Telemedicine Acceptance and Implementation in Developing Countries: Benefits, Categories, and Barriers


1 Medical Informatics Department, Faculty of Medicine,Mashhad University of Medical Sciences,Mashhad, IR Iran

2 Bio-technology Depatment, Islamic Azad University,Mashhad, IR Iran


Abstract Context: Distributing health care services in remote and rural areas have become a major health problem for many developing countries. Telemedicine presents solutions to developing countries for better disease prevention, diseasemanagement, emergency services and practicingmedicine in areaswith limited access to healthcare services and facilities. Although thewillingness of devel- oping countries to accept telemedicine and incorporate it into their health care systems is rising, due tomultidisciplinary and com- plicated characteristics of telemedicine, they will face challenges and barriers which will slow down their progress. This literature review attempts to explain the benefits, categories and barriers for acceptance and implementation of telemedicine in developing countries. Evidence Acquisition: This studywas conducted in 2016. Themain questionwas howis the general attitude to the acceptance and use of telemedicine in developing countries and what problems they are facing for the use of telemedicine. To find the solutions, we searched articles in two main databases, PubMed and Scopus, with the keywords and expressions related to the subject of the study (developing countries, telemedicine, tele-health, barriers, challenges, adoption, and acceptance). Totally, 103 articles were extracted. Duplicate articles andarticlespublishedbefore 1998were eliminatedandthe remaining oneswere screenedfor eligibility in accordance with subject of the study. The result was 47 articles from PubMed and 5 articles from Scopus. This review is based mainly on preliminary results, opinions and predictions. As limitations of our study, we limited ourselves to PubMed and Scopus databases and also reviewed articles only in English language. Results: The study did not find any article that totally disagrees with the implementation of telemedicine in developing countries. Most of the articles contain positive points associated with the use of telemedicine with respect to the barriers and challenges. Conclusions: Despite hopeful progresses in telemedicine, developing countries are facingmany problems in theirway toward suc- cessful application of telemedicine. High cost and cultural resistance are considered as themain barriers for developing countries in their approach to apply telemedicine. Developing countries must be fully aware that investment in telemedicine will not in- evitably yield clinical or economic benefits in short time. Theymust consider barriers and various outcomes of telemedicine before accepting and applying it.


  1. 1.Organization WH . Telemedicine: opportunities and developments in Member States: report on the second global survey on eHealth. World Health Organization; 2010.

