European Space Agency. Cost Benefit Analysis of Satellite-Enhanced Telemedicine and ehealth Services in Sub-Saharan Africa November 2008

Transcription

1 European Space Agency Cost Benefit Analysis of Satellite-Enhanced Telemedicine and ehealth Services in Sub-Saharan Africa November

2 Important Notice and Disclaimer This publication includes information obtained or derived from a variety of publicly available sources. PricewaterhouseCoopers LLP ("PwC") has not sought to establish the reliability of these sources or verified such information. PwC does not give any representation or warranty of any kind (whether express or implied) as to the accuracy or completeness of this publication. The publication is for general guidance only and does not constitute investment or any other advice. Accordingly, it is not intended to form the basis of any investment decisions and does not absolve any third party from conducting its own due diligence in order to verify its contents. Before making any decision or taking any action, the recipient should consult a professional adviser. PwC accepts no duty of care to any person for the preparation of this [publication/presentation], nor will recipients of the [publication/presentation] be treated as clients of PwC by virtue of their receiving the publication/. Accordingly, regardless of the form of action, whether in contract, tort or otherwise, and to the extent permitted by applicable law, PwC accepts no liability of any kind and disclaims all responsibility for the consequences of any person acting or refraining to act in reliance on this publication or for any decisions made or not made which are based upon the publication/presentation. For more information on the report please contact: Giorgio Parentela Telemedicine Task Force Manager giorgio.parentela@esa.int

3 Executive Summary Study Objectives The European Space Agency ( ESA ) commissioned PricewaterhouseCoopers LLP ( PwC ) to undertake an independent analysis of the costs and benefits for investment in satellite-enhanced telemedicine and ehealth services to support public health policy objectives in sub-saharan Africa. The overarching aim of this study has been to demonstrate the illustrative additional economic benefits of using satellite technology to extend the reach of telemedicine and ehealth services to the rural and most isolated areas of sub-saharan Africa. The findings from this study have relied upon a range of secondary, published data and information sources, supplemented by extensive stakeholder consultations. Inevitably, given the constraints of the study, the report has been based upon selective information. The case study examples used are considered representative of the aspects of the thematic areas that have been chosen for analysis but it should be noted that there is a wider population of case studies that cover telemedicine and ehealth which also may be consulted. This report begins by setting out the social, economic, health, ICT infrastructure and policy context of sub-saharan Africa to which such services would be applied. Based on this context, we have examined five thematic areas which could be addressed by satellite-based telecommunications. These consider the functional applications that satellite-based telemedicine and ehealth could provide in helping sub-saharan Africa to meet its health and wider development goals. These thematic areas are: The European Space Agency ( ESA ) commissioned PricewaterhouseCoopers LLP ( PwC ) to undertake an independent analysis of the costs and benefits for investment in satellite-based telemedicine and ehealth applications to support public health policy objectives in sub- Saharan Africa. The overarching aim of this study has been to demonstrate the illustrative additional economic benefits of using satellite technology to extend the reach of telemedicine and ehealth services to the rural and most isolated areas of sub-saharan Africa. ecare in the clinic ecare in the village elearning esurveillance eadministration/ egovernance. We have then identified with ESA seven case studies which illustrate the breadth of activities covered by the thematic areas and indicate how they could potentially be implemented more widely. The illustrative assessment of the potential benefits and costs, wider impacts and strategic linkages of these case studies, and the implications of scaling up these applications across sub- Saharan Africa, forms the core focus of the report. Executive Summary December 08 PricewaterhouseCoopers 1

4 Sub-Saharan Africa Context Sub-Saharan Africa has significant social and economic potential but currently faces a number of barriers to realising this potential and playing a more significant role in the global economy. The serious health problems which are evident across the continent are one such barrier. The poor health situation is reflected both in high concentrations of communicable diseases and the poor average health outcomes across the populations, especially amongst disadvantaged groups such as rural dwellers, the poor, women and children. In many places, there are insufficient human and financial resources to apply the required levels of health care needed to address these issues. This is often exacerbated in more remote areas where poor physical and telecommunications infrastructure have proved insufficient to provide the health care services required therefore raising significant barriers to delivery. Currently just over half of the sub-saharan African population are covered by the mobile phone network which leaves about 350 million outside of the network coverage. This number will be expected to shrink as mobile networks grow, though this is likely to be at a decreasing rate on an aggregate level as the networks initially reach the most populated and easy-to-access areas first. There are millions of people in sub-saharan Africa who live in areas that do not demonstrate the commercial potential for investment in ICT infrastructure in the short to medium term. This results in a lack of access to high impact telemedicine and ehealth initiatives. These people are also likely to live in areas with a lack of health and transport infrastructure, making a trip to the closest hospital a time intensive and expensive journey. There are millions of people in sub-saharan Africa who live in areas that do not demonstrate the commercial potential for investment in ICT infrastructure in the short to medium term. This results in a lack of access to high impact telemedicine and ehealth initiatives. These people are also likely to live in areas with a lack of health and transport infrastructure, making a trip to the closest hospital a time intensive and expensive journey. Addressing the needs of these areas and populations requires both the provision of required medical services and products, and also the means to effectively deliver them to all communities that need them. Executive Summary December 08 PricewaterhouseCoopers 2

