Integrating telemedicine into health systems: A qualitative study on availability of health workforce and infrastructure capacity at the Ashanti regional secondary level hospital, Ghana

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The Millennium Promise Alliance (MPA) and Ghana Health Service launched a national telemedicine program in 2010, scaling it across six regions, starting with the Ashanti Regional hospital. It aims to improve healthcare access in remote areas and strengthen primary-to-secondary referrals. Despite telemedicine’s potential, little research exists on service availability. This study evaluates workforce density, ICT training, and infrastructure capacity at Ashanti’s regional hospital to assess the effectiveness of telemedicine integration. Methods Qualitative in-depth interviews were conducted with the management team of the Ashanti Regional Hospital's teleconsultation centre using a semi-structured interview guide. Purposive sampling identified seven key informants who participated in the interviews. The interview guide was based on the Service Availability and Readiness Assessment (SARA) framework. Data collection occurred from April to May 2023, and thematic analysis was conducted. Responses were compared with the Novartis Foundation's interactive implementation guide for telemedicine. Results The operations of the teleconsultation centre have been significantly affected due to a critical server breakdown, which has led to frequent service disruptions and limited access to virtual consultations. Additionally, the lack of funding for staff training has reduced efficiency and limited capacity to adapt to evolving telehealth technologies. These combined challenges have negatively impacted the daily call volume and strained overall service delivery. Conclusion Server malfunctions and inadequate training funds have disrupted the telemedicine centre’s operations, limiting remote healthcare delivery. Addressing these challenges requires strategic investments in technology and staff training. Resource mobilization, partnerships, and phased development plans are essential to restore services and ensure sustainable, quality care. Without these fixes, the centre cannot meet its healthcare access goals. Telemedicine teleconsultation service availability health workforce infrastructure Ghana Background Telemedicine includes the use of audio, video, and other telecommunications and electronic information processing technologies to provide health services or assist healthcare personnel at distant sites [ 1 ]. Telemedicine is regarded as a complementary measure to face-to-face consultations in healthcare settings. It helps address structural barriers such as transportation, long waiting times, inconvenient appointment schedules, and a geographical shortage of medical care providers, as well as improving health outcomes in medically underserved communities [ 2 ]. According to the World Health Organization (WHO), the percentage of countries with established telemedicine services ranged from 13–33%. High-income countries such as the US, UK, and other European countries provided more telemedicine services compared to countries with other income statuses [ 3 – 6 ]. The first telemedicine project in Africa was launched in 1998 by the International Telecommunication Union’s Telecommunications Development Bureau (TDB) [ 7 ]. After that, other telemedicine projects like Frontline SMS by Medic mobile in Mali, Weltel in Kenya, WE CARE in Nigeria and the Africa tele-dermatology project in Botswana were developed [ 8 ]. The Pocket Digital Assistant (PDA) project at Sene was Ghana’s first mobile health project implemented in 2004 [ 9 ]. Further initiatives again, in Ghana, the Novartis Foundation for Sustainable Development and Millennium Villages launched a teleconsultation service in some sections of the Amansie-West district in 2010. In 2015, the pilot initiative was extended to the entire Amansie-West district, and in 2017, it was deployed to six regions. Reports indicated that the service was generally well-received as it enhanced the capacity to serve patients at the primary level (health centre) and as a result, had contributed to a reduction in referrals [ 10 ]. A retrospective study suggested a significant reduction in maternal and child mortality following the establishment of the teleconsultation centre for maternal health services [ 11 ]. Telemedicine in Ghana is being expanded to a comprehensive telehealth service, which will include training, referral management, direct telehealth services available to the general public, and telemonitoring services for Community Health Workers (CHSs) [ 12 ]. In sub-Saharan Africa, the implementation of telemedicine is hindered by numerous challenges, including limited access to reliable high-speed internet, irregular power supply, and a shortage of trained healthcare professionals [ 13 ]. In addition, a lack of standardized methods, unstable telecommunication networks, and financial limitations contribute to the slow uptake and its effectiveness [ 14 ]. Despite the potential benefits of telemedicine in improving healthcare access and delivery in Ghana, there is limited empirical evidence on how health workforce availability and infrastructure capacity affect its integration into existing health systems. There is little to no qualitative research exploring the capacity of staff and infrastructure to support telemedicine services. Most existing literature in Ghana focuses on telemedicine adoption at the policy level or in pilot programs, overlooking the practical, on-the-ground challenges faced by healthcare workers and administrators. This gap highlights the need for context-specific, qualitative insights to inform effective integration strategies. Methods Study design A descriptive cross-sectional qualitative design was used for this study. This study design was appropriate for answering the research question for this study by collecting detailed information on available health workers, infrastructure availability, and the services rendered by the teleconsultation centre at the Ashanti Regional Hospital. Sampling and participants Management and healthcare providers managing the teleconsultation centre at the Ashanti Regional Hospital were purposively selected for this study. The participants included the medical director, nurse manager, human resource manager, clinical coordinator, administrator, emergency nurse, and technical support expert. These seven were selected because of their in-depth knowledge about the teleconsultation centre and its operations which would better answer the research questions. Data collection procedure Semi-structured in-depth interviews were conducted in gathering data for this study. Semi-structured interviews were more flexible giving the interviewer the chance to elucidate and extend the participant’s responses. An interview guide was developed based on the SARA framework ( see attached file ). The study objectives were explained to the participants and participation was voluntary. Before participating in the study, each participant sought and signed informed consent. Follow-up questions were raised where necessary to gain a deeper understanding of the responses. All interviews were conducted face-to-face in English at the Ashanti Regional Hospital, lasting an average of 30 minutes. Additional data collection tools included an audio recorder for recording all interviews, a notepad, and a pen for jotting down any relevant observations. Data analysis Data was analysed using a qualitative analytical software, ATLAS.ti 24. Braun and Clarke’s thematic analysis method was used as a guide for the data analysis [ 15 ]. The analysis involved six steps: familiarizing with the data was done by reading and noting patterns; initial codes were generated for key features; themes were created by grouping codes; themes were reviewed for coherence; the themes were named and further analysed; the final stage involved producing the final report, offering a clear, compelling narrative of the findings. Responses were compared with the interactive implementation guide for telemedicine implementation by the Novartis Foundation. Results The study provides insights into the available infrastructure as well as human resources capacity for the telemedicine services in the Ashanti region of Ghana, offering valuable information for policymakers, healthcare providers, and stakeholders involved in integration of telemedicine services into the Ghana health system to improve healthcare access and outcomes. This section presents the key findings under the following themes: 1. Available infrastructure ● Physical infrastructure The physical