Enhancing Healthcare Access in Pakistan
Pros and Cons of Telemedicine in Pakistan
by Minal Zaman Cheema*
Healthcare in Pakistan faces an array of challenges, including issues of accessibility, affordability, and quality of service. The country has a mixed healthcare system which includes both public and private healthcare facilities. The government-run public system is inadequately managed and includes hospitals, clinics, and healthcare centers. More often than not, these facilities face severe challenges of insufficient funding, outdated infrastructure, and a shortage of properly trained healthcare professionals. The private healthcare sector in Pakistan is relatively well-developed and better equipped, with more advanced and specialized services compared to the public ones, making them expensive and less accessible to lower-income populations.
Pakistan faces a significant burden of communicable diseases such as tuberculosis, malaria, and hepatitis, in addition to non-communicable diseases like cardiovascular diseases and diabetes. Maternal and child health remains a concern, with issues such as high maternal mortality rates and malnutrition among children. The healthcare infrastructure in Pakistan varies across regions, with urban areas generally having better facilities compared to rural areas. Remote and underserved areas often lack access to basic healthcare services.
Efforts have been made by the government of Pakistan to initiate various programs to improve healthcare, including the Prime Minister's Health Program and the Sehat Sahulat Program in 2015, aimed at providing health coverage to lower income populations. However, these projects saw little success due to lack of funding and political instability in the country. Recently we did a research survey on the awareness of telemedicine, a digitalised branch of healthcare, in the region of Islamabad Pakistan.
What is Digital Health and Telemedicine?
Digital Health Interventions refers to the utilization of digital and mobile technology to support the health system in service delivery. Over the recent years, advanced computing, genomics, and artificial intelligence are considered part of digital health. In the context of the World Health Organization global strategy 2020–2025, digital health is defined as “the field of knowledge and practice associated with the development and use of digital technologies to improve health.” Under its umbrella, digital health interventions include mobile health apps, electronic health records, electronic medical records, wearable devices, telemedicine, as well as personalized medicine.
Telemedicine is the practice of medicine over a distance, in which interventions, diagnoses, therapeutic decisions, and subsequent treatment recommendations are based on patient data, documents and other information transmitted through telecommunication systems. This is the definition of telemedicine as described by the World Medical Association in 1999 and rescinded and archived at the WMA General Assembly, in 2022. According to WHO classification of Digital Health interventions telemedicine compromises of e-consultations between remote client and healthcare provider, remote monitoring of client health or diagnostic data by provider, transmission of medical data (e.g. images, notes, and videos) to healthcare provider and consultations for case management between healthcare providers.
Feasibility of Implementation of Telemedicine in Pakistan
Telemedicine has enormous potential in providing a diagnosis and delivering treatment over distance, especially virtual consultations between patients and healthcare providers, which became increasingly popular during the COVID-19 pandemic. Studies concerning the effectiveness of telemedicine show that it is the next step in the development of the art of medicine.
One of the objectives of telemedicine is to provide equal access to medical expertise irrespective of the geographical location of the person in need. However approximately 63% of the Pakistani population lives in peri-urban and rural areas, thus telehealth services are equally essential here, as it transcends the common barriers, which prevent people from accessing health care. These include long distances to a functional health facility, lack of doctors in rural areas, and the high cumulative costs associated with a doctor's visit (cost of transportation, income lost due to time off work, and the doctor's fee).
Telemedicine holds the promise of being able to connect patients in the remotest of regions to qualified doctors in urban areas. It is not dependent on time, with models working in real time (patient talking to doctor directly) and ‘store and forward’ methods (an assistant uploads all patient information into a database, and the doctor responds with his/her recommendations later).
Pakistan, like most emerging low-income countries, has a healthcare problem. The rapid increase in population combined with an unstructured system of healthcare has led to an uneven distribution of doctors, which manifests as a chronic shortage of doctors in peri-urban and rural areas. In 2016, there were 0.8 doctors per 1000 population. For this reason, telemedicine has become the need of the hour.
Doctors are also supportive of the benefits of telemedicine. A nation-wide survey of doctors across Pakistan was conducted in which 47% responded that almost half of the patients who visit their outpatient departments (OPDs) with minor complaints could have been handled outside the hospital using telemedicine consultations and 90% of them were of the opinion that connecting basic health units (BHUs) in rural areas with urban centers through telemedicine will be significant.
However, it’s no surprise that given the lack of infrastructure for telemedicine the literacy regarding telemedicine is extremely poor. A poll was conducted by pharmaceutical technology to assess the challenges to adoption of telemedicine during the COVID-19 outbreak. Analysis of the results shows that lack of awareness among patients is the biggest challenge to the adoption of telemedicine (52%), followed by legal and environmental challenges (15%), (12%) as desire to see physicians face to face and (11%) due to technological restraint.
