Effectiveness of Telepharmacy in Rural Communities in Africa: A Scoping Review

Abstract

Objectives: This review examined the effectiveness of telepharmacy in rural communities in Africa to identify the barriers that hinder its implementation and integration as well as highlight the gaps in the existing research on telepharmacy. Data Source: PubMed and Google Scholar search (2008-2023) was conducted using keywords related to telepharmacy, telemedicine, telehealth, and rural communities. Study Selection and Data Extraction: The inclusion criteria for the review include peer-reviewed articles published in English language and studies that focus on the implementation and evaluation of telepharmacy in rural communities. Data Synthesis: In all articles used, access to quality health care in rural communities has been a persistent challenge in Africa. Digital technologies such as telemedicine, telepharmacy, and artificial intelligence were reported to have emerged as promising solutions to improve health care access and outcomes in rural communities. Telepharmacy, in particular, has the potential to provide medication-related services to patients irrespective of one’s location. However, the implementation of telepharmacy in Africa has been slow, and there are several barriers affecting its integration and adoption in rural communities that include access to technology, limited infrastructure, and regulatory challenges. Gaps and limitations in the existing research on telepharmacy in rural communities were highlighted from the articles. Conclusion: Telepharmacy can improve health care access and outcomes in rural communities by bridging the gap between pharmacists and patients. However, the lack of infrastructure, inadequate funding, and regulatory challenges pose significant barriers to its implementation. Future research should focus on addressing these challenges and exploring the potential of telepharmacy to improve health care in rural communities in Africa.

Introduction

Health care in rural communities has been characterized by poor quality and accessibility, as compared with health care in urban communities. ¹ This has resulted in poor health outcomes both clinically and economically as they tend to pose burdens to the individual and the health care system. The era of the COVID-19 pandemic that was characterized by limited face-to-face interactions with people exaggerated the poor condition of health care in rural areas, especially those in developing and underdeveloped regions.^2,3 Health technology is seen as a feasible approach that can curb major barriers to health care in rural communities. Telemedicine, telepharmacy, and artificial intelligence (AI), among others, are profound areas of digital transformation in health care and are reshaping how health professionals and patients interact.

The concept of telepharmacy refers to the administration of pharmacy care and services to patients using information and communications technology irrespective of where they reside.^4,5 Telepharmacy is defined as a method used in pharmacy practice in which a pharmacist utilizes telecommunications technology to oversee aspects of pharmacy operations or provide patient-care services. ⁶ Evidence suggests that a wide range of clinical services and operational pharmacy activities can be conducted via telepharmacy such as patient assessment, medication review, patient education, prescription verification, disease prevention, and assessment of clinical outcomes. ⁷ The advent of telepharmacy in health care delivery has played a role in easy accessibility to health care services such as patient counseling, prescription filling, and medication review. This has been particularly beneficial for those who cannot easily access the local pharmacies in their location, thereby bridging the gap between pharmacists and patients. However, despite the numerous benefits obtainable with telepharmacy, it is still being poorly adopted and has several barriers to its implementation by countries of Africa, even more so among rural communities. ³ Rural communities often have limited access to social amenities. These include health care facilities, educational institutions, transportation services, and basic utilities like water, electricity, and internet connectivity. ⁸

This review assessed the effectiveness of telepharmacy in rural communities in Africa and highlights the barriers affecting the implementation and integration of telepharmacy in rural communities. It also highlights several limitations and gaps in the existing research on telepharmacy in rural communities that need to be addressed by future research.

Methods

The review followed the guideline for scoping review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). ⁹

Searching Strategy

A search of 2 electronic databases (PubMed and Google Scholar) was conducted to identify relevant studies between 2008 and 2023. A.U.U., J.C.O., I.N.C.-E., and C.C.A. carried out the database search using the keywords “Telepharmacy” OR “Telemedicine” OR “Telehealth” AND “Rural communities” AND “Africa.” Additional articles were also manually extracted from the reference list of selected articles to obtain relevant information on telepharmacy in rural communities in Africa.

Inclusion and Exclusion Criteria

Studies that were to be considered for the review were expected to describe the effectiveness of telepharmacy in rural communities in Africa. The inclusion criteria for the study include peer-reviewed articles between 2008 and 2023, studies published in the English language, descriptive, cross-sectional studies that focus on the implementation and evaluation of telepharmacy in rural communities, and studies that report on patient outcomes such as medication adherence and health outcome. Articles on rural areas were identified based on countries in Africa that are identified as low- and middle-income countries, for example, Nigeria, Ghana, Ethiopia, and South Africa. The exclusion criteria were clinical trials and studies from capital cities in Africa, and studies whose full text were not available. Supporting information were also gathered from commentaries and reviews that gave information about the effectiveness of telepharmacy.

Data Synthesis

All the articles identified were screened independently by A.I. and C.A.N. for inclusion. The collected articles were managed by using the Zotero reference manager after a prior review of the title and abstract. The retrieved data were then discussed under suitable headings narratively to explore the aim of the review.