5 Opportunities for Satellite-Enhanced Telemedicine and ehealth Services There is a significant opportunity for satellite-based telemedicine and ehealth services to provide effective, high-impact solutions for the identified public health needs in sub-saharan Africa. Although there has been significant progress in the development of information and communication technologies in the region over the past ten years, the fact still remains that mobile and broadband network access is concentrated in areas of high population density with coverage being poor or non existent in rural and more remote areas. It is for this reason that satellite-enhanced telemedicine and ehealth solutions could provide a significant role in addressing the needs of remote areas where telemedicine and ehealth solutions via wired networks are non-existent and commercially unviable to roll out. Satellite based communication technologies could address the lack of access in the region and provide a viable option for the expansion of a telehealth programme. This would allow policy makers to extend the reach of their health networks to more of their population, particularly those in remote areas who are most vulnerable. Satellites can be used for a wide variety of communications and observation roles. Specific examples of applications where satellites have been applied to health delivery in developing countries include: (i) linking clinicians to specialists; (ii) providing information to practitioners; (iii) training of medical personnel; (iv) observation and reaction to disease outbreaks; and (v) better control and management of services and resources. Similar to the development of the $100 laptop and other low cost ICT solutions, a number of affordable satellite access options are being developed to better meet the needs of the sub-saharan African market. These initiatives are likely to further lower the costs associated with satellite technology through increased competition in the market. It is for this reason that satellite based telemedicine and ehealth could provide a significant role in addressing the needs of remote areas where telemedicine and ehealth solutions via wired networks are non-existent and commercially unviable to roll out. All these areas offer the potential for significant improvement and extension of health services to populations who are currently underserved. They have strong potential to support and enhance other activities both in health and other development areas. Likewise, other areas of activity and investment (e.g. building new hospitals and clinics) will often be required to allow the satellitebased telemedicine and ehealth activities to operate at their full potential. Executive Summary December 08 PricewaterhouseCoopers 3

6 Case Studies The case studies under the thematic areas that were selected for detailed consideration, which are based on actual examples of applications in sub- Saharan Africa, are: ecare in the Clinic: IKON in Mali ecare in the Village: Uganda Health Information Network elearning: Kenyan Nurses; and Réseau Afrique Francophone de Télémédecine (RAFT) esurveillance: Nigeria Malaria Surveillance eadministration/ egovernance: Rwanda TRACnet; and Pharmaceuticals Tracking The details of each case study have been reviewed, and their impacts assessed using a combination of primary and secondary data sources. In particular we have focused on the key functionalities of the case studies in terms of their actual or potential application of satellite technology on delivery of public health services. The case studies each highlight a different means by which satellite technology could be applied to deliver impacts for sub-saharan Africa patients and health services. For each of the case studies, we have set out a description of the case study, the issues that the case study is designed to address, an illustration of the associated costs and the reported current impacts. We then set out our assessment of what might be the expected quantified economic benefits for each case study and the potential impact of scaling it up across sub-saharan Africa, the cost implications of the case studies, our qualitative assessment of the wider impacts and the strategic and policy linkages. Economic Benefits We have undertaken a quantitative economic analysis to assess the impact of satellite-enhanced telemedicine and ehealth activities across sub-saharan Africa. For most of the interventions, we have focussed our impact assessment on only those populations which are currently outside the mainstream telecommunications networks. Our analysis suggests that based on the potential application of telemedicine and ehealth services considered from our case studies, there are large potential economic benefits generated in terms of lives saved, reduced impact of illness, healthy years preserved, and the improved well being impact on individuals. Similar to the development of the $100 laptop and other low cost ICT solutions, a number of affordable satellite access options are being developed to better meet the needs of the sub-saharan African market. Tables 1 and 2 present the summary assessments of the potential impacts of the seven case study interventions if they were to be scaled up across sub- Saharan Africa. The impacts have been assessed on the estimated outcomes from a single year s operation for each programme (with the exception of esurveillance which estimates the impact on a five-year cohort of children). The single year values are the quantified impacts that would be expected to occur within twelve months of the activities being undertaken. The lifetime values assess the potential impact over the expected extension of lifespan for those patients who are impact by the programmes. Executive Summary December 08 PricewaterhouseCoopers 4