accessibility of the centre and its adequacy in terms of suitability for service delivery were the main considerations. According to the interactive implementation guide by Novartis Foundation, a teleconsultation centre should have a minimum of two rooms, 16 m 2 each – one to serve as a call centre, and the other as a staff room. Other items recommended include long tables and swivel chairs for the call centre, while the staff room should have a bed or a mattress for night shift workers. Additionally, storage lockers as well as a bathroom are mandatory. Participants reported that there was only one room available with good lighting and ventilation. The room was equipped with all the necessary tools for the centre to run smoothly. “It’s a one-room self-contained building, with everything packed inside. We have power backup, a server, computers, telephones, and a lighting system. The place isn’t very big, but the equipment is arranged in a way that makes it easy to move around. Ventilation is okay; there’s an air conditioner and windows as well.” (Participant_ 001) ● Technological infrastructure The teleconsultation centre possessed the required technological infrastructure, but for a broken server for operationalization as suggested by the telemedicine implementation guide. The centre had computers, a Private Branch eXchange (PBX), and six monitors, each accompanied by a swivel chair. Participants explained that even though internet connectivity was reliable at the centre, the same could not be said for those in the communities: “For now, we have the machines, the equipment itself… I can say at least, we have all… all are working except, as I said initially, there’s one machine that is not working well.” (Participant_005) “It has a PBX that can house the teleconsultation software. We had the PBX machine. And then we also had the GSM machine. And that machine has a port to put in the SIM cards. So, the GSM machine was somehow working like a mobile phone. That was where we had the SIM card, and the PBX had the call centre application on it which was recording the calls and then documenting the call log information. There was other equipment like computers to document teleconsultation. The software is also on the computer for that documentation... I think it was both cable and Wi-Fi.” (Participant_003) ● Maintenance of equipment The telemedicine implementation guide advises on full maintenance of the system every three months to ensure long-term functionality without interruptions. Additionally, all equipment should be kept clean and dry, with daily checks recommended. Although the frequency of maintenance varied among participants, participants acknowledged performing routine maintenance. “I will say daily we were doing it, but at least once a month, those in charge of the servers and the computers also come around to check.” (Participant_001) The status of a technology may vary depending on the regularity of maintenance. Therefore, it can be inferred that excellent maintenance leads to well-functioning technology, whereas poor maintenance can result in operational issues. Most computers were reported to be in good working condition; however, the system server developed some faults. “...until about a year, we had lots of issues with the server.” (Participant_007) These insights suggest that while routine maintenance practices were generally adhered to, inconsistencies in maintenance frequency impacted the overall performance of the system. 2. Human resource capacity ● Number and type of staff Telemedicine represents a unique and innovative approach in the field of medicine, necessitating a clear understanding of the skills and background required for employment. Beyond identifying the necessary skill set, it is crucial to determine the appropriate number of staff needed for the centre to function effectively. According to the telemedicine implementation guide, a teleconsultation centre should be staffed around the clock (24-hour coverage). The staff should encompass both public health and clinical roles, with a balanced mix of general nurses and midwives. Ideally, considering the levels of care provided (primary, secondary, and tertiary) the centre should also employ medical officers. The nurses and midwives should be qualified, experienced, and dedicated to providing exceptional care. Additionally, training in emergency response is advantageous for the staff. At the Ashanti Regional Hospital’s teleconsultation centre, staffing was deemed sufficient to provide primary, secondary, and tertiary services. Tertiary services were rendered through conference calls with specialists. Participants described the staffing arrangement: “So, at the centre, we had the general nurses and the midwives, but the specialist and the medical officers, we transferred the call to them.” (Participant_001) Participants generally reported that the centre had ten staff, aligning with the telemedicine implementation guidelines, which recommend a minimum of eight nurses or midwives working full-time, with at least two staff on duty per shift. “Okay, so there were eight core staff; nurses, midwives, and then, so we have two of us doctors here, so ten.” (Participant_007) The capacity to provide 24-hour service informed the number of staff allocated to the centre. As one participant noted: “I believe that was enough to run a 24-hour service at the centre.” (Participant_002) These responses suggest that the teleconsultation centre has the requisite staff according to the guidelines, ensuring comprehensive coverage and effective service delivery. ● Staff training Staff training is designed to equip employees with the necessary knowledge and skills to perform their jobs effectively while building their confidence in their abilities. The telemedicine implementation guide recommends that initial training be provided when the teleconsultation centre is first established, with continuous refresher sessions every six months. This training should be guided by the disease pack in the telemedicine toolkit, standard treatment guidelines, and other existing health service protocols. Participants reported that all staff received training even before being posted to the centre. Core staff members had already been trained during the pilot phase, allowing them to familiarize themselves with the telemedicine working environment and serve as trainers for other staff during the scale-up process. One participant explained: “The staff who came in from Amansie-West trained all the staff here so that every year there could be changes and whoever is sent there can work.” (Participant_002) The frequency of in-service training depended on the availability of funds, making it difficult to carry out regular, planned training exercises. In-service training also served as an awareness-creation effort for those in hard-to-reach areas. A participant shared: “Depends on as and when we have funds for in-service training.” (Participant_007) 3. Telemedicine service availability and future direction for health system integration ● Telemedicine service availability The teleconsultation centre aimed to improve access to healthcare by assisting community healthcare workers who might lack specific case management knowledge. Participants revealed the centre was accessible to all facilities within their reach and mandate. Thus, respondents indicated that, the telemedicine services are available to: “Everybody, there wasn’t a specific group because we were dealing with all the facilities within the peripheries.” (Participant_001) According to the Novartis implementation guide, monitoring how well the teleconsultation centre is functioning involves considering indicators such as the number of calls received on the one hand, and the unnecessary referrals prevented on the other hand. At the time of the study, call volume had reduced drastically compared to when the server was functional “Initially, when they came here and the gadgets were functioning, for that, they were really getting calls from the districts and the hinterlands” (Participant_004) The centre had not received the needed support to get the server back in shape. Hence, the teleconsultation centre has been under lock since the beginning of the year 2023.The services provided have been limited “Currently, it is not operational. Well... you can’t say it is not operational because the phone is still there. If somebody wants to call, the person can go ahead.” (Participant_001) Participants also discussed the challenges of limited funds for training, poor network connectivity for community-level callers, lack of protocols for certain conditions, and difficulties in reaching medical specialists. “Some were of the