Results and Discussion

The search process initially generated 115 results. After removing duplicates, 65 unique articles remained. These articles were then screened based on their titles and abstracts, resulting in 58 articles considered for further evaluation. Full-text access was obtained for the 58 articles, and their eligibility was assessed. Initially, 28 articles were deemed potentially eligible based on their abstracts. These 28 articles were thoroughly evaluated based on their full texts, resulting in a final selection of 13 articles that met the eligibility criteria. To ensure consistency and accuracy in the selection process, the authors engaged in discussions and reached a unanimous agreement on the eligibility of the 13 articles. No third-party involvement was required. Ultimately, 9 articles were included in the scoping review. Figure 1 provides a visual representation of the selection process.

Figure 1.

Study selection process according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart.

Health Care in Rural Communities

Health care service access in rural areas is hindered by factors such as high population growth, increased demand for health care, slow economic growth, and rising health costs. ¹⁰ The lack of proper health care infrastructure further limits the provision of comprehensive health care services to rural populations, exacerbating the need for patients to travel long distances to access health care professionals.

The shortage of health care professionals, including doctors, nurses, and pharmacists, in African rural areas, is a significant barrier to health care access.^11,12 Many professionals migrate to urban areas where resources and career opportunities are more abundant. This migration further affects health care access in rural communities. In addition, pharmacies in remote areas face challenges in service sustainability due to difficulties in hiring and retaining pharmacists, hindering long-term impacts on healthcare provision.

Certain practices and prevalent cultural norms in rural communities contribute to low health literacy, leading to a lack of awareness and understanding of health care options and services. This self-reliance and reluctance to seek medical attention can have negative consequences on health outcomes. ¹³ Addressing these factors is essential to empower rural residents with the knowledge and understanding necessary to make informed decisions about their health.

To improve health care access in rural communities, African countries like Ethiopia are implementing telemedicine and telepharmacy services. ¹⁰ These technologies enable remote consultations with health care professionals and provide access to pharmaceutical expertise and medication delivery. By leveraging telehealth solutions, health care services can reach remote areas, reducing the burden of travel and increasing access to quality care.

Telepharmacy as a Potential Solution in Health Care Delivery in Rural Communities

Health technology is seen as a feasible approach that can curb major barriers to health care in rural communities. ¹⁴ Studies agree that the health care system in rural communities needs reforming, and telepharmacy appears to be a suitable approach.^{3,10,12,15,16}

Telepharmacy is emerging as a promising solution to enhance health care delivery in rural communities in Africa where access to pharmacies and health care services is lacking. ¹⁵ By leveraging the power of telecommunications technology, telepharmacy enables pharmacists to provide pharmaceutical care remotely, bridging gaps and connecting with patients in need. A study carried out in Nandi County, Kenya, by Amdany et al ¹⁶ revealed that 54.5% of health care workers perceived telepharmacy as a critical emergency health care need, indicating its importance in health facilities. This demonstrates that telepharmacy is not just a retail pharmacy concept but is also applicable in a hospital setting.

The relevance of telehealth, of which telepharmacy is a prominent aspect, became prominent during the COVID-19 outbreak. Most studies on telepharmacy emerged as a response to the impact of the COVID-19 pandemic.^2,12,17 Telepharmacy held significant potential for rural communities in Africa during the COVID-19 pandemic and continues to offer numerous benefits, including remote medication consultation, medication delivery, refill management, medication adherence support, and screening services. By utilizing telecommunications technology and establishing infrastructural connectivity, telepharmacy could bridge the health care gap, improve medication access, and enhance health care delivery in remote areas.^3,12,15

Barriers Affecting the Implementation of Telepharmacy in African Rural Communities

Telepharmacy, with its potential to improve drug therapeutic monitoring and reduce adverse drug events, holds great promise for health care delivery in African rural communities. However, several significant barriers hinder its successful implementation in these areas. ¹⁰ The initial cost of establishing telepharmacy services is a major challenge, encompassing telecommunication expenses, training requirements for health care personnel, and patient education. ¹⁰ Moreover, the lack of essential infrastructure, such as reliable access to electricity, health information technologies, network coverage, and internet connectivity, further exacerbates the difficulties faced in implementing telepharmacy services. ¹⁰

Another critical barrier to telepharmacy implementation in Africa is the absence of a regulatory framework specific to this practice. Ogbonna et al ³ highlighted that most African countries lack laws governing online pharmacy practice, including telepharmacy services. This regulatory gap raises concerns about patient confidentiality and the privacy of health information, crucial aspects upheld by professional codes of ethics for pharmacists. ¹² With the accumulation of substantial amounts of personal health data in electronic form, the need to safeguard confidentiality, privacy, and security becomes even more pressing. ¹²

In addition to infrastructure and regulatory challenges, patient willingness to pay for telepharmacy services poses a significant barrier. Research conducted by Anosike et al ¹⁸ and Ogbonna et al ³ reveals that many patients in rural communities are reluctant to bear the financial burden associated with pharmacist-provided home telemonitoring services. The inability to afford these services due to low-income levels is a prevalent factor contributing to patient unwillingness to pay. This underscores the socioeconomic disparities that hinder the adoption of telepharmacy in resource-constrained rural areas.