7 Table 1: Illustrative Economic Benefits Associated with Case Studies Sub-Saharan Africa health impact Lives Saved p.a. One Year Value Lifetime Value 1 ecare in the Clinic 16,800 $680 million $746 million ecare in the Village 151,800 $259 million $2,576 million elearning 85,100 $145 million $1,444 million esurveillance 644,100 $1,248 million $55,902 million eadministration/ egovernance 477,900 $934 million TOTAL 1,375,700 $3,266 million $60,668 million Table 2: Illustrative Additional Outputs Associated with Case Studies Sub-Saharan Africa health impact Kenyan Nursing (elearning) RAFT (elearning) Pharmaceuticals Tracking (eadministration/egovernance) Impact Measure Additional Nurses Trained (total) Additional Physicians Involved in on-going training (total) Reduction in drugs lost Number 44,085 2,846 $299mn - $897mn p.a. Clearly the case study evidence suggests the potential for substantial economic benefits to be generated through improvements in public health outcomes. To provide context to these numbers, they represent about 0.5% of sub-saharan African economic output which would be an important contribution to growth while not being so large as to be unfeasible for a large policy programme to achieve. Whilst these figures are only illustrative, they clearly show the tremendous potential that a programme to widen satellite-based telemedicine and ehealth services across the continent could have in economic terms. Cost Implications The benefits associated with the introduction of satellite based telemedicine and ehealth programmes are clearly large. However, when considering the benefits of an intervention, it is important to also take the associated costs into account. For this reason, we have estimated the additional set up costs or capital expenditure as well as the additional running costs or operating expenditure associated with delivering the programmes using satellite based technology. We then provided an illustrative cost of scaling the programme up across sub- Saharan Africa so that those individuals who live outside the mobile phone For each intervention there exists a large differential between the one year operating costs and the single year estimated value of the benefits which could be achieved if these programmes were rolled out across sub-saharan Africa. 1 Differences in Lifetime value are attributed to the differences in target populations the programmes are designed to address. Executive Summary December 08 PricewaterhouseCoopers 5

8 network may also have access to quality telemedicine and ehealth service solutions. Table 3 below presents the summary assessment of the capital and one year operating costs associated with the seven case study interventions if they were to be scaled up across sub-saharan Africa. Table 3: Capital and One-year Operating Costs Associated with Scaling Up CAPEX Associated with scaling up One-year OPEX ecare in the clinic $55.7 million $23.6 million ecare in the village $41.4 million $23.6 million elearning $8.6 million $8.3 million esurveillance eadministration/egovernance Cost information unavailable $106 million Wider Impacts Alongside the direct benefits from health interventions, implementation of projects along the lines of the case studies would provide significant wider social and economic benefits. These potential applications could be expected to increase both technical and general skills and knowledge in the communities into which they would be introduced, thereby increasing the economic and social capabilities of these communities. They would offer the opportunity to increase the local demand and capacity for telecommunications links which would increase local and national connectivity. They would also lead to increased labour capacity and quality by increasing both the effective amount of labour available and the incentive to invest in education by lowering the morbidity and mortality rates in communities. They would allow for more effective and efficient health care delivery by helping to monitor and control the resources in the system. Finally, the impact of these interventions could help to improve the perceived attractiveness of more remote locations by lowering the risk of disease and increasing access to skilled health care. This should lead to an increased willingness by skilled workers and investors to access these areas to promote economic activity. Strategic Benefits Implementation of satellite-enhanced telecommunications and ehealth activities would support a wide range of current national, pan-african and international policy objectives in terms of both improving health outcomes and developing the capacity of local economies and public health services. Table 4 illustrates the link between the case studies examined in this report and the Millennium Development Goals. These policies are fundamental to delivering the wider socio economic development goals that are shared across a range of organisations, and in particular those relating to the delivery of the Millennium Development Goals. Executive Summary December 08 PricewaterhouseCoopers 6

9 Table 4a: Links between Case Studies and Millennium Development Goals 1 to 4 MDG 1 Eradicate Extreme Poverty and Hunger MDG 2 Promoting universal primary education MDG 3 Promoting gender equality MDG 4 Child Mortality ecare in the clinic Addresses local circumstances which limit development Provides direct support for children in rural areas ecare in the village Addresses local circumstances which limit development Promotes local knowledge on health Promotes education for women in local communities Provides direct support for children in rural areas elearning Addresses local circumstances which limit development Develops human capital in remote locations Empowers women to develop their potential through training Develops health worker capacity to help children in rural areas esurveillance Monitors disease vectors which lead to children getting these diseases eadministration / egovernance Addresses local circumstances which limit development Supports more effective resources in local areas including for education Supports more effective resources in local areas including for women Supports more effective and efficient allocation and monitoring of health system resources for child health Table 4b: Links between Case Studies and Millennium Development Goals 5 to 8 MDG 5 Maternal Health MDG 6 Combat HIV/AIDS, TB, Malaria MDG 7 Greater environmental sustainability MDG 8 Develop Global Partnerships ecare in the clinic ecare in the village elearning Provides direct support for mothers in rural areas Provides direct support for mothers in rural areas Develops health worker capacity to help mothers in rural areas Provides direct support for people with these diseases in rural areas Provides direct support for people with these diseases in rural areas Develops health worker capacity to help people with these diseases in rural areas esurveillance Monitors disease vectors which lead to these diseases Enables better monitoring of the environment and impacts on disease eadministration / egovernance Supports more effective and efficient allocation and monitoring of health system resources for maternal health Supports more effective and efficient allocation and monitoring of health system resources for preventing and treating these disease Enables more efficient and effective governance including better communications Executive Summary December 08 PricewaterhouseCoopers 7

