By J. Hibler, D.O.
Access to dermatologic care in rural Uganda remains a major healthcare problem. The need for timely and cost-effective skin care cannot be underestimated. The majority of certified dermatologists practice in the capital, Kampala, and larger cities such as Jinja, Lira, and Mbarara. Patients in rural areas are burdened by the cost and time spent to travel to these larger centers. Too often patients suffer from chronic diseases such as psoriasis, eczema, and infections because access is not available. Likewise, patients may seek dermatologic care for completely benign conditions such as acne, seborrheic keratoses, and simple cysts that can be diagnosed and managed by primary physicians, or even community healthcare workers.
Tele-consultation services such as tele-medicine/dermatology (TM/D) are a relatively new concept currently being used and piloted around the world to promote healthcare and access to medical advice and treatment. The services and technology developed by ClickMedix provide a fast, easy, and expert consultation service for patients of rural areas. The system uses mobile/cellular networks to convey medical information (imaging, laboratory, other pertinent data) from anywhere a cellular network is available to referral centers such as Mbarara or Kampala.
In a coordinated effort by ClickMedix founder, ICOD (Integrated Efforts for Community Development), Ugandan dermatologists, and a volunteer physician from the United States, patients presenting in various medical centers with dermatologic complaints were surveyed on tele-medicine/tele-dermatology as a whole.
Patients being seen in various areas and settings in Uganda were selected randomly to complete a survey on several aspects of TM/D. These areas and number of patients were as follows; Lyantonde District Hospital (6), Kitazigolokwa village area (5), and Mbarara Hospital Skin Clinic (11). Please see Appendix A for the patient survey. The survey was given to randomized patients regardless of their English literacy, and interpreters were used to assist those patients who could not read English. Pediatric patients and those accompanied by their caregivers had their caregivers complete the survey.
A summary of questions 1-20 are as follows:
1) Average age= 19, 36% male, 64% female
2) 100% of patients had no insurance or were cash/self pay
3) Cash/self paying patients paid an average of 0 (zero)Ush for physician visits at public facilities, while patients paid 15,000Ush for physician visits at private facilities
4) 73% of patients surveyed usually seek medical attention at a public/government hospital, while 27% preferred private clinics and hospitals,
5) 73 % of patients usually go to a skin specialist for problems with their skin
6) 64% of patients have never been to a skin specialist before, while 36% have
7) 55% of patients stated they had to wait or get an appointment or referral to see the dermatologist
8) Those who stated “yes” for waiting to see the dermatologist, waited an average of 1-2 weeks to see the dermatologist
9) 7 hours was the average travelling time to see the dermatologist (range ½ hour to 2 days)
10) 14,000Ush was the average travelling expenses to see the dermatologist (range 1 to 50,000USh)
11) 82% of patients stated they would allow their doctor to use tele-consultation
12) Of those patients (question #11) allowing their doctor to use tele-consultation, 73% said they would be willing to pay a little more money to get tele-consultation from a skin specialist.
13) 91% of patients participating in tele-consultation would accept having their face or sensitive areas such as the genitals/buttock photographed
14) 100% who preferred NOT to be photographed, stated “personal discomfort” as the reason they would prefer not to be photographed
15) 55% of patients would prefer face-to-face appointments over tele-consultation
16) 100% of those patients preferring tele-consultation over face-to-face interviews stated “reduced cost of travel” as their main reason for preferring tele-consultation
17) 45 % of patients thought treatment with tele-consultation would be better, while 36% of patients thought it would be worse, and 19% thought tele-consultation would result in the same treatment
18) 5,000Ush is the average price patients surveyed would pay for a remote consultation
19) 60% of patients would prefer a foreign (U.S./British/German) expert for tele-consultation, while 40% would prefer a local expert
20) 78% of patients stated they would NOT pay more for a foreign expert
A simple interpretation can be drawn from each of the questions listed on the survey:
1) The average patient in the survey was a 19 year old female; however, patients ranged from 4 months to 70+ years. While conducting the survey, it was clear that patients in the rural areas such as Kitazigolokwa tended to be older, while patients closer to the hospital/clinic were younger. This may be due to the fact that younger people are more mobile and have the ability to travel long distances. They may also have a better social network that allows them to access transportation to medical centers.
