Telemedicine for social inclusion

Background

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During the COVID-19 pandemic, like any other small municipality in Brazil and, ultimately, in Latin America and the Caribbean, the municipality of Bom Jardim has suffered from the effects of the virus and its impact on public health, as well as the corresponding isolation and forced confinement, and the effect this has had on society and the economy. In this context, the Prefeitura Municipal de Bom Jardim (Municipal Government of Bom Jardim) in Brazil, has seen its public services deteriorate, with health services for the most vulnerable particularly affected; losing both efficiency and effectiveness, with a negative impact on the well-being of the population. In light of this, the Ministry of Health and the Ministry of Social Assistance and Human Rights identified telemedicine as a modality that could effectively contribute to both the current challenges (shaped by the pandemic) and future challenges of health coverage, as well as access to health and social services.

Thanks to the involvement of resident experts from the Italian-Latin American Institute - IILA (Italy) in the municipality, the Prefeitura Municipal, familiar with the capacities of IILA in this area and their relational capital, approached the organisation to assess the possibility of occasional support or collaboration, in order to implement certain basic telemedicine services at the local level.

In the framework of this dialogue, the IILA identified the issue in the request from the Prefeitura, which affects many other municipalities in the region. It also represents a development challenge with a much broader scope than originally imagined, therefore requiring a response that, building on this specific case, is capable of creating a 'local telemedicine implementation model' that could be applied in many other similar environments. To this end, four key areas of work were identified: the legislative and regulatory framework at the national and intermediary levels (regulatory area), local health authorities and the particular health characteristics of the area (health area), adapted technologies (scientific-technological area) and the scale of the investment (budgetary area).

In response, IILA convened two of the leading entities in the field with which it has a long-standing bilateral relationship, thanks to various European Union development programmes, including EUROsociAL; a partnership that had been strengthened during the COVID-19 pandemic. These highly complementary entities are the Barcelona Institute for Global Health - ISGlobal, in Spain, and the Ministry of Health of Panama - Minsa, both leaders in advanced health research and in the search for and application of new solutions, based on the latest technologies. For example, these include ISGlobal's various innovative solutions, such as the 'Trip Doctor' telemedicine platform, among many others, as well as Minsa's recent telehealth law and its corresponding systems for telehealth, telemedicine and digital health.

These entities were joined by the Istituto Superiore di Sanità (National Institute of Health - ISS), in Italy, with its Centro Nacional para la Telemedicina y las Nuevas Técnicas de Asistencia (National Center for Telemedicine and New Assistive Technologies - CNT), as well as the Instituto Latinoamericano de Salud Cerebral (Latin American Institute for Brain Health - BrainLat) in Italy.

In response to IILA's proposal, each of these entities responded positively, thus creating a strong Triangular Cooperation Partnership aimed at generating a model to facilitate the implementation of telemedicine at the local level. In addition to each of these entities, there are others with whom they have directly worked, both in their countries of origin and within the framework of international projects and programmes, in such a way that each one contributes to the Partnership by offering all of its relational capital.

Entities and roles

Beneficiary entities

Prefeitura Municipal de Bom Jardim

Brazil

First provider entities

Ministerio de Salud de la República de Panamá

Panama

Second provider entities

Organización Internacional Ítalo - Latino Americana

Italy

Instituto de Salud Global de Barcelona

Spain

Collaborating entities

Multi-Partner Consortium to Expand Dementia Research in Latin America, Argentina

Centro Nazionale per la Telemedicina e le Nuove Tecniche Assistenziali, Italy

Development challenges

Thanks to this Triangular Cooperation Initiative, the Prefeitura Municipal de Bom Jardim was able to harness all the knowledge, experience and relational capital in solutions aimed at universal health care and access to quality basic health services. There was a focus on social inclusion, thanks to the solutions oriented towards the most vulnerable populations, led by the Barcelona Institute for Global Health (ISGlobal) and the Ministry of Health of Panama (Minsa), as a contribution to the goal of generating a 'model for the local implementation of telemedicine’.