10 Conclusions This study suggests that satellites have an important role to play in reaching those large geographical areas and populations of sub-saharan Africa that are currently underserved by public health services and are outside of the current telecommunications networks. Our analysis based on case study evidence demonstrates in an illustrative way that satellite enhanced telemedicine and ehealth services could generate significant public health benefits which are reflected in substantial socio-economic benefits. Whilst these benefits are significant in scale they also appear reasonable in proportion to the size of sub-saharan Africa s populations and economies. Executive Summary December 08 PricewaterhouseCoopers 8

11 Contents 1 Introduction 11 2 Context for Telemedicine and ehealth in Sub-Saharan Africa 15 3 Opportunities for Satellite-enhanced Telemedicine and ehealth Services 33 4 Case studies 41 5 Economic benefits 72 6 Cost Implications 84 7 Wider Socio-Economic Benefits 97 8 Strategic Benefits 101 Annex A Study Approach 105 Annex B Consultations 111 Annex C Impact Calculations 115 Annex D Glossary 149 Annex E References 151 Contents December 08 PricewaterhouseCoopers 9

12 Contents December 08 PricewaterhouseCoopers 10

13 1 Introduction 1.1 Introduction This section of the report presents the background to this study, and the key objectives of the European Space Agency (ESA) in commissioning PricewaterhouseCoopers LLP (PwC) to undertake an independent analysis of the costs and benefits for investment in satellite-based telemedicine and ehealth applications to support public health policy objectives in sub-saharan Africa (SSA). The overarching aim of this study has been to demonstrate the illustrative additional economic benefits of using satellite technology to extend the reach of telemedicine and ehealth services into sub- Saharan Africa, and in particular into the remote isolated areas of the continent. 1.2 Background The Telemedicine Task Force (TTF) developed from a 2006 workshop where the European Commission (EC) and ESA assessed the potential of satellite telecommunication technology to strengthen health systems in Africa. Participants recognised that land based and mobile telecommunications had limited reach but that this could be extended by satellite technology to remote, isolated areas of the continent. In their view, satellite communications should complement the terrestrial infrastructure to achieve complete telecommunications coverage for sub-saharan Africa. The TTF envisages the key interventions from satellite-based telemedicine and ehealth arising in terms of: (i) dissemination of medical information and (ii) communication links between clinicians. Wider information access is likely to promote significant societal benefits through raising public health standards and providing the quality health infrastructure that patients rely on. Direct communications between clinicians can have a large direct impact for the patients and medical staff involved, but there are also wider benefits from the overall societal reduction in risk from illnesses or injuries as the capacity for improved care increases. In both cases, there are likely to be significant health and socio-economic benefits arising from ehealth for Africa through the application of satellite-based interventions alongside other complementary interactions such as medical equipment provision, skills development and provision and dissemination of information content. These dependencies on other activities do not however diminish the validity of identifying the macro-economic benefit case for satellite-based ehealth programmes. 1.3 Study Objectives PwC have been commissioned by ESA to prepare a Cost Benefit Analysis of the potential for satellite-based telemedicine and ehealth investments in sub-saharan Africa within the framework of the EU-Africa Partnership on Infrastructure. The study specifically examines the economic benefits and identifiable costs of using satellite enhanced telemedicine and ehealth applications to extend the reach of ehealth and help overcome health service shortages in sub-saharan Africa. This study provides an independent and evidenced assessment of the potential economic impacts of investment in sub- Saharan Africa satellite-enhanced telemedicine and ehealth opportunities. In assessing the case for a programme to promote satellite-enhanced telemedicine and ehealth services in sub-saharan Africa, we have focussed on a number of case studies where the application of this technology has or is expected to lead to positive outcomes in people s lives. These case studies, which have been drawn from across a number of thematic areas, have been used to illustrate the potential wider implications of scaling up these applications across sub-saharan Africa. The potential scale of these economic benefit opportunities have been positioned in terms of illustrative costs of delivering these applications. Introduction December 08 PricewaterhouseCoopers 11