view that they had challenges with funds to train other people… at the centre, the network was working, but the one who was calling had challenges with the network, and sometimes in the middle of the communication, it dropped… and then if you want to get some of the specialists on board, it is a bit difficult because some of them claim they are a bit busy at the time you are calling… and then the teleconsultation is supposed to use protocols to work. You cannot just say anything anyhow, so some of the conditions didn’t have protocols.” (Participant_001) ● Future direction for health system integration The teleconsultation centre at the Ashanti regional hospital has been left without a clear plan or directive due to the government’s decision to centralize teleconsultation services across the country. Participant stated; “I can’t say for sure any plan made towards the future of this teleconsultation centre” (Participant_004) “So, we have come back to Ghana health service to implement a new technology and we are going to scale it up. That is the future direction now” (Participant_003) Discussion The findings of this study provide critical insights into the infrastructure, human resource capacity, and operational challenges of telemedicine services at the Ashanti Regional Hospital in Ghana. These results highlight both the progress made in implementing telemedicine and the systemic barriers that hinder its full potential. The discussion contextualizes these findings within existing literature, explores implications for policy and practice, and suggests recommendations for sustainable telemedicine integration into Ghana’s healthcare system. The study revealed that the teleconsultation centre had adequate physical and technological infrastructure, albeit with some limitations. The centre operated in a single room, contrary to the Novartis Foundation’s recommendation of two separate rooms [ 16 ]. However, the space was well-equipped with computers, a PBX system, and reliable internet connectivity, aligning with global telemedicine infrastructure standards [ 17 ]. The presence of backup power and air conditioning ensured uninterrupted service delivery, which is crucial in low-resource settings where electricity fluctuations are common [ 18 ]. Despite these strengths, the server malfunction, a critical operational challenge, led to service disruptions. This aligns with studies in other low- and middle-income countries (LMICs), where inadequate maintenance and funding constraints often undermine telemedicine sustainability [ 19 ]. Routine maintenance, as recommended by the telemedicine implementation guide, was inconsistently applied, leading to system failures. Similar challenges have been reported in Nigeria and Kenya, where poor equipment maintenance contributed to telemedicine program collapses [ 20 , 21 ]. These findings underscore the need for structured maintenance protocols and dedicated budgetary allocations for infrastructure sustainability. The study found that staffing at the teleconsultation centre met the recommended guidelines, with a mix of nurses, midwives, and medical officers ensuring 24/7 coverage. This is consistent with best practices in telemedicine, where multidisciplinary teams enhance service delivery [ 22 ]. However, training gaps were evident. While initial training was provided, refresher sessions were irregular due to funding constraints. Continuous professional development is essential for telemedicine success, as demonstrated in Rwanda, where regular training improved service quality [ 23 ]. The reliance on initial staff trained during the pilot-phase to train new recruits, though resourceful, highlights systemic dependency on ad-hoc training rather than institutionalized capacity-building. Similar challenges have been noted in South Africa, where inconsistent training led to skill attrition among telemedicine staff [ 24 , 25 ]. To address this, Ghana’s health system should integrate telemedicine training into national health workforce development programs, ensuring standardized and sustainable skill acquisition. The teleconsultation centre was designed to serve all peripheral health facilities, improving access to specialist care and reducing unnecessary referrals, a key indicator of telemedicine success [ 10 , 26 ]. However, identified challenges like server breakdowns severely limit operations, mirroring challenges faced by similar programs in Uganda, where technological failures led to service suspensions [ 27 ]. The study also revealed poor network connectivity at the community level, a common barrier in rural telemedicine initiatives [ 28 ]. Additionally, the lack of standardized protocols for certain conditions hindered effective teleconsultations. This aligns with findings from India, where protocol gaps reduced clinician confidence in telemedicine [ 29 ]. Addressing these issues requires investments in last-mile connectivity and the development of condition-specific telemedicine guidelines. The government’s plan to centralize telemedicine services presents both opportunities and risks. Centralization could improve coordination and resource allocation, as seen in Ethiopia’s national telemedicine strategy [ 30 ]. To ensure sustainability, Ghana must adopt a phased approach by securing funding for server upgrades, maintenance, and last-mile connectivity. Public-private partnerships (PPPs) could be explored, as demonstrated by Rwanda’s collaboration with private organisations for health supply chain management [ 32 ]. Secondly, institutionalizing telemedicine training within medical and nursing curricula would be important. Continuous professional development should be mandated, with funding ring-fenced in health budgets. Also, there must be a development of a national telemedicine strategy with clear protocols, monitoring frameworks, and stakeholder engagement. Strengths and limitations The study’s methodology provides valuable qualitative insights into telemedicine readiness but has limitations in generalizability and potential biases. Future research should expand to multiple sites, include patient perspectives, and integrate quantitative metrics for a more comprehensive assessment. Conclusion This study explored the integration of telemedicine into the healthcare delivery system at a secondary-level hospital in the Ashanti Region of Ghana, with a focus on infrastructure availability and human resource capacity. The findings indicate that while there is growing awareness of telemedicine’s potential to enhance healthcare access and efficiency, significant gaps remain in terms of infrastructure, such as stable internet connectivity in rural communities and access to digital equipment. Additionally, lack of funds to support regular training which had direct implications on its publicity and difficulties in reaching medical specialists presented major challenges to full integration. For telemedicine to be successfully embedded in health systems, a coordinated effort is needed to strengthen infrastructure and build the capacity of healthcare workers through targeted training and continuous professional development. Strategic investment and supportive policy frameworks will be essential to bridge these gaps and promote equitable, sustainable telemedicine adoption in Ghana’s healthcare system. This research contributed to shedding light on the integration of telemedicine services at the Ashanti Regional Hospital. The study’s findings can also support decisions to enhance the execution of telemedicine programs in Ghana in the future. Future studies could adopt mixed-methods approaches to evaluate the impact of telemedicine on health outcomes and service efficiency. Abbreviations CHRPE - Committee on Human Research, Publication and Ethics CHSs - Community Health Workers ICT - Information Communication Technology MPA - Millennium Promise Alliance PBX - Private Branch eXchange PDA - Pocket Digital Assistant PPPs - Public-private partnerships SARA - Service Availability and Readiness Assessment TDB - Telecommunications Development Bureau WHO - World Health Organization Declarations Ethical approval and consent to participate Ethical approval was obtained from the Committee on Human Research, Publication, and Ethics (KNUST) with reference number CHRPE/AP/327/23. This study adhered to the Declaration of Helsinki. Informed consent was obtained from all participants prior to their inclusion in the study. Participants were assured of confidentiality, anonymity, and their right to withdraw at any time without any consequences. Consent for publication Not applicable. Availability of data and materials The data that were analysed are included in this manuscript and available upon