A Framework for Evaluating Telemedicine-Based Healthcare Inequality Reduction in Ethiopia: A Grounded Theory Approach by MEKONNEN WAGAW TEMESGEN submitted in accordance with the requirements for the degree of DOCTOR OF PHILOSOPHY in the subject INFORMATION SYSTEMS at the UNIVERSITY OF SOUTH AFRICA Supervisor: Prof HH Lotriet Mentor: Prof Isabella Venter OCTOBER, 2019 ii Declaration Name: Mekonnen Wagaw Temesgen Student number: 4724-575-1 Degree: Doctor of Philosophy in Information Systems Thesis title: A Framework for Evaluating Telemedicine-Based Healthcare Inequality Reduction in Ethiopia: A Grounded Theory Approach I declare that the above thesis is my own work and that all the sources that I have used or quoted have been indicated and acknowledged by means of complete references. I further declare that I submitted the thesis to originality checking software and that it falls within the accepted requirements for originality. I further declare that I have not previously submitted this work, or part of it, for examination at Unisa for another qualification or at any other higher education institution. __________________________ _____October 25, 2019______ Signature Date iii Acknowledgement The author would like thank the following people and institutes: First and foremost, I would like to thank the God almighty for making my dream come true. My first gratitude goes to my supervisor, Prof HH Lotriet, for his guidance and support throughout the study. Thank you very much for your prompt constructive comments and feedbacks. I wish to express my appreciation to my mentor, Prof Isabella Venter, for her support and comments. Thank you very much for supporting me and shaping the thesis. I wish to present my gratitude to the language editor of the thesis, Mrs Ann Bytheway. I wish to thank my family for their support and patience throughout the course of the study. I would like to appreciate particularly my elder brother, Getachew Wagaw, for his advice and support. My last gratitude goes to the University of South Africa and Bahir Dar University for giving me the opportunity to conduct this study. iv Dedication I would like to dedicate the thesis to my family and my beloved wife, Tirukelem Haile, my son Kaleb Mekonnen and my daughter Maryamawit Mekonnen. Without their support, it would not have been possible to complete the study. v Summary Telehealth makes healthcare services accessible by underserved and resource-constrained rural communities of developing countries such as Ethiopia. However, the limitation of frameworks on telemedicine-based healthcare inequality reduction is a challenge for developing countries. In Ethiopia there are four telemedicine projects; however, there is no evidence that any of these projects have been evaluated by considering contextual issues. This academic research explored telehealth practices in Ethiopia with the aim of developing a comprehensive telehealth evaluation framework for developing countries. Such a conceptual framework could be used to inform health institutes and governmental policy makers and in so doing create a vehicle for the implementation of improved health practices in Ethiopia. A grounded theory approach is used to qualitatively explore the usefulness of telemedicine practices in Ethiopia, in mitigating healthcare inequality. Grounded theory makes use of emerging insights in order to contribute to new knowledge. From the inductive analysis of the study, themes such as barrier removal, service quality, synergetic effect, localization, technical setup, resource utilization and managerial readiness emerged to formulate a framework for evaluating telemedicine-based healthcare inequality reduction in the context of developing countries like Ethiopia. This study contributes to the understanding of the question of how telemedicine practices can be evaluated, to support the healthcare service and reduce the healthcare inequalities in resource constrained communities in Ethiopia. Moreover, the framework could be used during evaluation of telemedicine-based healthcare inequality reduction in the context of developing countries like Ethiopia. KEY TERMS: Telemedicine; Telemedicine evaluation; Telemedicine framework; Telehealth; Healthcare inequality reduction; ICT in health; Grounded Theory; Telemedicine in Ethiopia; Telehealth evaluation model; Telemedicine in developing countries; Telemedicine and healthcare inequality reduction; Inductive analysis vi Table of Contents Declaration ....................................................................................................................................... iii Acknowledgement ............................................................................................................................ iv Dedication ......................................................................................................................................... v Summary .......................................................................................................................................... vi Table of Contents ............................................................................................................................. vii List of Figures ..................................................................................................................................... x List of Tables ..................................................................................................................................... xi List of Acronyms .............................................................................................................................. xii INTRODUCTION ................................................................................................................... 1 1.1 Background ............................................................................................................................. 1 1.2 Problem context ...................................................................................................................... 3 1.2.1 International Telecom Union (ITU) .................................................................................................................... 5 1.2.2 Pan-African e-Network (Ethio-Indian Telemedicine) ......................................................................................... 5 1.2.3 Johns Hopkins University (Tsehay Project) ........................................................................................................ 6 1.2.4 I-TECH Ethiopia (Swinfen Charitable Trust) ....................................................................................................... 6 1.3 Problem Statement ................................................................................................................. 7 1.4 Research Aim ........................................................................................................................... 8 1.5 Objectives ................................................................................................................................ 8 1.6 Research Questions ................................................................................................................. 8 1.7 Scope of the Study ................................................................................................................... 9 1.8 Summary ................................................................................................................................. 9 RELATED LITERATURE........................................................................................................ 11 2.1 Introduction ........................................................................................................................... 11 2.2 Healthcare inequality ............................................................................................................ 11 2.2.1 Healthcare inequality and its causes in the developing world ........................................................................ 13 2.2.1.1 Socio-economic status .......................................................................................................................... 13 2.2.1.2 Education .............................................................................................................................................. 16 2.2.1.3 Minority groups .................................................................................................................................... 18 2.2.1.4 Spatial differences ................................................................................................................................ 19 2.2.1.5 Gender .................................................................................................................................................. 22 2.2.1.6 Environmental factors .......................................................................................................................... 22 2.2.1.7 Culture .................................................................................................................................................. 23 2.2.2 Healthcare inequality in Ethiopia .................................................................................................................... 24 2.3 Overview of Telemedicine ..................................................................................................... 26 2.3.1 Historical background of telemedicine...........................................................................................................