Introduction

Africa, more so sub-Saharan Africa, has an acknowledged and marked shortage of healthcare professionals, an excessive burden of disease, and poorly funded healthcare provision [1–4]. To combat some of these concerns and issues, use of innovative interventions such as eHealth / digital health [4] is recommended (including telemedicine–"The delivery of health care services, where distance is a critical factor, by all health-care professionals using information and communications technologies…") [2]. Similarly, development of an eHealth / digital health strategy by each country is recommended [5, 6]. Indeed, Maina and Singh recently argued that “eHealth strategies have become mainstream” and guide intervention [7]. However, this global endeavour to implement eHealth has not yet yielded the desired outcomes.

Except for the concept of technology leapfrogging, the evolution and growth of telemedicine within the developing world mirrors that of the developed world a decade or more ago, with typically slow, often ad hoc, and unplanned development, plus musing about the value of national strategy [8]. Thus, telemedicine uptake in sub-Saharan Africa has also been slow [1], despite many countries having some form of information and communication technologies (ICT), health information system, or even eHealth strategy [9]. A potential explanation for this dichotomy may be that if telemedicine is not an embedded focus of an existing strategy, insufficient attention will be given to its adoption and implementation. In contrast, some developed countries have embedded telemedicine into their eHealth strategies and implemented specific telemedicine action plans, calling telemedicine the ‘key to health services of the future’, thereby improving their nationwide application of telemedicine [10]. Given COVID-19, the US now considers telemedicine a ‘low resource’ option whose use will be maintained, perhaps increase, post-pandemic [11]. Botswana developed its eHealth strategy while concomitantly trialling several mHealth initiatives with little success. Yet few sustained telemedicine initiatives or benefits have been realised from this investment [12], perhaps because of ‘poor strategy development’ or the absence of a specific telemedicine strategy.

The Government of Botswana, through the Ministry of Health and Wellness, provides free healthcare services to its citizens but as a fee for service to foreign nationals. The healthcare system is well structured, highly decentralised, and provides primary care through a hierarchical network of health facilities (mobile posts, health posts, clinics, primary hospitals, district hospitals, and tertiary hospitals). These health facilities are grouped into 27 health districts and include some private health facilities [13]. Similar to many countries, Botswana has a maldistribution of healthcare workers [14], being relatively concentrated in the largest and only city with a population over 100,000, Gaborone (~ 208,500).

Studies have shown a marked burden of both communicable and non-communicable diseases (NCD) in sub-Saharan Africa (SSA), with a surge in NCDs in the last two decades which are expected to exceed communicable, maternal, neonatal, and nutritional diseases (combined) as the leading cause of mortality by 2030 [15, 16]. Exacerbating this is the shortage of healthcare workers; 0.8 workers per 1,000 population across Africa, with just 9 countries in SSA with a health workforce density above 2.28 per 1,000 people, the minimum MDG density threshold (Botswana at 2.7) [17, 18]. There are only 815 general practitioners and 38 specialists in Botswana to address the healthcare needs of the ~2.35 million residents [17, 19]. In perspective, the WHO reports one physician for every 3,623 Africans, compared to one for every 232 Europeans, and notes that the shortage contributes to the inequalities in health service coverage and burden of disease experienced by SSA [20], including Botswana [21].

The country’s National eHealth Strategy, many years in development, was formally approved and released on 10 March 2020 [22]. It makes no mention of telemedicine and, as a consequence, the strategy does not culminate in a distinct, evidence-based strategy and subsequent implementation plan for telemedicine in the country. This lack of focus on telemedicine is a major omission of the National eHealth Strategy that must not be overlooked. Its remedy necessitates the development of a separate but complementary telemedicine strategy for Botswana.

This need has been amplified by the recent COVID-19 pandemic, which continues to disrupt already overburdened and short-staffed healthcare delivery systems, especially those in Africa. The pandemic has inadvertently raised awareness of eHealth (in particular telemedicine), and spurred rapid adoption and new innovations to leverage the technology’s health system, healthcare, and health benefits [23]. The wider literature also suggests this renewed application and integration of telemedicine implementations will continue beyond the pandemic era [23–25]. This will necessitate the resolution of many legal, regulatory, and ethical issues that appear to be overlooked or conveniently bypassed in the desire to mitigate the risks of the current pandemic. Planned, evidence-based, and health needs-based implementation of technologically appropriate, culturally sensitive, and environmentally aware telemedicine solutions (within a legal, regulatory, and ethically sound setting) could be effectively addressed in a distinct but complementary telemedicine strategy.