The exercise paid special attention to the characteristics of certain particularly vulnerable sectors of the population, and sought specially adapted solutions for chronic patients, the elderly, isolated rural communities, Indigenous peoples, socially marginalised groups and detained persons, among others; thus ensuring the approach of 'access to essential services for the most vulnerable'.

The experience in Bom Jardim greatly enriched all of the participant entities in the process, which now have a powerful source of insights that will benefit their own models.
ISGlobal's participation in the main health research and development networks in Europe and all over the world, as well as Minsa's participation in all of the coordination and dialogue networks among the ministries of health in Latin America and the Caribbean, serves as a unique platform for sharing this experience far beyond the scope of the participating countries.

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This Triangular Cooperation Initiative strengthened the capabilities of the Beneficiary entity to establish a local telemedicine deployment model, based on a four-fold approach (regulatory, health, scientific-technological and budgetary), which effectively contributes to universal health coverage and access to quality essential health services, with a focus on social inclusion through solutions oriented towards the most vulnerable.

Triangular approach

There is a strong consensus on the need to mobilise and invest, through multi-stakeholder and multi-level partnerships, in innovative solutions that contribute 'to ensuring that all men and women, particularly the poor and most vulnerable, have equal rights of access to essential services,' and, in the field of health in particular, to achieve 'universal health coverage and access to quality basic health services'.

The COVID-19 pandemic and the resulting confinement and isolation measures have highlighted the importance of telemedicine, not only as a useful tool for health services, but also as an essential way to guarantee health and social rights, as well as tackle the Sustainable Development Goals associated with these issues.

However, due to its complexity, telemedicine cannot be implemented as a one-off exercise or only through the lens of healthcare, but instead requires a complex and multidisciplinary approach; one that addresses the legislative and legal, health, scientific and technological and budgetary aspects in a balanced and more comprehensive way. This is especially important when it involves a 'bottom-up' approach, in addition to the traditionally more robust 'top-down' processes.

This Initiative was able to harness the existing knowledge, experience, networks and models in European and Latin American public and academic entities in the field of telemedicine, as a contribution to universal health coverage and access to quality basic health care services, making them available to the Prefeitura de Bom Jardim and to all local entities in the region that might be interested in this initiative.

Sectoral approach - Contribution to the 2030 Agenda

Primary SDG

Goal 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

Secondary SDG

Goal 1.4 By 2030, ensure that all men and women, in particular the poor and the vulnerable, have equal rights to economic resources, as well as access to basic services, ownership and control over land and other forms of property, inheritance, natural resources, appropriate new technology and financial services, including microfinance

ADELANTE SDG

Goal 10.3 Ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory laws, policies and practices and promoting appropriate legislation, policies and action in this regard

Goal 17.9 Enhance international support for implementing effective and targeted capacity-building in developing countries to support national plans to implement all the sustainable development goals, including through North-South, South-South and triangular cooperation

Territorial approach

Intervention methodology

This Triangular Cooperation Initiative was based on a close relationship between the representatives of the Partnership entities, which sought mutual support, as well as a work methodology to find balance between an effective response to the particular challenges faced by Bom Jardim and the challenge of creating a local telemedicine model; one that could be easily replicated in other municipalities with similar characteristics.

The first activity carried out was an internal coordination workshop among the Partnership entities, which also included a presentation and launch of the Initiative.

The workshop was immediately followed by a study on the state of telemedicine, in particular at the local level, in a number of relevant European and Latin American countries. The study was designed with a four-fold approach: the legislative and regulatory framework at the national and regional levels (regulatory), local health authorities and the particular health characteristics of the area (health), adapted technologies (scientific-technological) and the scale of the investment (budgetary). Special attention was paid to the ethical reflections and debates surrounding telemedicine that have taken place in each country, and to the solutions adapted to the most vulnerable groups.

The study was complemented by a specific consultancy on one of the main challenges of telemedicine today: cyber-security and data protection as part of the regulatory approach, which is a necessary condition that affects the entire exercise.

Following the study, a seminar was held that had initially been planned as a face-to-face event but took place virtually, due to the risks of the COVID-19 ‘omicron wave’ and thanks to the flexibility demonstrated by all those involved. The objective was to share the results of the study, as well as the specific experiences of each of the Partnership member entities in telemedicine, as the first step towards jointly designing a manual for the creation of telemedicine centres, to be directly implemented in Bom Jardim. All of the civil servants and public employees of the Secretariat of Health and the Secretariat of Social Assistance and Human Rights were also involved, along with the entire Prefeitura staff. Input from civil society was also taken into account, including patients' associations.