reasonable request from the corresponding author. Competing interests The authors declare no conflict of interest. Funding This work was supported by the eHealth Research Partner Group (eHRPG) at the Kwame Nkrumah University of Science and Technology, Kumasi under Grant No.: 01DG20020 from the budget of the German Federal Ministry of Education and Research (BMBF). The funding source was not involved in the design, conduct, or reporting of the work. Authors’ contributions Conceptualization: EO, PT; Methodology: EO, PT, DO; Data curation: EO, RAB; Formal analysis: EO, RAB; Writing initial draft: EO, RAB; Reviewing and editing: EO, PT, DO, KAM, RAB, VF, WQ; Project administration: DO, RAB; Supervision: PT, DO, KAM; Acquisition of funding: WQ, DO. All the authors have read and approved the final manuscript. Acknowledgments The authors gratefully acknowledge the German-West African Centre for Global Health and Pandemic Prevention (G-WAC) at Kwame Nkrumah University of Science and Technology (KNUST) for their generous support and funding of this research. We also extend our sincere appreciation to the management and staff of Ashanti Regional Hospital, Kumasi for their invaluable contributions and collaboration throughout this study. Authors’ information 1 School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Emmanuella Oppong, Peter Twum, Kofi Akohene Mensah, Richard Abeiku Bonney & Daniel Opoku 2 eHealth Research Partner Group (eHRPG) at the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Emmanuella Oppong, Kofi Akohene Mensah, Richard Abeiku Bonney & Daniel Opoku 3 Department of Health Care Management, Technische Universität Berlin, Berlin, Germany Vincent Findeiss, Richard Abeiku Bonney & Daniel Opoku 4 Chair of Planetary & Public Health, Universität Bayreuth, Bayreuth, Germany Wilm Quentin 5 German West-African Centre for Global Health and Pandemic Prevention (G-WAC) at Kwame Nkrumah University of Science and Technology Vincent Findeiss Wilm Quentin & Daniel Opoku References Nazviya M, Kodukula S. Evaluation of critical success factors for telemedicine implementation. Int J Comput Appl. 2011;12(10):29–36. 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Telemedicine is regarded as a complementary measure to face-to-face consultations in healthcare settings. It helps address structural barriers such as transportation, long waiting times, inconvenient appointment schedules, and a geographical shortage of medical care providers, as well as improving health outcomes in medically underserved communities [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to the World Health Organization (WHO), the percentage of countries with established telemedicine services ranged from 13\u0026ndash;33%. High-income countries such as the US, UK, and other European countries provided more telemedicine services compared to countries with other income statuses [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe first telemedicine project in Africa was launched in 1998 by the International Telecommunication Union\u0026rsquo;s Telecommunications Development Bureau (TDB) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. After that, other telemedicine projects like Frontline SMS by Medic mobile in Mali, Weltel in Kenya, WE CARE in Nigeria and the Africa tele-dermatology project in Botswana were developed [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The Pocket Digital Assistant (PDA) project at Sene was Ghana\u0026rsquo;s first mobile health project implemented in 2004 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFurther initiatives again, in Ghana, the Novartis Foundation for Sustainable Development and Millennium Villages launched a teleconsultation service in some sections of the Amansie-West district in 2010. In 2015, the pilot initiative was extended to the entire Amansie-West district, and in 2017, it was deployed to six regions. Reports indicated that the service was generally well-received as it enhanced the capacity to serve patients at the primary level (health centre) and as a result, had contributed to a reduction in referrals [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A retrospective study suggested a significant reduction in maternal and child mortality following the establishment of the teleconsultation centre for maternal health services [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Telemedicine in Ghana is being expanded to a comprehensive telehealth service, which will include training, referral management, direct telehealth services available to the general public, and telemonitoring services for Community Health Workers (CHSs) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn sub-Saharan Africa, the implementation of telemedicine is hindered by numerous challenges, including limited access to reliable high-speed internet, irregular power supply, and a shortage of trained healthcare professionals [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In addition, a lack of standardized methods, unstable telecommunication networks, and financial limitations contribute to the slow uptake and its effectiveness [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the potential benefits of telemedicine in improving healthcare access and delivery in Ghana, there is limited empirical evidence on how health workforce availability and infrastructure capacity affect its integration into existing health systems. There is little to no qualitative research exploring the capacity of staff and infrastructure to support telemedicine services. Most existing literature in Ghana focuses on telemedicine adoption at the policy level or in pilot programs, overlooking the practical, on-the-ground challenges faced by healthcare workers and administrators. This gap highlights the need for context-specific, qualitative insights to inform effective integration strategies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eA descriptive cross-sectional qualitative design was used for this study. This study design was appropriate for answering the research question for this study by collecting detailed information on available health workers, infrastructure availability, and the services rendered by the teleconsultation centre at the Ashanti Regional Hospital.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSampling and participants\u003c/h3\u003e\n\u003cp\u003e Management and healthcare providers managing the teleconsultation centre at the Ashanti Regional Hospital were purposively selected for this study. The participants included the medical director, nurse manager, human resource manager, clinical coordinator, administrator, emergency nurse, and technical support expert. These seven were selected because of their in-depth knowledge about the teleconsultation centre and its operations which would better answer the research questions.\u003c/p\u003e\n\u003ch3\u003eData collection procedure\u003c/h3\u003e\n\u003cp\u003eSemi-structured in-depth interviews were conducted in gathering data for this study. Semi-structured interviews were more flexible giving the interviewer the chance to elucidate and extend the participant\u0026rsquo;s responses. An interview guide was developed based on the SARA framework (\u003cem\u003esee attached file\u003c/em\u003e). The study objectives were explained to the participants and participation was voluntary. Before participating in the study, each participant sought and signed informed consent. Follow-up questions were raised where necessary to gain a deeper understanding of the responses. All interviews were conducted face-to-face in English at the Ashanti Regional Hospital, lasting an average of 30 minutes. Additional data collection tools included an audio recorder for recording all interviews, a notepad, and a pen for jotting down any relevant observations.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eData was analysed using a qualitative analytical software, ATLAS.ti 24. Braun and Clarke\u0026rsquo;s thematic analysis method was used as a guide for the data analysis [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The analysis involved six steps: familiarizing with the data was done by reading and noting patterns; initial codes were generated for key features; themes were created by grouping codes; themes were reviewed for coherence; the themes were named and further analysed; the final stage involved producing the final report, offering a clear, compelling narrative of the findings. Responses were compared with the interactive implementation guide for telemedicine implementation by the Novartis Foundation.