Addressing these barriers is essential for unlocking the full potential of telepharmacy in African rural communities. Governments and health care organizations need to allocate resources for the establishment and maintenance of telecommunication infrastructure, ensuring reliable access to electricity, network coverage, and internet connectivity. ¹⁰ Furthermore, regulatory frameworks should be developed and implemented to protect patient confidentiality and privacy while adhering to professional ethical standards. ¹² To bridge the financial gap, innovative strategies such as subsidized or community-funded telepharmacy services should be explored, enabling affordable access for patients in rural communities. ¹⁸ Barriers to the implementation of telepharmacy in rural communities are summarized in Table 1.

Table 1.

Barriers Affecting the Implementation of Telepharmacy.

S/N	Author(s)	Identified barrier
1	Sagaro et al 10	• High initial cost of establishing telepharmacy services • Limited access to electricity for telepharmacy operations • Limited access to health information technologies for telepharmacy • Limited network coverage for telecommunication
2	Ogbonna et al 3	• Absence of a regulatory framework specific to telepharmacy
3	Anosike et al 18	• Patient unwillingness to pay for telepharmacy services
4	Hedima and Okoro 12	• Concerns about patient confidentiality, privacy, and security in telepharmacy

It is important to consider the identified barriers while implementing telepharmacy in rural areas as well as the unique circumstances in which it will be introduced while developing effective strategies to overcome these barriers.

Discussion on the Gaps in Existing Research and Recommendations

One major gap in existing research is the lack of robust, high-quality studies on the efficacy and effectiveness of telepharmacy interventions in rural communities in Africa. Although there have been some small-scale studies and pilot projects that have shown promise, there is a need for larger, more rigorous studies to evaluate the long-term impacts of telepharmacy on patient outcomes and pharmacist workloads.

The second is limitations in the lack of standardization and consistency in telepharmacy practice. There is currently no set of guidelines for telepharmacy, which can make it difficult to compare and replicate results across studies. There is a need to institute appropriate guidelines for telepharmacy models that should serve as a standard reference for its implementation. Training and education should be provided to all telepharmacy staff to ensure they understand the standards and best practices for telepharmacy practice. There should also be regular monitoring and evaluation of telepharmacy operations that can help identify areas for improvement and ensure that standards and best practices are being followed consistently.

In addition, there is a gap in research on the economic and financial sustainability of telepharmacy in rural communities. While telepharmacy has the potential to reduce costs by eliminating the need for travel and increasing the efficiency of services, there is a need for further research to determine the costs and potential reimbursement models for telepharmacy services. Researchers should engage with key stakeholders, such as patients, health care providers, insurers, and policymakers, to understand their perspectives on telepharmacy and its economic and financial sustainability.

Last, there is a gap in research on the impact of telepharmacy on patient-pharmacist communication and trust. Telepharmacy can potentially facilitate more frequent and efficient communication between patients and pharmacists, but it is important to study the potential impact of telepharmacy on trust and loyalty between patients and pharmacists.

By addressing these gaps, there can be an improvement and access to high-quality pharmacy services in rural communities and support the long-term sustainability of telepharmacy services. Summary of the gaps existing in researches and recommendations is presented in Table 2.

Table 2.

The Gaps in Existing Researches and Possible Recommendations.

S/N	Gaps in existing researches	Recommendations
1	Lack of robust, high-quality studies on the efficacy and effectiveness of telepharmacy interventions in rural communities	• A need for more extensive studies to evaluate the long-term impacts of telepharmacy on patient outcomes and pharmacist workloads.
2	Lack of standardization and consistency in telepharmacy practice	• Institute appropriate guidelines for telepharmacy model • Provide training and education to all telepharmacy staff • Monitor and evaluate telepharmacy operations
3	Lack of findings on the economic and financial sustainability of telepharmacy in rural communities.	• Engage with key stakeholders such as patients, health care providers, insurers, and policymakers
4	Lack of studies that focused on the impact of telepharmacy on patient-pharmacist communication and trust.	• Conduct qualitative research by gathering feedback from patients, pharmacists, and other stakeholders who have experience with telepharmacy. This can be done through interviews, focus groups, or surveys specifically designed to explore their perceptions of communication and trust in telepharmacy settings.

Conclusion

Telepharmacy shows promise as an effective solution to enhance medication access and management in rural communities in Africa. It can help overcome challenges like geographical isolation, pharmacist shortages, and high health care costs, leading to improved patient satisfaction. However, implementing telepharmacy in rural Africa faces obstacles such as lack of infrastructure, limited internet connectivity, and insufficient funding. Although this study provides valuable insights, there are still gaps in research. Future studies should focus on the cost-effectiveness of telepharmacy; gather perspectives from patients, health care providers, and pharmacists; and develop sustainable and scalable telepharmacy models that integrate into existing health care systems. Collaboration among policymakers, health care providers, and stakeholders is crucial to address challenges and seize the opportunities presented by telepharmacy in rural Africa, ensuring equitable access to medication and health care services for all.