A study visit to Italy had also been planned but was cancelled due to the risk of the COVID-19 'omicron wave.' The visit had been planned to the National Center for Telemedicine and New Assistive Technologies (CNT) of the Italian National Institute of Health (ISS), in order to learn all about the Center's telemedicine model and to determine which elements could be best adapted to a local telemedicine model. In order not to lose this potential contribution, considerable attention was focused on the CNT during the seminar and, to the extent possible, it was possible to expand on the planned content, thus adding to the success of the seminar.

The second study visit took place in Panama with the Ministry of Health (Minsa), in order to learn more about the Telehealth System, the Telemedicine System and the Integrated Digital Health System, particularly with regard to their application at the local level in vulnerable municipalities located far from the capital. Work was also carried out with all of Minsa's strategic partners in each of these areas.

Both the seminar and the study visit were specifically aimed at analysing the conditions in Bom Jardim for the design and implementation of telemedicine services, which required strong commitment by the Prefeitura and an intense training exercise for the health professionals and officials involved.

The Initiative concluded with a study specifically aimed at creating a framework document that, on the one hand, systematised the insights gained throughout the Initiative and, on the other hand, outlined a roadmap towards a 'local telemedicine implementation model'. It is an open document and is now available to all interested local actors. In fact, the document continues to benefit from the follow-up of the Bom Jardim experience, and is open to other experiences that may be added. All of the entities involved also pledged to continue collaborating and to establish a 'Partnership for local telemedicine.'

Direct beneficiaries (individuals)

According to Rule 9 of the Guidelines for Applicants: all persons participating in the activities of the Initiative.

This Initiative had 50 direct beneficiaries, all of whom were professionals from the Partnership entities with varying responsibilities, in order to effectively support each of the four pillars on which the model is based: legal teams, health teams, scientific teams and planning/investment teams. Due to the characteristics of the Partnership entities, these professionals primarily work in the public sector, academia and research.

Work was also carried out periodically with all of the public officials and employees of the Secretariat of Health and the Secretariat of Social Assistance and Human Rights of the government of Bom Jardim, as well as with representatives from other secretariats and local civil society. Patients' associations were particularly involved, in order to receive their input in defining the telemedicine services model.

Budget

EU contribution: 10,909.32 €

Co-financing - Triangular Cooperation Partnership: 4,494.00 €

Total budget: 15,403.32 €

The information gathered in this IMPACT section is the result of the first 'joint ex post analysis exercise' of the Initiative which, as foreseen in the policy framework of the ADELANTE Window, took place one year after the end of the implementation period.

For more information on these exercises, please consult the ADELANTE Window 2021 Impact Report.

Continuity of the Partnership

STARTING POINT: Existing North-South relationship that was strengthened by the addition of partners from Latin America and the Caribbean as First providers.

The Partnership, as such, has not been consolidated and has not been maintained over time.

Application of generated knowledge

The knowledge generated has been applied by the First provider* in terms of actions and policy.

Improvement of teleconsultation services from telephone call to video call, and extension of these services to hard-to-reach areas of Panama.

Impact

Applying this knowledge has enabled the First provider entity to increase the impact of its interventions.

It has also enabled the entity to become a knowledge provider in various regional processes.

FACTORS THAT HAVE ENABLED THE IMPACT:

In the country of the First provider: the policy priority given to the subject matter of the Initiative, the commitment of the First provider and the commitment of all the professionals involved.

FACTORS THAT HAVE HINDERED IMPACT:

In the context of the Beneficiary entity: changes in political and institutional priorities.

Future perspectives

With regard to the First provider: continue to make progress in applying knowledge and gaining access to international funding in order to broaden its scope in the development of new public policies.

NEW EX POST EXERCISE:

Yes (2024)

(*) The particularity of this Initiative is that the knowledge generated has been applied especially by the First provider entity, to a greater extent than the Beneficiary entity.

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