14 The findings from this study have relied upon a range of secondary, published data and information sources, supplemented by extensive stakeholder consultations. We have not undertaken any audit or independent verification of this data / information as part of the scope of this work. Also, inevitably, given the constraints of the study, the report has been based upon selective information. The case study examples used are considered representative of the aspects of the thematic areas that have been chosen for analysis, but it should be noted that there is a wider population of case studies that cover telemedicine and ehealth which also may be consulted. Therefore, this study considers: The extent to which sub-saharan Africa will derive socio-economic benefit from satellite-based telemedicine and ehealth investment; Identification and quantification of benefits health, economic and social for both individual users and the wider society; Identification of cost drivers and quantification of costs to deliver the service applications; and Identify the strategic and political benefits for key stakeholders in supporting current policy direction and goals. 1.4 Report Structure The rest of the report consists of nine sections as follows: Section 2 provides the context for Telemedicine and ehealth interventions in Sub-Saharan Africa in terms of the socioeconomic circumstances, the health needs, the state of the technological infrastructure and the strategic policy commitments related to telemedicine and ehealth delivery; Section 3 highlights the areas of opportunity for implementing telemedicine and ehealth with a review of five thematic key areas where satellite-based interventions have been undertaken; Section 4 introduces and describes the seven case studies which have been selected under the five thematic areas; Section 5 provides the quantitative analysis on the economic health benefits which could potentially be achieved through both the current delivery and wider scaling-up of the satellite-based telemedicine and ehealth activities; Section 6 introduces the cost information and considerations related to the case studies; Section 7 provides detail on wider socio-economic benefits from implementation of the case studies; and Section 8 highlights the key strategic and political linkages with national, regional and international policies. Introduction December 08 PricewaterhouseCoopers 12

15 The report also contains five annexes covering: Annex A - the study approach; Annex B results and details of the consultations; Annex C calculations for the estimates of economic benefits; Annex D glossary; and Annex E references Introduction December 08 PricewaterhouseCoopers 13

16 Introduction December 08 PricewaterhouseCoopers 14

17 2 Context for Telemedicine and ehealth in Sub-Saharan Africa 2.1 Introduction Sub-Saharan Africa has significant social and economic potential but faces significant barriers to realising this potential and playing a more inclusive role in the global economy. Health outcomes and burden are central to delivering answers to African issues. There is growing but still limited infrastructure to address these problems. There is policy interest to tackle these problems at national, pan-african and international levels to address these issues through use of advanced and appropriate technologies. In this section, we provide an overview of the key factors underpinning the rationale for the establishment of a comprehensive satellite-based telemedicine and ehealth programme in sub-saharan Africa. The main drivers of this programme are: The demographic and socio-economic nature of the continent which is characterized by low population density and low income citizens; Heavy disease burden and the requirement for improved healthcare systems; Low levels of fixed line, mobile phone and broadband internet access due to high costs resulting in the need for a technology which has a much wider reach than currently exists; and Firm policy commitments to the development of ehealth made by sub-saharan African countries with the view to addressing health needs. 2.2 African Context Africa is a vast continent with huge geographical differences. It has a large and varied population with significant human and environmental potential to play a key role in global development. However, a mixture of natural, social and economic factors has limited the ability to achieve the continent s potential. The current circumstance in many countries is frequently characterised by widespread poverty, heavy burdens from ill-health and mortality, social tensions, limited public services and insufficient physical infrastructure (including transportation, telecommunications and sanitation). Sub-Saharan Africa is made up of 47 countries 2, located fully or partially south of the Sahara Desert (Figure 1: Map of Sub-Saharan Africa). These countries cover 24.2 million square kilometres (16% of global land surface area) with 800 million people 3 in 2007 (12% of global population). 2 Countries of sub-saharan Africa according to the United Nations are: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Congo - Brazzaville, Democratic Republic of Congo, Cote d Ivoire, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Tanzania, Togo, Uganda, Zambia and Zimbabwe. For our study, South Africa has been excluded from the analysis due to the relatively advanced state of its communications and health system infrastructure. 3 World Bank, World Development Indictors (accessed worldbank.org, 10 November 2008) Context for Telemedicine and ehealth in Sub-Saharan Africa December 08 PricewaterhouseCoopers 15

18 The populations of the sub-saharan Africa countries are very diverse in their circumstances and outcomes. Nevertheless, they share some significant social and economic needs which have large social, economic and environmental costs. A large proportion of the population lives below the poverty line with average gross national income per capita standing at only US$952 4 in 2007 compared to an average of $2,337 in low and middle income countries globally. In addition, life expectancy at birth in the region remains the lowest in the world at 50 years. These issues are not unique to sub-saharan Africa as they are present in many other parts of the developing world, but the concentration and interlinkages of these needs in SSA is particularly high. Figure 1: Map of Sub-Saharan Africa Source : Demographics and Socio-Economic Landscape in Sub-Saharan Africa Sub-Saharan Africa is characterized by demographic and socio-economic factors which make it a unique region, therefore requiring tailored solutions to meet its development needs. Although regional statistics give an indication of the generic challenges, the countries of sub-saharan Africa also differ in their socio-economic indicators and policy makers in these countries face very different issues due to the specific characteristics of their countries; for example whether they are landlocked or not, post-conflict or not, resource rich or resource poor, languages spoken and others. Sub-Saharan Africa covers a vast area with low population density across many regions. As indicated in Table 1, nearly two thirds of sub-saharan Africa s population live in rural areas. Low levels of resources and infrastructure and an often difficult operating environment create challenges for policy makers aiming to extend the reach of its services and 4 World Bank, World Development Indictors (accessed worldbank.org, 10 November 2008) Context for Telemedicine and ehealth in Sub-Saharan Africa December 08 PricewaterhouseCoopers 16