However, there is limited published guidance for eHealth strategy development, with perhaps only four practical and detailed guidance documents for generic eHealth strategies available [6, 9, 26, 27]. In this current study, the strategy development framework proposed by Scott and Mars was adopted, and several of the 7 Steps outlined in the eHealth Strategy Development Framework (eHSDF) are emulated [9], focussed on situational assessment and review. Because telemedicine is a subset of eHealth, this emulation process can be used to develop a telemedicine-specific strategy that identifies needs, inhibitors and enablers as well as the preferred telemedicine solutions for Botswana. The theoretical grounding and applied evidence-based research underpinning the eHSDF, together with the clarity of its described Steps, provided the rationale for its adoption. Nonetheless for academic purposes, as is the case in this study setting, limitations exist. The level and scope of activity required at a national level could not be achieved within a study, requiring the eHSDF process to be mimicked.

Seven fundamental principles guide the eHSDF process [9]. There are also seven sequential steps. Step1 (‘Evidence Gathering and Situational Assessment’) refers to gathering, reviewing and interrogating the available information related to specific health issues of most importance. Step 2 (‘Holistic Review’) is a situational assessment, examining other confounding factors beyond health issues (e.g. social determinants of health such as socioeconomic, political, and contextual aspects). Step 3 (‘Differential Diagnosis’) applies to information and geographical disaggregation to discover any differences in identified health issues which might appear similar, yet require different solutions. Step 4 (‘Preliminary Prioritisation’) identifies the top priority health issues for further review. Step 5 (‘Identifying Solutions’) is when a range of possible solutions that could address the identified needs (both technological and non-technological) are also identified. Step 6 (‘Considering eHealth Solutions’) is the stage at which only eHealth interventions, i.e., technological solutions, are identified for consideration. Step 7, (‘Secondary Prioritisation’) is the most critical stage when the most ‘technologically appropriate’ solutions [9] are selected and prioritised for implementation, thus providing the direction for investment decisions and policy developments. Thereafter the findings from Steps 1–7 are synthesised, culminating in the eHealth strategy document.

In emulating aspects of Steps 1, 2 and 3 this study serves as a formative undertaking towards the development of an evidence-informed telemedicine strategy to complement the existing eHealth strategy for Botswana. To this end, the study used questionnaires to achieve its aims: to explore the perceptions, attitudes, views and knowledge of patients and healthcare professionals about telemedicine, its use, and the factors that might influence implementation of telemedicine in Botswana, as well as their perceptions of the current health-related issues that they face in order to inform future development of a telemedicine-specific strategy.

Methods

An exploratory survey study was conducted, using both open-ended and closed-ended questions. Healthcare professionals and patients at 12 health facilities were surveyed using convenience sampling.

Results

The demographic and contextual results for both groups are presented in Table 1.

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Table 1. Demographic characteristics and context (awareness and use of technology) of healthcare professionals and patients.

https://doi.org/10.1371/journal.pone.0281754.t001

The themes and sub-themes derived from qualitative analysis of the open-ended questions are presented in Table 2.

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Table 2. Themes and sub-themes from qualitative analyses.

https://doi.org/10.1371/journal.pone.0281754.t002

Discussion

Fewer than half of the doctors (42%) had used telemedicine and only 10% of the nurses, whilst patients had little experience of telemedicine, but generally believed they would like to have it. These findings were despite HCP generally having access to and using computers both at work and at home, and over half of employed patients also having access to and using computers at work. There was a strong willingness to learn about and use telemedicine and to use telemedicine for clinical, and educational purposes. This was potentially tempered by factors such as cultural attitudes and preconceptions (e.g., existing health beliefs and traditional medicine practices) and the concern of some patients about reluctance to change, age, and privacy issues.

Both groups identified similar benefits for the use of telemedicine: improved access to specialists and health facilities, cost savings, convenience, and preventive healthcare, and also believed telemedicine would be able to help address some of the identified healthcare issues. Given that most patients believed little or no effort had been made to address their previously identified health issues, this presents an opportunity for TM interventions. Although financial, infrastructural and technical issues were identified as challenges to telemedicine, as in other developing countries, human resource, equipment shortages, funding were the prime concerns of both healthcare professionals and patients [31, 32].