    1. Praveen KB, Ali SS. Telemedicine in primary health care: the road ahead. Int J Prev Med. 2013;4(3):377–8. [PubMed: 23626897]. Razavi Int J Med. 2016; 4(3):e38332. 5 Hassibian MR and Hassibian S
    2. Kifle M, Solomon A, Okoli C, Mbarika V. Critical success factors for telemedicine in Ethiopia. International Conference IT Management in Healthcare’, In Information Resources Management Association (IRMA 2004). New Orleans. .
    3. Kim EW, Teague-Ross TJ, Greenfield WW, Keith Williams D, Kuo D, Hall RW. Telemedicine collaboration improves perinatal regionalization and lowers statewide infant mortality. J Perinatol. 2013;33(9):725–30. doi: 10.1038/jp.2013.37. [PubMed: 23579490].
    4. de Waure C, Cadeddu C, Gualano MR, Ricciardi W. Telemedicine for the reduction of myocardial infarction mortality: a systematic review and a meta-analysis of published studies. Telemed J E Health. 2012;18(5):323–8. doi: 10.1089/tmj.2011.0158. [PubMed: 22468983].
    5. Lilly CM, Cody S, Zhao H, Landry K, Baker SP, McIlwaine J, et al. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305(21):2175–83. doi: 10.1001/jama.2011.697. [PubMed: 21576622].
    6. Organization WH . The world health report: 2006: working together for health. 2006
    7. Bagchi S. Telemedicine in rural India. PLoS Med. 2006;3(3):82. doi: 10.1371/journal.pmed.0030082. [PubMed: 16509768].
    8. Vijayakumar G, Arun R, Kutty VR. High prevalence of type 2 diabetes mellitus and other metabolic disorders in rural Central Kerala. J Assoc Physicians India. 2009;57:563–7. [PubMed: 20209716].
    9. Wootton R. Realtime telemedicine. J Telemed Telecare. 2006;12(7):328– 36. doi: 10.1258/135763306778682387. [PubMed: 17059648].
    10. Shimmura S, Shinozaki N, Fukagawa K, Shimazaki J, Tsubota K. Realtime telemedicine in the clinical assessment of the ocular surface. Am J Ophthalmol. 1998;125(3):388–90. [PubMed: 9512159].
    11. Weiner M, Schadow G, Lindbergh D, Warvel J, Abernathy G, Dexter P, et al. Secure Internet video conferencing for assessing acute medical problems in a nursing facility. Proc AMIA Symp. 2001:751–5. [PubMed: 11825286].
    12. Pal A, Mbarika VW, Cobb-Payton F, Datta P, McCoy S. Telemedicine diffusion in a developing country: the case of India (March 2004). IEEE Trans Inf Technol Biomed. 2005;9(1):59–65. [PubMed: 15787008].
    13. Gagnon MP, Duplantie J, Fortin JP, Landry R. Implementing telehealth to support medical practice in rural/remote regions: what are the conditions for success?. Implement Sci. 2006;1:18. doi: 10.1186/1748- 5908-1-18. [PubMed: 16930484].
    14. Kristensen GB, Nerhus K, Thue G, Sandberg S. Results and feasibility of an external quality assessment scheme for selfmonitoring of blood glucose. Clin Chem. 2006;52(7):1311–7. doi: 10.1373/clinchem.2006.068114. [PubMed: 16690732].
    15. Doolittle GC. A costmeasurement study for a home-based telehospice service. J Telemed Telecare. 2000;6 Suppl 1:S193–5. [PubMed: 10794017].
    16. Woodend AK, Sherrard H, Fraser M, Stuewe L, Cheung T, Struthers C. Telehome monitoring in patients with cardiac disease who are at high risk of readmission. Heart Lung. 2008;37(1):36–45. doi: 10.1016/j.hrtlng.2007.04.004. [PubMed: 18206525].
    17. Conde JG, De S, Hall RW, Johansen E, Meglan D, Peng GC. Telehealth innovations in health education and training. Telemed J E Health. 2010;16(1):103–6. doi: 10.1089/tmj.2009.0152. [PubMed: 20155874].
    18. esh Mangrulkar R, Athey B. Telemedicine and medical/health education.. 49. University of Michigan: Contracting organization; 2001.
    19. Wootton R, Bonnardot L. In what circumstances is telemedicine appropriate in the developing world?. JRSM Short Rep. 2010;1(5):37. doi: 10.1258/shorts.2010.010045. [PubMed: 21103129].
    20. Hersh WR, Helfand M, Wallace J, Kraemer D, Patterson P, Shapiro S, et al. Clinical outcomes resulting from telemedicine interventions: a systematic review. BMC Med Inform Decis Mak. 2001;1:5. [PubMed: 11737882].
    21. Cartwright M, Hirani SP, Rixon L, Beynon M, Doll H, Bower P, et al. Effect of telehealth on quality of life and psychological outcomes over 12 months (Whole Systems Demonstrator telehealth questionnaire study): nested study of patient reported outcomes in a pragmatic, cluster randomised controlled trial. BMJ. 2013;346:f653. doi: 10.1136/bmj.f653. [PubMed: 23444424].
    22. Marcolino MS, Maia JX, Alkmim MB, Boersma E, Ribeiro AL. Telemedicine application in the care of diabetes patients: systematic review and meta-analysis. PLoS One. 2013;8(11):79246. doi: 10.1371/journal.pone.0079246. [PubMed: 24250826].
    23. Schopf TR, Bolle R, Solvoll T. The workload of web-based consultations with atopic eczema patients at home. BMC Res Notes. 2010;3:71. doi: 10.1186/1756-0500-3-71. [PubMed: 20226049]. 25. Davalos ME, French MT, Burdick AE, Simmons SC. Economic evaluation of telemedicine: review of the literature and research guidelines for benefit-cost analysis. Telemed J E Health. 2009;15(10):933–48. doi: 10.1089/tmj.2009.0067. [PubMed: 19954346].