19 infrastructure to all its citizens. countries. Figure 2 provides an overview of the population density for sub-saharan African Figure 2: Population Density Map Source: After many years of under performance, African economies have improved their sustained economic growth rates in recent years, driven by greater local stability and in many cases high commodity demand. This has been stimulated by increasing Africa s economic and trade linkages with the rest of the world. Average growth in the sub-saharan Africa economies was 5.4% in 2005 and Since 2000, economic growth in sub-saharan Africa has outpaced global economic growth and that of the advanced economies as they have been closely aligned with the high rates of growth in the emerging economies of Asia and the Middle East 5. This solid growth has had positive impacts on sub-saharan Africa s human development outcomes. However, given the significant underperformance over many decades, there has been relatively limited sustained socio-economic progress, especially in comparison to other developing regions 6. Table 1 presents aggregate development indicators for the region as a whole. The region s economic output is dominated by the two largest economies, South Africa and Nigeria, who comprise over half of sub-saharan Africa s total economic output. 5 International Monetary Fund (October 2008), World Economic Outlook 6 Anand and Segal 2008 Context for Telemedicine and ehealth in Sub-Saharan Africa December 08 PricewaterhouseCoopers 17

20 Table 1: Sub-Saharan African Socio-Economic and Demographic Indicators Sub-Saharan Africa Indicators (2007) Population (millions) Land area (thousands of sq km) 24,242 GNI per capita $952 GDP Growth 5.70% Rural Population % 64.70% Rural Population Growth 1.4 Gross enrolment ratio primary school (% of relevant age group) 96% (2006) Gross enrolment ratio secondary school (% of relevant age group) 31% (2006) Source: World Bank World Development indicators (accessed worldbank.org, 10 November 2008), There are significant differences in outcomes between sub-saharan Africa countries. To highlight the varying nature between countries, Table 2 shows a number of indicators related to socio-economic, health and infrastructure development. Context for Telemedicine and ehealth in Sub-Saharan Africa December 08 PricewaterhouseCoopers 18

21 Table 2: Socio-Economic Data Indicator Lowest performer Highest performer Gross National Income per capita 7 Burundi ($110) Equatorial Guinea ($12,860) Female participation in the labour force Sudan (22.5%) Burundi (90.5%) Bottom quintile s share of national consumption South Africa (3.5%) Ethiopia (9.1%) Children reaching fifth year of school Chad (33%) Mauritius 97% Primary school enrolment Djibouti (33%) Sao Tome and Principe (97%) Gains in average life expectancy in last decade Botswana (-21 years), Lesotho (-17 years), Swaziland (-16 years) Rwanda (+12 years), Uganda (+7 years) Adult literacy rate Mali and Burkina Faso (24%) Seychelles (92%) Children per primary school teacher Ethiopia (72 children) Mauritius (22 children) Share of Population Living in Rural Burundi (90%) Gabon (16%) Areas 8 Population with access to safe source of water Population with access to improved sanitation facilities Ethiopia (22%) Gabon (88%) Chad (9%) Djibouti (82%) Population living on under $1 per day Nigeria (71%) South Africa (11%) Source: World Bank World Development indicators (accessed worldbank.org, 10 November 2008), WHO WHOSIS data base (accessed 29 October 2008) In addition, sub-saharan Africa lacks much of the infrastructure that is required to promote sustained growth and performance. Sub-Saharan Africa lags at least 20 percentage points behind the average for International Development Association countries on almost all major infrastructure measures. Even for those countries which are more advanced in this region, providing basic infrastructure investment needs to the rural population remains a huge challenge. There exist large inequalities in access to household infrastructure services, with coverage rates in rural areas lagging behind those in urban areas. The region s unmet infrastructure needs are estimated at $22 billion a year (5 percent of GDP), plus another $17 billion for operations and maintenance costs. In sub-saharan Africa, three out of every four people have no access to electricity. In rural areas, this figure is magnified where only eight percent of the population have access to electricity. This is a major issue when considering the use of Information and Communication Technologies (ICTs) for health as nearly all end-user devises need electrical power. Energy shortages and power failures escalate the costs to 7 World Bank, World Development Indicators database Context for Telemedicine and ehealth in Sub-Saharan Africa December 08 PricewaterhouseCoopers 19