Significant research has been performed on the knowledge, attitude, practice, and perceptions of both clinicians and patients regarding eHealth, telehealth, telemedicine, and mHealth in Middle Eastern, Asian, and African developing countries. Literature findings align well with those of this study regarding general level of knowledge, belief in telemedicine as a solution, and willingness to use telemedicine for both HCP and patients or the public.

For example, in Saudi Arabia nearly half (46%) of physicians had low knowledge of telemedicine, with just over half (53%) being unfamiliar with telemedicine tools and associated medical applications and technology [32]. That study also identified more than 90% perceived telemedicine as a viable option for providing medical care services to patients, and more than 90% of specialists agreed that telemedicine could save time and money. Although a 2015 study, in Iran a survey found most clinicians (96%) had “little knowledge about telemedicine” [33]. This may have since changed with a recent review indicating that progress, although slow, has been made in Middle-Eastern countries despite cultural, technological, regulatory and other challenges [34].

Within Asia findings are also similar. In Bangladesh a survey indicated one quarter of doctors had good knowledge of eHealth, half had average knowledge, and one quarter had poor knowledge, with the mobile phone as the most frequently used modality [34, 35]. A study from Pakistan noted 65% of physicians were already familiar with telemedicine services, and that most agreed that telemedicine would improve physician efficacy (75%) and that such services would improve access to healthcare (80%) [36]. More positively, a second Pakistani study showed 81% of physicians were aware of a definition of telemedicine, with 28% believing telemedicine could provide faster care, but with 43% believing it disrupted the doctor-patient relationship and led to privacy breaches, and almost all (91%) believing poverty and lack of education were the greatest barriers to telemedicine in the developing world [37].

In Africa, a Nigerian study found that of multiple indicators, healthcare professionals possessed good overall knowledge of ‘ehealthcare’ delivery (86%), although eHealth use was low [38]. Of the general population of Egypt, half had used a telemedicine tool (50.4%; even before the COVID-19 pandemic) and it was concluded most Egyptians “perceive the benefits of telemedicine positively and are willing to use it” [39]. Even with the advent COVID-19 and introduction of telemedicine services within the country, only 37% of Libyan healthcare workers reported high awareness of telemedicine, whether in the public or private sectors, and the study identified the need for telemedicine training and support of healthcare workers [40].

The present study did not specifically pursue educational issues, cultural issues, or legal, ethical, and regulatory issues, although some responses touched on these topics, indicating a level of awareness. Again, findings were similar to published insight, where the need for training, resolution of legal and standards issues, and consideration of cultural issues are identified as requiring attention [31, 32]. Highlighting the need for training, a cross-sectional study in Ethiopia, designed to assess the basic digital competency of healthcare providers at public health facilities, concluded they lacked problem solving, safety, and communication competencies in using digital devices [41]. Also, half (50%) of healthcare workers in an Egyptian study were aware of telehealth, with their knowledge and attitude scores increasing after attending an educational program, demonstrating the value of training [42].

This study provides insights and specific guidance on how to frame an evidence-based telemedicine-specific strategy for the country. Thus, the results highlight areas identified by HCPs and patients upon which to focus: Clinical, Educational and Administrative. Based upon responses, clinical solutions could include consultations in areas such as radiology, pathology, and surgery, although 36 areas of medicine were identified for possible application. Similarly, use of telemedicine for education of both HCP (e.g. clinical skill building; training to use telemedicine) and patients (e.g. health awareness; training to use telemedicine) was identified by both groups. Even applications for administrative uses were proposed (e.g. access to laboratory results). Whilst not comprehensive, or necessarily literature based, these suggestions do show both HCP and patients see the potential applications of telemedicine to address identified health issues, needs, and concerns.

Conclusions

In general, knowledge and awareness of telemedicine in developing countries are poor, although perceptions and willingness to use are higher. The good alignment between the findings of this study and published studies lends strength to the intended use of the data for developing an evidence-based telemedicine-specific strategy for Botswana, as an adjunct to the existing eHealth strategy. Furthermore, although detailed knowledge and insight amongst healthcare workers and patients may be lacking in Botswana, the general acceptance, willingness to use, and perspective that telemedicine is helpful bodes well for any attempt to introduce telemedicine more systematically in the future, guided by an evidence-based strategy.

Supporting information

Acknowledgments

The authors appreciate support provided by the Botswana Ministry of Health and Wellness, study site personnel, and the University of Kwa-Zulu Natal.