patient privacy and which can erode the trust in an entire healthcare system (not just RPM interventions).

Additionally, a lack of clarity or transparency in the consent process can result in patients being unaware of how their data is being used or shared, compromising their privacy rights.This especially comes into play when patients data is used for clinical research. The informed consent process for clinical trial participants may be negatively impacted by challenges pertaining to understanding, comprehension, competence, and voluntary participation of patients. Ethical issues for example arise when a data subject is provided monetary incentive to share sensitive information – particularly in LMICs where incomes may be low (diminishing autonomy of the data subject) – or where the patients’ anxiety over their debilitating health conditions currently overrides their comprehension of longer term implications and risks.

Article 5 of the GDPR sets out 7 principles for the lawful processing of personal data that have become standard for a number of Data Protection Laws around the world. These are summarized as: 1) Lawfulness, fairness and transparency; 2) Purpose limitation; 3) Data minimisation; 4) Accuracy; 5) Storage limitation; 6) Integrity and confidentiality; 7) Accountability.  These principles and good practices have been adopted in many data protection laws in Africa. However, even where clear and transparent privacy policies should be established (as of 2022, 36 out of 54 African countries had data protection laws), enforcement of such policies and laws might still be wanting due to lack of implementation resourcing and independence of the offices responsible to enforce these laws. This in turns means that processes that auditing and monitoring data, conducting periodic risk assessments, and performing audits to identify and address any vulnerabilities or non-compliance issues are still severely lacking.

Lastly, the African setup is intricately intertwined with diverse cultures and traditions, which significantly shape the way healthcare is approached and received. Many healthcare products and tools developed primarily in the Global North often fail to account for the cultural distinctions present in Africa. These tools, designed without considering the local customs, languages, and practices, struggle to resonate with the African context, hindering their ability to deliver optimal healthcare outcomes. For example, in Africa, the notions of community rights hold great significance and are deeply rooted in the cultural, social, and historical contexts of the continent. Community rights recognize the collective rights of communities, encompassing their land, natural resources, cultural heritage, and traditional knowledge. These rights are often intertwined with the principles of stewardship, self-determination, sustainability, and intergenerational equity, collective-responsibility;  emphasizing the responsibility of communities to protect and preserve their resources and knowledge.  The lack of cultural relevance creates a disconnect between the healthcare solutions offered and the cultural values and beliefs of the African people, underscoring the importance of developing healthcare technologies and interventions that pursue sustainable technological advancements that are in harmony with traditional norms and values.

4. A proposed way forward

Moving forward, addressing the challenges facing RPM in Africa requires a multi-faceted approach that encompasses infrastructure development, data governance, privacy protection, and cultural relevance.

Beyond investments in infrastructure and capacity, the development of remote patient monitoring (RPM) tools should also ensure interoperability of data and adherence to data standards. In local ecosystems, various stakeholders, including healthcare professionals, tech developers, patient advocacy groups, and policy makers, play vital roles in this process. Collaborating among these stakeholders is crucial to establishing well-informed standards that may address the interoperability of data and promote adherence to data standards.

It is also argued that for data governance frameworks that oversee these technologies to be robust, they should not just be based on international principles, but should also be culturally relevant to values and traditional norms in Africa. Collaboration with local communities, healthcare professionals, and policymakers is essential to ensure that RPM solutions are aligned as stated.

In conclusion, to ensure successful implementation of remote patient monitoring (RPM) in Africa, a collaborative and bottom-up approach is needed. It is essential to actively involve local stakeholders in the design and implementation of RPM solutions, considering their cultural context and healthcare needs.

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