2) Of the patients surveyed, all had no insurance or were cash/self pay which means they used their own money to access medical care. However, the centers in which the survey was conducted were all government centers, and patients normally do not pay to see physicians at these hospitals and clinics.
3) Patients that did pay to see the doctor, paid about 15,000Ush on average. It is unclear whether this is for primary or specialty care. Regardless, patients do not normally pay money to visit government/public centers, while they do at private offices.
4) The majority of patients normally sought care at public institutions; but this may be a biased result, for the survey was conducted at a public institution.
5-6)Most patients will go see a skin specialist for their skin problems. And the majority of those patients are first time patients to the dermatology clinic. This means that patients prefer to have a dermatologist for their skin problems, and are either lost to follow up, or receive proper and healing treatment at the initial visit.
7-8)Most (55%) patients had to wait to see the dermatologist an average of 1-2 weeks. Considering the serious and sometimes life threatening conditions patients may have, this may be a significant cause to morbidity and mortality.
9-10)Patients travelled an average of 7 hours and spent 14,000Ush on travelling expenses to see the dermatologist. Both time and money spent on getting to the dermatologist is seen as a major burden and deterrent to accessing skin care. It is estimated that using tele-consultation, patients will travel half as much, if any time at all, and spend much less to use the tele-consultation service.
11) Most patients (82%) said they would allow their primary doctor or community health worker to use tele-consultation which means patients would be able to access skin expert diagnosis and treatment recommendations, as well as other areas of tele-medicine.
12) While the majority of patients would allow their doctor to use TM/D, they also would not object to paying a little more money to access skin expert advice via tele-consultation; this also suggests that monetary barriers to using TM/D are not as large as once thought.
13-14) Most patients would not mind having their face or other sensitive areas photographed; another once-perceived barrier to TM/D that may not be such an issue with patients.
15-16) About half (55%) of patients preferred face-to-face interaction over TM/D; again, conclusions can be drawn that 1) patients are indifferent about preferring face time with a physician, compared to TM/D, and 2) the reasons for this (reduced cost of travel) are mainly monetary.
17) More than half (64%) of patients thought treatment with TM/D would be as good or better than traditional face-to-face diagnosis and treatment. Once again, the public perception of TM/D as an inferior substitute to face-to-face medicine is not as valid as once thought.
18) A modest fee of 5,000Ush is the average price patients are willing to pay for a tele-consultation service. While the long-term, sustainable fee and cost structure of TM/D remains to be finalized, this amount is perceived as good compromise to the high price patients already pay to access skin expert care. Pricing structure may be highly dependent on government input such as the Ministries of Health of Uganda.
19-20) While more than half (60%) of patients would prefer a foreign skin expert, only 22% would be willing to pay more for a foreign expert such as a certified dermatologist. While the perception of being treated by an international expert in skin disease may be appealing to the public, most are not willing to pay more for this service. Because of this, domestic TM/D (community health workers referring photo cases to higher centers such as Mulago in Kampala) seems to be a more realistic and attainable system to implement initially.
It is clear from the above data that patients can benefit from TM/D in many ways. Most importantly,
TM/D saves the patient time and money. After speaking with several of the country’s dermatologists, costs can be saved at the national level as well. This is because all too often, patients will present with skin conditions that can be handled at the primary care level, or even by the community health worker (CHW). A perfect scenario of using this cost-saving system would be a CHW photographing a benign mole on a worried patient, and the consulting dermatologist on the other end making the recommendation to do nothing, and just monitor the lesion. This simple exchange by TM/D could potentially save the patient 110,000Ush, based on the data above (50,000Ush x2ways + 15,000Ush for physician costs, less the 5,000Ush for the tele-consultation). The organizations that we have been working with (ICOD), are committed to serving their rural communities and are willing to work with domestic and foreign physicians to improve their healthcare needs and access to expert medical advice.