According to the World Health Organization (WHO), telemedicine is the delivery of health care services by health care professionals, using information and communication technologies (ICT) for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research, and evaluation, and for the continuing education of health care providers, all in the interest of advancing the health of individuals and their communities [1]. In recent times, significant advancement in ICT has accelerated the field of telemedicine globally [2]. The use of telemedicine in Nigeria dates to 2007 when the National Space Research and Development Agency (NASRDA) and Federal Ministry of Health (FMoH) inaugurated its pilot project in two teaching hospitals and six Federal Medical Centres across the country [3]. Telemedicine can serve as a viable means of making up for the shortfall in the number of health care professionals available to serve Nigeria’s fast-growing population [4]. This article briefly discusses the state, prospects, current challenges, and recommendations for telemedicine in Nigeria. 

Telemedicine is broadly divided into two main categories based on the timing of interaction between the healthcare providers and patients. The first category, known as asynchronous telemedicine, stores and disseminates messages from healthcare providers to patients at anytime.  It does not require real-time communication between patients and healthcare providers, as does the synchronous telemedicine, which leverages video conferencing facilities to achieve real-time audio-visual communication [5]. Both synchronous and asynchronous telemedicine have been in use across Nigeria , with the COVID-19 pandemic and the resultant restriction of movements encouraging remote consultations with patients across many hospitals in urban centers like Lagos and Abuja [6]. Telemedicine in Nigeria can prospectively improve the health and well-being of the population by making up for the deficit in healthcare professionals in the country, reducing delay in accessing health care due to transit time to health facilities in urban cities like Lagos, and increasing access to quality health information and services in rural and hard-to-reach communities. 

Despite the prospects of telemedicine in Nigeria, there have been challenges limiting its adoption across the country a few of which are highlighted below:   

Provider Challenges 

Provider challenges include inadequate iinfrastructural development,  high cost of set up, and resistance to change. 

• Inadequate infrastructural development: Telemedicine requires some infrastructural commitment including but not limited to high-resolution digital camaras, specialized medical examination tools, computers, customized software, data storage hardware or servers that is neither fully available nor equitably distributed across health facilities in the country [7]. Furthermore, many hospitals do not have steady electricity supply whether from the national power grid or from alternative power sources [8], and without steady electricity supply, telemedicine becomes near impossible to implement. Other infrastructural challenges reported by early adopters of telemedicine in Nigeria, include limited broadband and internet connectivity.   

• High cost of setup: This is a significant barrier to the adoption of telemedicine in Nigeria. The cost of specialized medical equipment, computers, cameras and screens for video conferencing can be daunting and is usually deprioritized for more urgent or even higher priorities in health care budgetting and procurement. It is also important to highlight here that many potential entrepreneurs considering investing in/setting up telemedicine facilities, do not readily have access to reasonable single-digit credit facilities that could help cushion the high set-up cost [9, 10].  

• Resistance to change: According to a report on telemedicine adoption in Nigeria, although significant in terms of absolute cost, technology represents only 10 to 20% of the total cost of implementing a telemedicine system. It is estimated that 80 to 90% of the challenges are related to people. This includes amongst others, rigid organizational structures, the paucity of skilled professionals in new technology, complicated change management systems that make it almost impossible to change the status quo [11]. 

• Lack of access to required gadgets and internet connectivity: The use of telemedicine is dependent on internet connectivity and electronic gadgets such as android phones and tablets, through which patients access health information and services. Although there is an increasing penetration of phones and internet facilities across the country, people in remote communities still have limited access to these facilities and are therefore at a disadvantage to benefit from the ease of access to healthcare that telemedicine promises [12]. 

• Lack of affordability of telemedicine services: The high cost of setting up an effective telemedicine system and the fact that the system is technology-driven makes makes financial cost both a real (providers-perspective) and perceived (patient-perspective) barrier to adoption of telemedicine in urban slums and rural communities [13]. While there is no publication on standard cost of care through telemedicine, the pervasive cultural perception of telemedicine is that, telemedicine is for the wealthy [14].  

• Financial incentives: Considering the high cost of set up for providers, and the financial constraints to access for patients, immediate/short-term solutions to address financial challenges in the provision of telemedicine services could include, the  provision of single-digit loan facilities to providers to support set up costs and incentivize the provision of telemedicine services. In the same vein, integrating telemedicine services in health insurance packages for patients who have insurance cover and innovative affordable payment plan such as payment through airtime for those without cover, can alleviate the financial risks to patients and encourage uptake of telemedicine services.  

