Posted by Duncan Maru
The AMD/OAN award has catalyzed for Nyaya Health the development of our telecommunication strategy. This is critical given how remote we are, in a hilly region with minimal communication infrastructure and over eight hours (and nearly a month’s per capita income) from the nearest functioning operating theatre. In this post, I will describe some of the processes that we have been engaged in to develop connectivity in our project. See also our strategy brief here. Additionally, I’ll provide our mission statement taken from the most recent version of our telecomm strategy.
Our approach to information technology and telecommunications involves incremental amplification of available tools to match the expanding information available to describe the local epidemiological information and institutional capacity of the Saphe Bagar clinic. Telemedicine does not replace professional staff, effective generalist physicians, or an accountable health system; rather, its success relies on these very factors. We will use telecommunications as a tool to improve health services delivery and empower populations in the area to obtain access to vital resources that will serve as platforms for further economic improvement of the area.
Specifically, we will integrate a “telecommunications center” into an overall development strategy of the Nyaya Health, with a four-fold broad vision: (i) economic empowerment for the community, (ii) increased efficiency and effectiveness of clinic services, (iii) enhanced epidemiological and outcomes monitoring and evaluation systems, (iv) democratization of medical, economic, and political knowledge
To meet this vision, we plan to conduct a number of telecommunications activities, under the sponsorship of the computer company AMD and their Open Architecture Network:
i. perform a baseline assessment of the perceived knowledge, attitudes and behaviors of clinical staff and community members around the issue of perceived telecommunications, computing and information technology needs;
ii. determine the associated training requirements that new technology would require for both staff and community members;
iii. itemize appropriate phone, email, and file transfer systems that are cost- and power-efficient;
iv. introduce the technology and associated new staff in a manner that facilitates its easy maintenance, training, and potential future replacement or updating of technologies;
v. use telecommunications to improve staff training, enhance job performance and the ability to communicate with other Nyaya members regarding clinic performance, maintain stock of key supplies and pharmaceuticals, improve morale and retention in remote areas, and exchange expertise with healthcare workers in other areas;
vi. integrate telemedicine technologies into the design and daily function of the center, to facilitate rapid and reliable tertiary recommendations and expert opinion for clinic staff;
vii. rigorously develop epidemiological performance monitors and costing tools to assess the impact of our interventions.
Due to the highly dispersed nature of the site and the location of the poorest villages typically at least 2-4 hours by walk to the clinic, a distributed network of cost-effective technology and personnel is required to ensure equitable access. This is similar to our overall clinical and public health model, in which we use our physician-run clinic as a main referral center for the network of community health workers. As such, the building to be designed for the competition should best be conceived of as a “telecommunications hub”, which houses the main equipment for internet connectivity (internet service provider, ISP) and relay (via Wi-Fi typically) to peripheral sites. Additionally, it should have some community space and community labs for centralized educational activities and experimentation. The community spaces and community labs would be located on the bottom floor; the technology for the ISP would be located on the top floor, along with staff quarters. This approach mirrors our general strategy for expanding healthcare access in the region in which a central clinic provides specialized services and trainings but the main public health activities happen at the village level. The design should be scaleable to other locations throughout Nepal, in which the telecom hub is centered at a district hospital or primary health centre.
For our purposes, telecommunications hub will be based in Sanfe Bagar in a wooded area about seven minutes by foot from the clinic. This location has a line-of-site to the clinic, to the hospital site at Bayalpada, and to another hill that is the location of a proposed CDMA repeater tower by Nepal Telecom (NTC).
There are two satellite options available to us: Very Small Aperture Terminal (VSAT) and Broadband Global Area Network (BGAN). VSAT has a high up-front cost at around $6000 for a 1.2 meter dish. Through the consortium Sustainable Networks, which pools together several hospitals and other NGOs, guaranteed 32 kbps is available for approximately $160 per month. The reliability and maintenance issues of VSAT in rural areas has been problematic in Achham, however.
In the short-term, assuming that CDMA would not be available, we had purchased a BGAN terminal with usage from Inmarsat from I4Technologies. For short-term emergency purposes, given the absolute need for our Achham-based staff to communicate with the US-based technical assistance team, we had decided that this was the best option that required the lowest up-front costs. Subsequently, when we reached Achham, the BGAN device was not as reliable as expected. It did connect most of the time with good speeds, however. More importantly, we were able to achieve a dial-up CDMA connection with a special 12 dB antenna and fixed wireless terminal provided by NTC to us because of a personal connection that Bijay had with one of the directors. The internet only works during the low-usage hours between 9PM and 7AM, but this is sufficient to achieve basic email connection for now. Incidentally, the antenna also gave us a reliable phone connection which had previously been elusive. Finally, Rina had been pursuing several options for getting subsidized MBs and was running into the basic obstacle that BGAN is just not designed for high-MB routine use. Given this, the BGAN started to seem like an incredibly wasteful proposition even in the short-term and certainly in the long-term. I thus brought it back with me to KTM and have returned it. I4Technologies was gracious in providing us a refund for the unused MBs. It was a technical mistake that fortunately didn’t hurt us in the end.
So back to CDMA. The AMD/OAN team during their site visit emphasized that CDMA was the long-term solution. AMD 50×2015 director Dan Shine even suggested that they could pay NTC for the construction of a CDMA tower in Bayalpata. Even with the tower, however, the connection would be dial-up speeds, worse during the peak hours when CDMA bandwidth was decreased. Mr. Shine suggested some strategy of linking several CDMA connections in parallel to achieve broadband connectivity even over the first generation towers found in our area. Rina is actively pursuing this possibility.
The next issue is intranet connectivity, connecting the villages to our telecomm center via Wi-Fi…