Deploying Telemedicine in Capacity Constrained Contexts: Lessons from the Vanuatu Inter-Island Telemedicine and Learning Project

This paper studies the implementation and impact of a telemedicine deployment in the remote island of Maewo in Vanuatu. This network uses satellite backhaul, with Wi-Fi last mile architecture distributed to two primary health centers staffed by local nurses and community health workers. For three years, community health workers have used these access points with a basic telemedicine platform run over a messaging application to confer with doctors in referral hospitals located in three different islands, often a six-hour mountain trek and a US$300+ flight away. Through in-depth interviews with government entities, doctors, nurses and community health workers, fieldwork in Vanuatu and Maewo, and messages shared over the telemedicine platform, this paper documents lessons for implementation of Internet-supported healthcare in contexts with high resource and capacity constraints. The paper documents practices that were utilized to incentivize high utilization of the network, and the subsequent changes in social norms that ensued within the otherwise hierarchical healthcare system. Further, through the study of anonymized health records and messages, the paper finds that since the network’s first deployment in mid to late 2016, over 9000 messages have been shared. The paper shares several insights for the successful design and implementation of rural and remote telemedicine interventions in language-diverse contexts with capacity constraints. Only 3% of households in Vanuatu use English or French on a daily basis, preferring to speak local, indigenous language or Bislama, the national language. The traditional literacy within these communities low - less than 10% of the island’s population had graduated high school. Deploying telemedicine in low-capacity constraints through a messaging platform instead of a text-oriented or synchronous video platform was beneficial to the community in several ways. Messaging applications lower costs - both by removing the need for the design and development of a new platform, and by reducing costs incurred in training community health workers from villages in their use. Training and onboarding can be costly in areas with poor infrastructure, or geographies like the Small Island Developing States; use of intuitive applications can aid tremendously in ensuring take-up when limited resources can be expended on long-drawn training programs. Lastly, the messaging application used, from our interviews, helped reduce the hierarchical, reporting-oriented and often burdensome task of case maintenance online, and can be incredibly useful especially in contexts with low skilled manpower, low rates of literacy, and an over-reliance on community/village health workers. Design features built into the messaging system by the healthcare workers - such as regular check-ins through the application every day - served a dual purpose of checking the status of the system (in a context with no technical support for repair of the infrastructure) as well as providing a source of community between far-flung community workers and doctors. Deploying and fostering adoption of telemedicine has been a challenge in several low-income countries. The lessons from Vanuatu can help design and scale other similar efforts in contexts with supply constraints on the healthcare infrastructure.