22 operators as they must run their own generators. Saharan Africa. This in turn adds to the high prices associated with ICTs in sub- Recent progress however is encouraging. Except roads, indicators of infrastructure access rose between the 1990s and 2000s as shown in Table 3. Access to energy and ICT infrastructure in sub-saharan Africa is presented in Table 4. Table 3: Improvements in African Infrastructure Access Service 1990s 2000s % Change Telephones (per 1,000 people) Improved water (% of households) Improved sanitation (% of households) Grid electricity (% of households) Source: World Bank, 2007 Table 4: Infrastructure Data Indicator 9 Lowest performer Highest performer Electricity power usage Ethiopia (32.7kW/h) South Africa (4,885kW/h) Population outside mobile telephone network 10 (2006) Ethiopia (90%) Mauritius (1%) Internet users per 10,000 inhabitants 11 (2007) Sierra Leone -(19) Seychelles (3,567) Source: World Bank, 2007 These differences highlight the variation in development between countries in sub-saharan Africa and provide an insight into the challenges associated with designing regional programmes. At the same time, however, most countries in sub- Saharan Africa face fiscal constraints making the need for regional cooperation and the sharing of cross boarder infrastructure costs critical to providing basic services to their citizens. Although there are a number of differences, there are also a number of similarities between countries in sub-saharan Africa (such as large geographical areas, low levels of infrastructure and limited public and private resources) which make the use of satellite-based telemedicine and ehealth services a strong contender for regional collaboration. Low population density combined with a lack of adequate infrastructure in rural areas provides significant challenges for policy makers attempting to ensure that all citizens have access to basic services in the areas of education and in particular health. All over the world, individuals living in rural areas must travel further than their urban counterparts to 9 World Health Organisation, WHOSIS database (unless otherwise noted) 10 International Telecommunications Union (2008). African Telecommunication/ICT Indicators 2008: At A Crossroads. 11 International Telecommunications Union (2008). African Telecommunication/ICT Indicators 2008: At A Crossroads. Context for Telemedicine and ehealth in Sub-Saharan Africa December 08 PricewaterhouseCoopers 20

23 find medical care. Equally, health practitioners in rural areas are isolated from their colleagues in urban centres where more sophisticated medical expertise is often located. In sub-saharan Africa, this isolation is compounded by the fact that the transport infrastructure is poor or non existent thus isolating people even further. It is these two characteristics that are magnified in sub-saharan Africa compared to other regions in the world and mean that Telemedicine could provide assistance to strengthen health provision. For telemedicine and ehealth programmes to be successful, however, a base level of telecommunications infrastructure must be in place. This is explored further in Section A Need for Improved Healthcare Health outcomes are both a cause and a consequence of sub-saharan Africa s development position. Some outcomes are linked to specific environmental and locational factors, but most are created or accentuated by poverty, lack of resources and limited skills. Health and economic outcomes are closely interrelated. The figure below shows how improving health and economic outcomes have a circular relationship. Starting at the upper right of the diagram, improved health outcomes raise the available labour and allow greater resource to be invested in economic outcomes. The increased economic output in turn leads to higher skills generation which can aid delivering health outcomes and more resources to be spent on health interventions. Figure 3: Linkages between Economic and Health Development Labour Force Investment Chief AU Goal: Economic Growth African Health Outcomes Skills Resources African Health Needs Types of Interventions Clinical Education Management Surveillance Benefits for individual cases and communities at any one time Requires specific skills, facilities and resources Benefits for both health professionals and citizens Benefits spread across population Requires access to media and also skills in literacy and numeracy Benefits of understanding how the health systems are operating Requires data collection and analysis plus management Benefits of understanding how disease patterns are operating Requires communication facilities plus governance and analytical resources Context for Telemedicine and ehealth in Sub-Saharan Africa December 08 PricewaterhouseCoopers 21

24 The disease burden in sub-saharan Africa is particularly acute and Africa s people face a huge burden of preventable and treatable health problems whose solutions are known. Although some progress has been made, sub-saharan Africa currently lags behind the global average in health indicators. To achieve the Millennium Development Goals target 12, the maternal mortality rate will need to drop from between 500 and 1,500 to 228 per 100,000 and Under 5 mortality from 171 to 61 per 1,000. Life expectancy on the continent, already low, has been reduced further to an average of 47years for sub-saharan Africa in Women and children carry a disproportionate share of sub-saharan Africa s heavy disease burden, with 4.8 million children dying annually, mostly from preventable diseases. Women carry the major responsibility for care and poor education may detract from their ability to address these challenges. Table 5 shows a number of key health indicators for sub-saharan Africa. Table 5: Sub-Saharan Africa Health Indicators Sub Saharan Africa 2005 Life expectancy at birth (years) 47.1 Under five mortality rate (per 1,000) 163 Share of children immunized against measles (%) 64% HIV/AIDS Prevalence Rate (%) 6.1% Source: World Bank, 2007 As with the socio-economic indicators presented in the section above, there is considerable variation between countries in terms of health (see Table 6). Table 6: Health Data Indicator 13 Lowest performer Highest performer Life Expectancy at birth (2006) Sierra Leone (40 years) Mauritius (73 years) Healthy Life Expectancy at birth (2003) Sierra Leone (29 years) Mauritius ( 62 years) Under-five mortality rate (per 1,000 live births) (2006) Rural under-five mortality rates (per 1,000 live births) (various) Nurses and midwives per 10,000 population (2002, 2003, 2004) Sierra Leone (269) Seychelles (13) Mali (253) Namibia (66) Ethiopia (2) Seychelles (79) Physicians per 10,000 population (2004) Twenty countries have less than one physician per 10,000 population Seychelles (15) 12 See section for more details on the Millennium Development Goals 13 World Health Organisation, WHOSIS database accessed 29 October 2008 (unless otherwise noted) Context for Telemedicine and ehealth in Sub-Saharan Africa December 08 PricewaterhouseCoopers 22