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study provides insights into the available infrastructure as well as human resources capacity for the telemedicine services in the Ashanti region of Ghana, offering valuable information for policymakers, healthcare providers, and stakeholders involved in integration of telemedicine services into the Ghana health system to improve healthcare access and outcomes. This section presents the key findings under the following themes:\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e1. Available infrastructure\u003c/h2\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e● Physical infrastructure\u003c/h2\u003e\u003cp\u003eThe physical accessibility of the centre and its adequacy in terms of suitability for service delivery were the main considerations. According to the interactive implementation guide by Novartis Foundation, a teleconsultation centre should have a minimum of two rooms, 16 m\u003csup\u003e2\u003c/sup\u003e each \u0026ndash; one to serve as a call centre, and the other as a staff room. Other items recommended include long tables and swivel chairs for the call centre, while the staff room should have a bed or a mattress for night shift workers. Additionally, storage lockers as well as a bathroom are mandatory. Participants reported that there was only one room available with good lighting and ventilation. The room was equipped with all the necessary tools for the centre to run smoothly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s a one-room self-contained building, with everything packed inside. We have power backup, a server, computers, telephones, and a lighting system. The place isn\u0026rsquo;t very big, but the equipment is arranged in a way that makes it easy to move around. Ventilation is okay; there\u0026rsquo;s an air conditioner and windows as well.\u0026rdquo;\u003c/em\u003e (Participant_ 001)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003e● Technological infrastructure\u003c/h3\u003e\n\u003cp\u003eThe teleconsultation centre possessed the required technological infrastructure, but for a broken server for operationalization as suggested by the telemedicine implementation guide. The centre had computers, a Private Branch eXchange (PBX), and six monitors, each accompanied by a swivel chair. Participants explained that even though internet connectivity was reliable at the centre, the same could not be said for those in the communities:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For now, we have the machines, the equipment itself\u0026hellip; I can say at least, we have all\u0026hellip; all are working except, as I said initially, there\u0026rsquo;s one machine that is not working well.\u0026rdquo;\u003c/em\u003e (Participant_005)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It has a PBX that can house the teleconsultation software. We had the PBX machine. And then we also had the GSM machine. And that machine has a port to put in the SIM cards. So, the GSM machine was somehow working like a mobile phone. That was where we had the SIM card, and the PBX had the call centre application on it which was recording the calls and then documenting the call log information. There was other equipment like computers to document teleconsultation. The software is also on the computer for that documentation... I think it was both cable and Wi-Fi.\u0026rdquo;\u003c/em\u003e (Participant_003)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e● Maintenance of equipment\u003c/h2\u003e\u003cp\u003eThe telemedicine implementation guide advises on full maintenance of the system every three months to ensure long-term functionality without interruptions. Additionally, all equipment should be kept clean and dry, with daily checks recommended. Although the frequency of maintenance varied among participants, participants acknowledged performing routine maintenance.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I will say daily we were doing it, but at least once a month, those in charge of the servers and the computers also come around to check.\u0026rdquo;\u003c/em\u003e (Participant_001)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe status of a technology may vary depending on the regularity of maintenance. Therefore, it can be inferred that excellent maintenance leads to well-functioning technology, whereas poor maintenance can result in operational issues. Most computers were reported to be in good working condition; however, the system server developed some faults.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...until about a year, we had lots of issues with the server.\u0026rdquo;\u003c/em\u003e (Participant_007)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThese insights suggest that while routine maintenance practices were generally adhered to, inconsistencies in maintenance frequency impacted the overall performance of the system.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e2. Human resource capacity\u003c/h2\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e● Number and type of staff\u003c/h2\u003e\u003cp\u003eTelemedicine represents a unique and innovative approach in the field of medicine, necessitating a clear understanding of the skills and background required for employment. Beyond identifying the necessary skill set, it is crucial to determine the appropriate number of staff needed for the centre to function effectively. According to the telemedicine implementation guide, a teleconsultation centre should be staffed around the clock (24-hour coverage). The staff should encompass both public health and clinical roles, with a balanced mix of general nurses and midwives. Ideally, considering the levels of care provided (primary, secondary, and tertiary) the centre should also employ medical officers. The nurses and midwives should be qualified, experienced, and dedicated to providing exceptional care. Additionally, training in emergency response is advantageous for the staff. At the Ashanti Regional Hospital\u0026rsquo;s teleconsultation centre, staffing was deemed sufficient to provide primary, secondary, and tertiary services. Tertiary services were rendered through conference calls with specialists. Participants described the staffing arrangement:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, at the centre, we had the general nurses and the midwives, but the specialist and the medical officers, we transferred the call to them.\u0026rdquo;\u003c/em\u003e (Participant_001)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Participants generally reported that the centre had ten staff, aligning with the telemedicine implementation guidelines, which recommend a minimum of eight nurses or midwives working full-time, with at least two staff on duty per shift.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Okay, so there were eight core staff; nurses, midwives, and then, so we have two of us doctors here, so ten.\u0026rdquo;\u003c/em\u003e (Participant_007)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe capacity to provide 24-hour service informed the number of staff allocated to the centre. As one participant noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I believe that was enough to run a 24-hour service at the centre.\u0026rdquo;\u003c/em\u003e (Participant_002)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e These responses suggest that the teleconsultation centre has the requisite staff according to the guidelines, ensuring comprehensive coverage and effective service delivery.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e● Staff training\u003c/h2\u003e\u003cp\u003eStaff training is designed to equip employees with the necessary knowledge and skills to perform their jobs effectively while building their confidence in their abilities. The telemedicine implementation guide recommends that initial training be provided when the teleconsultation centre is first established, with continuous refresher sessions every six months. This training should be guided by the disease pack in the telemedicine toolkit, standard treatment guidelines, and other existing health service protocols.\u003c/p\u003e\u003cp\u003eParticipants reported that all staff received training even before being posted to the centre. Core staff members had already been trained during the pilot phase, allowing them to familiarize themselves with the telemedicine working environment and serve as trainers for other staff during the scale-up process. One participant explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The staff who came in from Amansie-West trained all the staff here so that every year there could be changes and whoever is sent there can work.