    24. Dharmar M, Romano PS, Kuppermann N, Nesbitt TS, Cole SL, Andrada ER, et al. Impact of critical care telemedicine consultations on children in rural emergency departments. Crit Care Med. 2013;41(10):2388–95. doi: 10.1097/CCM.0b013e31828e9824. [PubMed: 23921273].
    25. Pemberton PJ, Goldblatt J. The Internet and the changing roles of doctors, patients and families. Med J Aust. 1998;169(11-12):594–5. [PubMed: 9887903].
    26. Whitten P, Love B. Patient and provider satisfaction with the use of telemedicine: overview and rationale for cautious enthusiasm. J Postgrad Med. 2005;51(4):294–300. [PubMed: 16388172].
    27. Gulliford SM, Schneider JK, Jorgenson JA. Using telemedicine technology for pharmaceutical services to ambulatory care patients. Am J Health Syst Pharm. 1998;55(14):1512–5. [PubMed: 9676298].
    28. O’Mahony D, Banach L, Mahapa DH, Lancaster EW, Van der Linde GD, Williams BH, et al. Teledermatology in a rural family practice. South African Family Practice. 2002;25(6):4–8.
    29. Tran K, Ayad M, Weinberg J, Cherng A, Chowdhury M, Monir S, et al. Mobile teledermatology in the developing world: implications of a feasibility study on 30 Egyptian patients with common skin diseases. J Am Acad Dermatol. 2011;64(2):302–9. doi: 10.1016/j.jaad.2010.01.010. [PubMed: 21094560].
    30. Sawai T, Uzuki M, Kamataki A, Tofukuji I. The state of telepathology in Japan. J Pathol Inform. 2010;1 doi: 10.4103/2153-3539.68327. [PubMed: 20922030].
    31. Ford JC. If not, why not? Reasons why Canadian postgraduate trainees chose–or did not choose–to become pathologists. Hum Pathol. 2010;41(4):566–73. doi: 10.1016/j.humpath.2009.09.012. [PubMed: 20004951].
    32. Harrison P. Laboratory medicine needs higher profile with medical students, MDs, pathologists say. CMAJ. 1995;153(6):805–8. [PubMed: 7664233].
    33. Nakhleh RE, Bekeris LG, Souers RJ, Meier FA, Tworek JA. Surgical pathology case reviews before sign-out: a College of American Pathologists Q-Probes study of 45 laboratories. Arch Pathol Lab Med. 2010;134(5):740–3. doi: 10.1043/1543-2165-134.5.740. [PubMed: 20441505].
    34. Burute N, Jankharia B. Teleradiology: The Indian perspective. Indian J Radiol Imaging. 2009;19(1):16–8. doi: 10.4103/0971-3026.45337. [PubMed: 19774131].
    35. Lamminen H, Voipio V, Ruohonen K, Uusitalo H. Telemedicine in ophthalmology. Acta Ophthalmol Scand. 2003;81(2):105–9. [PubMed: 12752046].
    36. Bowles KH, Baugh AC. Applying research evidence to optimize telehomecare. J Cardiovasc Nurs. 2007;22(1):5–15. [PubMed: 17224692].
    37. Finkelstein SM, Speedie SM, Lundgren JM, Ideker M. TeleHomeCare: connecting the home and the home care agency. Caring. 2000;19(7):32–5. [PubMed: 11010440].
    38. Jensen BT, Kristensen SA, Christensen SV, Borre M. Efficacy of tele-nursing consultations in rehabilitation after radical prostatectomy: a randomised controlled trial study. Inter J Urological Nurs. 2011;5(3):123–30. 6 Razavi Int J Med. 2016; 4(3):e38332. Hassibian MR and Hassibian S
    39. Russo H. Window of opportunity for home care nurses: telehealth technologies. Online J Issues Nurs. 2001;6(3):5. [PubMed: 11936944].
    40. Edworthy SM. Telemedicine in developing countries. BMJ. 2001;323(7312):524–5. [PubMed: 11546681].
    41. Wootton R. Telemedicine support for the developing world. J Telemed Telecare. 2008;14(3):109–14. doi: 10.1258/jtt.2008.003001. [PubMed: 18430271].
    42. Laouyane A. Telemedicine and developing countries. J Telemed Telecare. 1998;4.
    43. Latifi R, Merrell RC, Doarn CR, Hadeed GJ, Bekteshi F, Lecaj I, et al. "Initiate-build-operate-transfer"–a strategy for establishing sustainable telemedicine programs in developing countries: initial lessons from the balkans. Telemed J E Health. 2009;15(10):956–69. doi: 10.1089/tmj.2009.0084. [PubMed: 19832055].
    44. Kuszler PC. Telemedicine and integrated health care delivery: compounding malpractice liability. Am J Law Med. 1999;25(2-3):297–326. [PubMed: 10476332].
    45. Moffatt JJ, Eley DS. Barriers to the up-take of telemedicine in Australia– a view from providers. Rural Remote Health. 2011;11(2):1581. [PubMed: 21385004].
    46. Jang-Jaccard J, Nepal S, Alem L, Li J. Barriers for delivering telehealth in rural australia: a review based on Australian trials and studies. Telemed J E Health. 2014;20(5):496–504. doi: 10.1089/tmj.2013.0189. [PubMed: 24801522].
    47. LeRouge C, Garfield MJ. Crossing the telemedicine chasm: have the U.S. barriers to widespread adoption of telemedicine been significantly reduced?. Int J Environ Res Public Health. 2013;10(12):6472–84. doi: 10.3390/ijerph10126472. [PubMed: 24287864].
    48. Alverson DC, Shannon S, Sullivan E, Prill A, Effertz G, Helitzer D, et al. Telehealth in the trenches: reporting back from the frontlines in rural America. Telemed J E Health. 2004;10 Suppl 2:S–95-109. [PubMed: 23570220].
    49. Steele RE. Telemedicine in Greenland: the case for and against implementation. Int J Circumpolar Health. 1998;57 Suppl 1:686–8. [PubMed: 10093368].
    50. Saghaeiannejad-Isfahany S, Jahanbakhsh M, Shayan A. Telemedicine operational feasibility in selected hospitals of Isfahan University of Medical Sciences in 1393. Inter J Health System Disaster Manage. 2015;3(4):189.