25 Indicator 13 Lowest performer Highest performer Skilled attendance at birth Ethiopia (5.7% of births) Mauritius (99.2% of births) Total health expenditure as share of GDP (2006) Equatorial Guinea (1.5%) Malawi (12.3%) AIDS death rate per 100,000 inhabitants Botswana (1,870.8) Sao Tome and Principe (0.6) (2002) 14 Malaria death rate per 100,000 inhabitants (2002) Tuberculosis death rate per 100,000 inhabitants (2002) Diarrhoeal and childhood disease death rate per 100,000 inhabitants (2002) Maternal death rate per 100,000 inhabitants (2002) Perinatal death rate per 100,000 inhabitants (2002) Liberia (205.2) Mauritius (0.0) Swaziland (94.1) Mauritius (0.8) Sierra Leone (541.6) Mauritius (2.3) Sierra Leone (95.5) Seychelles (0.3) Sierra Leone (264.0) Seychelles (6.6) Source: World Bank, 2007 High educational inequality, low life expectancy and low rates of investment in skills are closely inter-related. Low average life expectancies reduce the incentive to invest in education 15. Poor health reduces available working years, productivity when in employment, cognitive ability, available household resources and the benefits to investing in education. Poverty increases the likelihood of disease by decreasing nutritional intake, limiting available resources and reducing the quality of the environment. Health inputs have a significant impact on individual s economic outcomes. Sub-Saharan Africa needs support in both directly reducing diseases and improving the capacity of the health systems to further advances. The key health issues for SSA countries are communicable diseases (especially HIV/AIDS, malaria, tuberculosis and African-specific diseases), childhood illness and maternal health Disease Burden In our case studies, we have focussed on six areas three specific diseases (HIV/Aids, Malaria, and tuberculosis) and three key population groups (mothers, newborns and children under five years of age) as the basis for our assessment. These are certainly not the only areas and groups that would benefit from satellite-based telemedicine and ehealth 14 World Health Organisation (2004) Age-standardized death rates per 100,000 by cause, and Member State, 2002 fior statistics on AIDS, malaria, Tuberculosis, Diarrhoeal and Childhood Disease, Maternal and Perinatal death rates 15 Castelló-Climent and Doménech Sachs 2001 Context for Telemedicine and ehealth in Sub-Saharan Africa December 08 PricewaterhouseCoopers 23

26 interventions. However, they do allow us to estimate the impact on some of the largest and highest profile health issues facing sub-saharan Africa. HIV/AIDS HIV/AIDS has a massive impact on sub-saharan Africa. It has damaged the gains of decades of health, economic and social progress while lowering life expectancy significantly, deepening poverty and contributing to food shortages 17. Almost 6% of sub-saharan Africa s population aged is HIV positive 18, though rates climb to close to 40% for countries such as Swaziland and Botswana 19. Since 1990, HIV infection rates have more than doubled in sub-saharan Africa with infection rates five times higher than any other world region 20. When treatment is undertaken for those who have acquired an HIV infection, effective patient care monitoring is vital for anti-retroviral treatment to monitor toxicology, ensure a regular treatment regime and minimise the risks of HIV mutations which can make ART less effective 21. Malaria Malaria kills around one million people (90% of worldwide deaths) each year in sub-saharan Africa where it is the leading cause of childhood death. Though the vast majority of cases are not fatal, malaria causes significant suffering and costs, including impact on economic growth and development 22. In sub-saharan Africa, malaria is estimated to account for 30% of outpatient visits, hospital admissions and hospital deaths 23. Malaria infection is closely linked with poverty and the inability to take preventative measures. Malaria can be a recurrent disease and prevention while simple and effective needs to be provided constantly and consistently to reduce the risk of acquiring the disease. Tuberculosis Tuberculosis is a bacterial infection which commonly (but not always) infects the patient s lungs. It is the second highest cause of adult death in developing countries after HIV/AIDS to which its increasing prevalence in recent years is linked to increasing drug-resistance. Sub-Saharan Africa has the highest rate of tuberculosis cases of any region in the world with 490 cases per 100,000 people. Additionally, sub-saharan Africa has particular dangerous strains of tuberculosis, and the rate of non-hiv related infection has increased by 50% since Tuberculosis infection is closely linked to poverty and malnutrition which prevents people s immune system from being able to clear the pathogen itself. 17 Anand and Rivett DfID 2007a 19 Cutler DfID 2007a 21 UN Foundation and Vodafone Group Foundation, DfID 2007a 23 DfID 2007b 24 DfID 2007c Context for Telemedicine and ehealth in Sub-Saharan Africa December 08 PricewaterhouseCoopers 24