The rationale of our research was to create general awareness on telemedicine among the sample population and develop suggestions for making telemedicine more accessible and thus reducing the burden of tertiary health care hospitals. It also addressed the patients attitudes to this digital healthcare practice, including their inhibitions and inability to use this technology.
Knowledge, Attitude, Perception & Practice of Patients Regarding Telemedicine
A descriptive, cross-sectional study was conducted in Lahore, Pakistan in 2019 with an objective to assess the capacity and willingness to use information technology for managing chronic diseases among patients. The study population consisted of patients aged ≥18 years and diagnosed with a minimum of one chronic non-communicable disease. This study concluded that nearly half of the respondents were willing to use text messages; whereas, the majority was reluctant in using video conference and e-mail as a source of communication with healthcare providers.
Reasons for unwillingness to use e-mail was the patients’ desire to be directly examined by the doctor; whereas unfamiliarity with the use of text message and video conference was the major reason for not using these technologies. Most of the respondents who were located farther from the health care provider were willing to use video conferencing.
A descriptive study was conducted regarding the benefits and barriers of Telehealth in 2021. Telehealth provides access to resources and care for patients in rural areas or areas with provider shortages, improves efficiency without higher net costs, reduces patient travel and wait times, and allows for comparable or improved quality of care. Better access to care, convenience, and reduced stress with telehealth use also can increase patient satisfaction.
Although patients and providers enjoyed the benefits of telehealth, some disadvantages of telehealth include limitations with performing comprehensive physical examinations, possibilities for technical difficulties, security breaches, and regulatory barriers.
Results of our Study
Our study was confined to the awareness of patients about telemedicine and their willingness to use it after an interventional session. The intervention was an awareness conducted on the topic of telemedicine, its uses and benefits using a self-made video and tutorial by researchers. The queries of participants regarding telemedicine were discussed and resolved after tutorial. 98 people participated in the study, all residents of Islamabad.
Regarding pre interventional accessibility and practice; 45% of participants had heard of the term telemedicine and 43.9% reported accessibility to telemedicine services. A total of 14.3% were patients of public hospitals, 41.8% of private hospitals and clinics whereas 43.9% reported that they visited both set ups. Most patients currently preferred in person visitations (76%) as compared to online consultation (23.5%). Regarding barriers in accessing telemedicine, the majority (41.3%) wanted in-person checkup, followed by 26.9% of people who did not know how to use it. Post session willingness to use telemedicine showed that 69.4% participants agreed that telemedicine was extremely time savingand 30.6% agreed that it was moderately time saving. 95.9% of participants also agreed to give this method a try in the future.
Downsides to Digital Health
While our study showed positive results in regards to patients' awareness and willingness to use technology for healthcare purposes, there are some serious disadvantages to the methods being promoted – we as researchers are mindful about them and agree that they must be discussed and highlighted alongside the benefits.
Reflecting on the participants’ concerns in using telemedicine services, our study revealed that 41.3% want in person checkup and 26.9% do not know how to use telemedicine services. These findings corresponded with other surveys as in an Indian population, 13.7% of the participants were not aware of the process/ technology of having a telemedicine appointment and 36% of the participants were worried about the quality of healthcare.
Not all patients have access to the necessary technology or possess the digital literacy skills required to effectively use digital health tools, creating a potential disparity in healthcare access. Pakistan's literacy rate in 2019 was 58%, rendering telemedicine useless for about half the population. Other than the patient's concerns, integrating digital health systems with pre-existing infrastructure is a real challenge. Interoperability issues between different platforms and systems will definitely hinder seamless collaboration and communication.
In terms of cost and accessibility, the implementation and maintaining digital health solutions is quite expensive. This cost is a barrier to smaller healthcare providers or individuals with limited financial resources, further exacerbating the social and welfare inequalities. Although one of the main objectives of digitalisation is to make healthcare more accessible, studies show that 73% of telemedicine implementation in Pakistan was focused on urban populations, leaving the majority (62%) of the Pakistanis deprived from the facility.
Most importantly, digital health must not undermine actual government healthcare policies and budget. The disruption of established healthcare workflows may prove disastrous for the physical healthcare system. Primary healthcare providers, especially young doctors, nurses and technicians are the backbone of our system and they must be provided with better systems, platforms, practices and salaries.
In conclusion, it is essential to address all these challenges proactively to ensure that digital healthcare technology contributes positively to healthcare outcomes while mitigating potential risks to the maximum.
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