\u0026rdquo;\u003c/em\u003e (Participant_002)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe frequency of in-service training depended on the availability of funds, making it difficult to carry out regular, planned training exercises. In-service training also served as an awareness-creation effort for those in hard-to-reach areas. A participant shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Depends on as and when we have funds for in-service training.\u0026rdquo;\u003c/em\u003e (Participant_007)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3. Telemedicine service availability and future direction for health system integration\u003c/h2\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e● Telemedicine service availability\u003c/h2\u003e\u003cp\u003eThe teleconsultation centre aimed to improve access to healthcare by assisting community healthcare workers who might lack specific case management knowledge. Participants revealed the centre was accessible to all facilities within their reach and mandate. Thus, respondents indicated that, the telemedicine services are available to:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Everybody, there wasn\u0026rsquo;t a specific group because we were dealing with all the facilities within the peripheries.\u0026rdquo;\u003c/em\u003e (Participant_001)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAccording to the Novartis implementation guide, monitoring how well the teleconsultation centre is functioning involves considering indicators such as the number of calls received on the one hand, and the unnecessary referrals prevented on the other hand. At the time of the study, call volume had reduced drastically compared to when the server was functional\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Initially, when they came here and the gadgets were functioning, for that, they were really getting calls from the districts and the hinterlands\u0026rdquo;\u003c/em\u003e (Participant_004)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe centre had not received the needed support to get the server back in shape. Hence, the teleconsultation centre has been under lock since the beginning of the year 2023.The services provided have been limited\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Currently, it is not operational. Well... you can\u0026rsquo;t say it is not operational because the phone is still there. If somebody wants to call, the person can go ahead.\u0026rdquo;\u003c/em\u003e (Participant_001)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Participants also discussed the challenges of limited funds for training, poor network connectivity for community-level callers, lack of protocols for certain conditions, and difficulties in reaching medical specialists.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e \u0026ldquo;Some were of the view that they had challenges with funds to train other people\u0026hellip; at the centre, the network was working, but the one who was calling had challenges with the network, and sometimes in the middle of the communication, it dropped\u0026hellip; and then if you want to get some of the specialists on board, it is a bit difficult because some of them claim they are a bit busy at the time you are calling\u0026hellip; and then the teleconsultation is supposed to use protocols to work. You cannot just say anything anyhow, so some of the conditions didn\u0026rsquo;t have protocols.\u0026rdquo;\u003c/em\u003e (Participant_001)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e● Future direction for health system integration\u003c/h2\u003e\u003cp\u003eThe teleconsultation centre at the Ashanti regional hospital has been left without a clear plan or directive due to the government\u0026rsquo;s decision to centralize teleconsultation services across the country. Participant stated;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I can\u0026rsquo;t say for sure any plan made towards the future of this teleconsultation centre\u0026rdquo;\u003c/em\u003e (Participant_004)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, we have come back to Ghana health service to implement a new technology and we are going to scale it up. That is the future direction now\u0026rdquo;\u003c/em\u003e (Participant_003)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study provide critical insights into the infrastructure, human resource capacity, and operational challenges of telemedicine services at the Ashanti Regional Hospital in Ghana. These results highlight both the progress made in implementing telemedicine and the systemic barriers that hinder its full potential. The discussion contextualizes these findings within existing literature, explores implications for policy and practice, and suggests recommendations for sustainable telemedicine integration into Ghana\u0026rsquo;s healthcare system.\u003c/p\u003e\u003cp\u003eThe study revealed that the teleconsultation centre had adequate physical and technological infrastructure, albeit with some limitations. The centre operated in a single room, contrary to the Novartis Foundation\u0026rsquo;s recommendation of two separate rooms [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, the space was well-equipped with computers, a PBX system, and reliable internet connectivity, aligning with global telemedicine infrastructure standards [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The presence of backup power and air conditioning ensured uninterrupted service delivery, which is crucial in low-resource settings where electricity fluctuations are common [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite these strengths, the server malfunction, a critical operational challenge, led to service disruptions. This aligns with studies in other low- and middle-income countries (LMICs), where inadequate maintenance and funding constraints often undermine telemedicine sustainability [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Routine maintenance, as recommended by the telemedicine implementation guide, was inconsistently applied, leading to system failures. Similar challenges have been reported in Nigeria and Kenya, where poor equipment maintenance contributed to telemedicine program collapses [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These findings underscore the need for structured maintenance protocols and dedicated budgetary allocations for infrastructure sustainability.\u003c/p\u003e\u003cp\u003e The study found that staffing at the teleconsultation centre met the recommended guidelines, with a mix of nurses, midwives, and medical officers ensuring 24/7 coverage. This is consistent with best practices in telemedicine, where multidisciplinary teams enhance service delivery [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, training gaps were evident. While initial training was provided, refresher sessions were irregular due to funding constraints. Continuous professional development is essential for telemedicine success, as demonstrated in Rwanda, where regular training improved service quality [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe reliance on initial staff trained during the pilot-phase to train new recruits, though resourceful, highlights systemic dependency on ad-hoc training rather than institutionalized capacity-building. Similar challenges have been noted in South Africa, where inconsistent training led to skill attrition among telemedicine staff [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. To address this, Ghana\u0026rsquo;s health system should integrate telemedicine training into national health workforce development programs, ensuring standardized and sustainable skill acquisition.\u003c/p\u003e\u003cp\u003eThe teleconsultation centre was designed to serve all peripheral health facilities, improving access to specialist care and reducing unnecessary referrals, a key indicator of telemedicine success [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, identified challenges like server breakdowns severely limit operations, mirroring challenges faced by similar programs in Uganda, where technological failures led to service suspensions [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe study also revealed poor network connectivity at the community level, a common barrier in rural telemedicine initiatives [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Additionally, the lack of standardized protocols for certain conditions hindered effective teleconsultations. This aligns with findings from India, where protocol gaps reduced clinician confidence in telemedicine [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Addressing these issues requires investments in last-mile connectivity and the development of condition-specific telemedicine guidelines.