BACKGROUND: Despite acceleration of remote consulting throughout the COVID-19 pandemic, many health care professionals are practicing without training to offer teleconsultation to their patients. This is especially challenging in resource-poor countries, where the telephone has not previously been widely used for health care.
OBJECTIVE: As the COVID-19 pandemic dawned, we designed a modular online training program for REmote Consulting in primary Health care (REaCH). To optimize upscaling of knowledge and skills, we employed a train-the-trainer approach, training health workers (tier 1) to cascade the training to others (tier 2) in their locality. We aimed to determine whether REaCH training was acceptable and feasible to health workers in rural Tanzania to support their health care delivery during the pandemic.
METHODS: We developed and pretested the REaCH training program in July 2020 and created 8 key modules. The program was then taught remotely via Moodle and WhatsApp (Meta Platforms) to 12 tier 1 trainees and cascaded to 63 tier 2 trainees working in Tanzania\'s rural Ulanga District (August-September 2020). We evaluated the program using a survey (informed by Kirkpatrick\'s model of evaluation) to capture trainee satisfaction with REaCH, the knowledge gained, and perceived behavior change; qualitative interviews to explore training experiences and views of remote consulting; and documentary analysis of emails, WhatsApp texts, and training reports generated through the program. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed thematically. Findings were triangulated and integrated during interpretation.
RESULTS: Of the 12 tier 1 trainees enrolled in the program, all completed the training; however, 2 (17%) encountered internet difficulties and failed to complete the evaluation. In addition, 1 (8%) opted out of the cascading process. Of the 63 tier 2 trainees, 61 (97%) completed the cascaded training. Of the 10 (83%) tier 1 trainees who completed the survey, 9 (90%) would recommend the program to others, reported receiving relevant skills and applying their learning to their daily work, demonstrating satisfaction, learning, and perceived behavior change. In qualitative interviews, tier 1 and 2 trainees identified several barriers to implementation of remote consulting, including lacking digital infrastructure, few resources, inflexible billing and record-keeping systems, and limited community awareness. The costs of data or airtime emerged as the greatest immediate barrier to supporting both the upscaling of REaCH training and subsequently the delivery of safe and trustworthy remote health care.
CONCLUSIONS: The REaCH training program is feasible, acceptable, and effective in changing trainees\' behavior. However, government and organizational support is required to facilitate the expansion of the program and remote consulting in Tanzania and other low-resource settings.

OBJECTIVE: Remote or mobile consulting is being promoted to strengthen health systems, deliver universal health coverage and facilitate safe clinical communication during coronavirus disease 2019 and beyond. We explored whether mobile consulting is a viable option for communities with minimal resources in low- and middle-income countries.
METHODS: We reviewed evidence published since 2018 about mobile consulting in low- and middle-income countries and undertook a scoping study (pre-coronavirus disease) in two rural settings (Pakistan and Tanzania) and five urban slums (Kenya, Nigeria and Bangladesh), using policy/document review, secondary analysis of survey data (from the urban sites) and thematic analysis of interviews/workshops with community members, healthcare workers, digital/telecommunications experts, mobile consulting providers, and local and national decision-makers. Project advisory groups guided the study in each country.
RESULTS: We reviewed four empirical studies and seven reviews, analysed data from 5322 urban slum households and engaged with 424 stakeholders in rural and urban sites. Regulatory frameworks are available in each country. Mobile consulting services are operating through provider platforms (n = 5-17) and, at the community level, some direct experience of mobile consulting with healthcare workers using their own phones was reported - for emergencies, advice and care follow-up. Stakeholder willingness was high, provided challenges are addressed in technology, infrastructure, data security, confidentiality, acceptability and health system integration. Mobile consulting can reduce affordability barriers and facilitate care-seeking practices.
CONCLUSIONS: There are indications of readiness for mobile consulting in communities with minimal resources. However, wider system strengthening is needed to bolster referrals, specialist services, laboratories and supply chains to fully realise the continuity of care and responsiveness that mobile consulting services offer, particularly during/beyond coronavirus disease 2019.

OBJECTIVE: The poorest populations of the world lack access to quality healthcare. We defined the key components of consulting via mobile technology (mConsulting), explored whether mConsulting can fill gaps in access to quality healthcare for poor and spatially marginalised populations (specifically rural and slum populations) of low- and middle-income countries, and considered the implications of its take-up.
METHODS: We utilised realist methodology. First, we undertook a scoping review of mobile health literature and searched for examples of mConsulting. Second, we formed our programme theories and identified potential benefits and hazards for deployment of mConsulting for poor and spatially marginalised populations. Finally, we tested our programme theories against existing frameworks and identified published evidence on how and why these benefits/hazards are likely to accrue.
RESULTS: We identified the components of mConsulting, including their characteristics and range. We discuss the implications of mConsulting for poor and spatially marginalised populations in terms of competent care, user experience, cost, workforce, technology, and the wider health system.
CONCLUSIONS: For the many dimensions of mConsulting, how it is structured and deployed will make a difference to the benefits and hazards of its use. There is a lack of evidence of the impact of mConsulting in populations that are poor and spatially marginalised, as most research on mConsulting has been undertaken where quality healthcare exists. We suggest that mConsulting could improve access to quality healthcare for these populations and, with attention to how it is deployed, potential hazards for the populations and wider health system could be mitigated.