• Infrastructural development: Medium term interventions to improve adoption of telemedicine in communities with limited infrastructural development like hard-to-reach communities could include setting up kiosks or mobile facilities powered by solar energy and equipped with basic gadgets. Through this kiosks or mobile facilities,  telemedicine service providers can deliver remote health care to members of the community who do not have access to phones and internet services required to uptake telemedicine services. . Such kiosks or mobile facilities should be built and situated in locations agreed to by the community to ensure community ownership, protection of the facility and sustainability.   

• Integrated health system: Telemedicine can be integrated into the conventional healthcare delivery system such that all patients potentially get information and services remotely and only show up for physical appointment if required after initial assessments through the telemedicine platforms. This would however require sector-wide policy reviews, adoption and implementation with its attendant budgetary implications, behavioural change communications and community acceptance. 

Patient Challenges 

Patient challenges include lack of access to required gadgets and lack of affordability of telemedicine services.  

Although there is a dearth of data on the population-level benefits of the existing telemedicine services in Nigeria, findings from literature show that telemedicine has high prospects in Nigeria. Considering the prospects of telemedicine in Nigeria, the following recommendations will help the country to extract the goldmine in telemedicine. 

Recommendations 

Short Term: 

Medium Term 

Long Term 

In conclusion, telemedicine is providing healthcare information and services remotely with the aid of modern technology. Its adoption has been very low due to challenges which are both provider-related (include inadequate iinfrastructural development,  high cost of set up, , and resistance to change) and patient-related (lack of access to required gadgets and lack of affordability of telemedicine services). Introduction of financial incentives, infrastructural development and integration of telemedicine into the existing health service delivery system are some recommendations to improve the adoption of telemedicine in Nigeria.  

References 

1. Kruse, C.S., et al., Measures of effectiveness, efficiency, and quality of telemedicine in the management of alcohol abuse, addiction, and rehabilitation: systematic review. Journal of medical Internet research, 2020. 22(1): p. e13252. 

2. Organization, W.H., Global diffusion of eHealth: making universal health coverage achievable: report of the third global survey on eHealth. 2017: World Health Organization. 

3. Adekunle, Y., Evolving usage and access to ICTs in the Nigerian health care sector: challenges and prospects. 2016, University of Westminster. 

4. Epundu, U., et al., Medical tourism, public health and economic development in Nigeria: Issues and Prospects. Asian Journal of Medicine and Health, 2017. 7(2): p. 1-10. 

5. Talal, A.H., et al., A framework for patient-centered telemedicine: Application and lessons learned from vulnerable populations. Journal of biomedical informatics, 2020. 112: p. 103622. 

6. Ekanoye, F., et al., Telemedicine diffusion in a developing country: A case of Nigeria. Science Journal of Public Health, 2017. 5(4): p. 341-346. 

7. Meyer, C., et al., Rural Telehealth Use during the COVID-19 Pandemic: How Long-term Infrastructure Commitment May Support Rural Health Care Systems Resilience. Journal of Agromedicine, 2020: p. 1-5. 

8. Nkordeh, N., et al., Nigeria’s Power Generation: Analyzing the Cost Implication of Poor Generation on the Running Cost of Telecom Business in Nigeria. 2017. 

9. Adenuga, K.I., N.A. Iahad, and S. Miskon, Towards reinforcing telemedicine adoption amongst clinicians in Nigeria. International journal of medical informatics, 2017. 104: p. 84-96. 

10. Nwosu, C. and R. Ochu, Small and Medium Enterprises Financing in Nigeria: Benefits, Challenges and Way Forward. Journal of economics and sustainable development, 2017. 

11. Kamal, S.A., M. Shafiq, and P. Kakria, Investigating acceptance of telemedicine services through an extended technology acceptance model (TAM). Technology in Society, 2020. 60: p. 101212. 

12. Smith, W.R., et al., Implementation guide for rapid integration of an outpatient telemedicine program during the COVID-19 pandemic. Journal of the American College of Surgeons, 2020. 231(2): p. 216-222. e2. 

13. Scott Kruse, C., et al., Evaluating barriers to adopting telemedicine worldwide: A systematic review. Journal of telemedicine and telecare, 2018. 24(1): p. 4-12. 

14. Bajowala, S.S., J. Milosch, and C. Bansal, Telemedicine pays: billing and coding update. Current Allergy and Asthma Reports, 2020. 20(10): p. 1-9