\u003c/p\u003e\u003cp\u003eThe government\u0026rsquo;s plan to centralize telemedicine services presents both opportunities and risks. Centralization could improve coordination and resource allocation, as seen in Ethiopia\u0026rsquo;s national telemedicine strategy [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. To ensure sustainability, Ghana must adopt a phased approach by securing funding for server upgrades, maintenance, and last-mile connectivity. Public-private partnerships (PPPs) could be explored, as demonstrated by Rwanda\u0026rsquo;s collaboration with private organisations for health supply chain management [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Secondly, institutionalizing telemedicine training within medical and nursing curricula would be important. Continuous professional development should be mandated, with funding ring-fenced in health budgets. Also, there must be a development of a national telemedicine strategy with clear protocols, monitoring frameworks, and stakeholder engagement.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThe study\u0026rsquo;s methodology provides valuable qualitative insights into telemedicine readiness but has limitations in generalizability and potential biases. Future research should expand to multiple sites, include patient perspectives, and integrate quantitative metrics for a more comprehensive assessment.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study explored the integration of telemedicine into the healthcare delivery system at a secondary-level hospital in the Ashanti Region of Ghana, with a focus on infrastructure availability and human resource capacity. The findings indicate that while there is growing awareness of telemedicine\u0026rsquo;s potential to enhance healthcare access and efficiency, significant gaps remain in terms of infrastructure, such as stable internet connectivity in rural communities and access to digital equipment. Additionally, lack of funds to support regular training which had direct implications on its publicity and difficulties in reaching medical specialists presented major challenges to full integration. For telemedicine to be successfully embedded in health systems, a coordinated effort is needed to strengthen infrastructure and build the capacity of healthcare workers through targeted training and continuous professional development. Strategic investment and supportive policy frameworks will be essential to bridge these gaps and promote equitable, sustainable telemedicine adoption in Ghana\u0026rsquo;s healthcare system. This research contributed to shedding light on the integration of telemedicine services at the Ashanti Regional Hospital. The study\u0026rsquo;s findings can also support decisions to enhance the execution of telemedicine programs in Ghana in the future. Future studies could adopt mixed-methods approaches to evaluate the impact of telemedicine on health outcomes and service efficiency.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCHRPE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Committee on Human Research, Publication and Ethics\u003c/p\u003e\n\u003cp\u003eCHSs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Community Health Workers\u003c/p\u003e\n\u003cp\u003eICT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Information Communication Technology\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMPA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Millennium Promise Alliance\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePBX\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Private Branch eXchange\u003c/p\u003e\n\u003cp\u003ePDA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pocket Digital Assistant\u003c/p\u003e\n\u003cp\u003ePPPs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Public-private partnerships\u003c/p\u003e\n\u003cp\u003eSARA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Service Availability and Readiness Assessment\u003c/p\u003e\n\u003cp\u003eTDB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Telecommunications Development Bureau\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;- \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Committee on Human Research, Publication, and Ethics (KNUST) with reference number CHRPE/AP/327/23. This study adhered to the Declaration of Helsinki. Informed consent was obtained from all participants prior to their inclusion in the study. Participants were assured of confidentiality, anonymity, and their right to withdraw at any time without any consequences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that were analysed are included in this manuscript and available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the eHealth Research Partner Group (eHRPG) at the Kwame Nkrumah University of Science and Technology, Kumasi under Grant No.: 01DG20020 from the budget of the German Federal Ministry of Education and Research (BMBF). The funding source was not involved in the design, conduct, or reporting of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: EO, PT; Methodology: EO, PT, DO; Data curation: EO, RAB; Formal analysis: EO, RAB; Writing initial draft: EO, RAB; Reviewing and editing: EO, PT, DO, KAM, RAB, VF, WQ; Project administration: DO, RAB; Supervision: PT, DO, KAM; Acquisition of funding: WQ, DO. All the authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors gratefully acknowledge the German-West African Centre for Global Health and Pandemic Prevention (G-WAC) at Kwame Nkrumah University of Science and Technology (KNUST) for their generous support and funding of this research. We also extend our sincere appreciation to the management and staff of Ashanti Regional Hospital, Kumasi for their invaluable contributions and collaboration throughout this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eSchool of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana\u003c/p\u003e\n\u003cp\u003eEmmanuella Oppong, Peter Twum, Kofi Akohene Mensah, Richard Abeiku Bonney \u0026amp; Daniel Opoku\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eeHealth Research Partner Group (eHRPG) at the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana\u003c/p\u003e\n\u003cp\u003eEmmanuella Oppong, Kofi Akohene Mensah, Richard Abeiku Bonney \u0026amp; Daniel Opoku\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eDepartment of Health Care Management, Technische Universit\u0026auml;t Berlin, Berlin, Germany\u003c/p\u003e\n\u003cp\u003eVincent Findeiss, Richard Abeiku Bonney \u0026amp; Daniel Opoku\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eChair of Planetary \u0026amp; Public Health, Universit\u0026auml;t Bayreuth, Bayreuth, Germany\u003c/p\u003e\n\u003cp\u003eWilm Quentin\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e5\u003c/sup\u003eGerman West-African Centre for Global Health and Pandemic Prevention (G-WAC) at Kwame Nkrumah University of Science and Technology\u003c/p\u003e\n\u003cp\u003eVincent Findeiss Wilm Quentin \u0026amp; Daniel Opoku\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNazviya M, Kodukula S. 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Healthcare professionals\u0026rsquo; perceptions of the benefits and challenges of a teleconsultation service in the Amansie-West district of Ghana. Telemed e-Health. 2015;21(9):748\u0026ndash;55. \u003c/li\u003e\n\u003cli\u003eReva Z, Yılmaz BK, Satılmış D. Adolescent pregnancy in terms of adolescent rights: A retrospective study on adolescent giving births between 2015-2022 in a metropolitan hospital in T\u0026uuml;rkiye. J Aware. 2023;8(2):115\u0026ndash;22. \u003c/li\u003e\n\u003cli\u003eAtiwoto WK, Kpodonu J, Kpodonu J. Establishing National Telehealth Service in a Lower Middle-Income Country\u0026mdash;the Ghana Model. Glob Card Surg Capacit Dev Low Middle Income Ctries. 2022;459\u0026ndash;71. \u003c/li\u003e\n\u003cli\u003eDodoo JE, Al-Samarraie H, Alzahrani AI. Telemedicine use in Sub-Saharan Africa: Barriers and policy recommendations for Covid-19 and beyond. Int J Med Inform. 2021;151:104467. \u003c/li\u003e\n\u003cli\u003eYan Y, Qian Y, Sharif H, Tipper D. A survey on smart grid communication infrastructures: Motivations, requirements and challenges. IEEE Commun Surv tutorials. 2012;15(1):5\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Thematic analysis. American Psychological Association; 2012. \u003c/li\u003e\n\u003cli\u003eNovartis Foundation. Ghana Telemedicine Toolkit: Interactive Implementation Guide [Internet]. 2020 [cited 2025 Mar 23]. Available from: https://www.novartisfoundation.org/sites/arctic_novartisfoundation/files/2020-11/interactive-implementation-guide.pdf\u003c/li\u003e\n\u003cli\u003eW.H.O. Global strategy on digital health 2020-2025 [Internet]. World Health Organisation. 2021 [cited 2025 Mar 26]. Available from: https://www.who.int/docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d.pdf\u003c/li\u003e\n\u003cli\u003eDodoo JE, Al-Samarraie H, Alsswey A. The development of telemedicine programs in Sub-Saharan Africa: progress and associated challenges. Health Technol (Berl). 2022;12(1):33\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eLestari HM, Miranda AV, Fuady A. Barriers to telemedicine adoption among rural communities in developing countries: a systematic review and proposed framework. Clin Epidemiol Glob Heal. 2024;101684. \u003c/li\u003e\n\u003cli\u003eDodoo JE, Al-Samarraie H, Alsswey A. The development of telemedicine programs in Sub-Saharan Africa: Progress and associated challenges. Health Technol (Berl). 2021;1\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eAyo-Farai O, Ogundairo O, Maduka CP, Okongwu CC, Babarinde AO, Sodamade OT. Telemedicine in Health Care: A Review of Progress and Challenges in Africa. Matrix Sci Pharma. 2023;7(4):124\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eBashshur RL, Howell JD, Krupinski EA, Harms KM, Bashshur N, Doarn CR. The empirical foundations of telemedicine interventions in primary care. Telemed e-Health. 2016;22(5):342\u0026ndash;75. \u003c/li\u003e\n\u003cli\u003eNisingizwe MP, Ndishimye P, Swaibu K, Nshimiyimana L, Karame P, Dushimiyimana V, et al. Effect of unmanned aerial vehicle (drone) delivery on blood product delivery time and wastage in Rwanda: a retrospective, cross-sectional study and time series analysis. Lancet Glob Heal. 2022;10(4):e564\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eMars M. Building the capacity to build capacity in e-health in sub-Saharan Africa: the KwaZulu-Natal experience. Telemed e-Health. 2012;18(1):32\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eMorris C, Scott RE, Mars M. A Survey of Telemedicine Use by Doctors in District Hospitals in KwaZulu-Natal, South Africa. Int J Environ Res Public Health. 2022;19(20):13029. \u003c/li\u003e\n\u003cli\u003eZanaboni P, Scalvini S, Bernocchi P, Borghi G, Tridico C, Masella C. Teleconsultation service to improve healthcare in rural areas: acceptance, organizational impact and appropriateness. BMC Health Serv Res. 2009;9:1\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eKiberu VM, Mars M, Scott RE. Barriers and opportunities to implementation of sustainable e-Health programmes in Uganda: A literature review. African J Prim Heal Care Fam Med. 2017;9(1):1\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eBrown CT. Barriers To Telemedicine: Factors Influencing The Adoption Of Telemedicine. 2024; \u003c/li\u003e\n\u003cli\u003eMalik K, Upreti K, Chaudhary A, Kumar N, Singh O, Tharewal S. Integrating Telemedicine Into Population Health Management for Pharmacogenomics and Patient-Centered Care in Rural India. In: Convergence of Population Health Management, Pharmacogenomics, and Patient-Centered Care. IGI Global; 2025. p. 169\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eTilahun B, Zeleke A, Kifle M, Fritz F. The Ethiopian national eHealth strategy and its alignment with the health informatics curriculum. J Heal Informatics Africa. 2014;2(2). \u003c/li\u003e\n\u003cli\u003eMwogosi A. Telemedicine in Tanzania: a systematic literature review. J Health Organ Manag. 2025; \u003c/li\u003e\n\u003cli\u003eByomuhangi E. Evaluation of public-private partnerships (ppps): In health supply chain management in Rwanda. University of Rwanda; 2019. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-digital-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Digital Health](https://bmcdigitalhealth.biomedcentral.com/)","snPcode":"44247","submissionUrl":"https://submission.nature.com/new-submission/44247/3","title":"BMC Digital Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Telemedicine, teleconsultation, service availability, health workforce, infrastructure, Ghana","lastPublishedDoi":"10.21203/rs.3.rs-6761555/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6761555/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eTelemedicine has become a key part of health system transformation, particularly in Africa. The Millennium Promise Alliance (MPA) and Ghana Health Service launched a national telemedicine program in 2010, scaling it across six regions, starting with the Ashanti Regional hospital. It aims to improve healthcare access in remote areas and strengthen primary-to-secondary referrals. Despite telemedicine\u0026rsquo;s potential, little research exists on service availability. This study evaluates workforce density, ICT training, and infrastructure capacity at Ashanti\u0026rsquo;s regional hospital to assess the effectiveness of telemedicine integration.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eQualitative in-depth interviews were conducted with the management team of the Ashanti Regional Hospital's teleconsultation centre using a semi-structured interview guide. Purposive sampling identified seven key informants who participated in the interviews. The interview guide was based on the Service Availability and Readiness Assessment (SARA) framework. Data collection occurred from April to May 2023, and thematic analysis was conducted. Responses were compared with the Novartis Foundation's interactive implementation guide for telemedicine.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe operations of the teleconsultation centre have been significantly affected due to a critical server breakdown, which has led to frequent service disruptions and limited access to virtual consultations. Additionally, the lack of funding for staff training has reduced efficiency and limited capacity to adapt to evolving telehealth technologies. These combined challenges have negatively impacted the daily call volume and strained overall service delivery.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eServer malfunctions and inadequate training funds have disrupted the telemedicine centre\u0026rsquo;s operations, limiting remote healthcare delivery. Addressing these challenges requires strategic investments in technology and staff training. Resource mobilization, partnerships, and phased development plans are essential to restore services and ensure sustainable, quality care. Without these fixes, the centre cannot meet its healthcare access goals.\u003c/p\u003e","manuscriptTitle":"Integrating telemedicine into health systems: A qualitative study on availability of health workforce and infrastructure capacity at the Ashanti regional secondary level hospital, Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-25 11:30:42","doi":"10.21203/rs.3.rs-6761555/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-22T14:40:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-19T19:31:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-09T22:48:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313642203019843043314838196923843960719","date":"2025-09-08T08:25:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"94996263228096371266017416798881547930","date":"2025-09-08T08:17:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"220960821970052723938620087796707620796","date":"2025-09-02T14:03:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-21T19:41:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176659711093625074319833483399940492469","date":"2025-08-05T07:03:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143880226765602488223237674377137241309","date":"2025-08-04T01:45:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53991430957990409299297718724480997598","date":"2025-07-23T11:43:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-23T09:25:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-05T09:24:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-04T21:49:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Digital Health","date":"2025-06-04T21:46:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-digital-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Digital Health](https://bmcdigitalhealth.biomedcentral.com/)","snPcode":"44247","submissionUrl":"https://submission.nature.com/new-submission/44247/3","title":"BMC Digital Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f0cff6db-54a2-48a0-bf5e-86f6ebcb3eab","owner":[],"postedDate":"July 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-19T09:53:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-25 11:30:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6761555","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6761555","identity":"rs-6761555","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}