Recipient Institution:
HealthNet Nepal

P. B. 2533, Maharajgunj, Kathmandu, Nepal

Tel/Fax: 977-1-4429722

Email: mpradhan@healthnet.org.np

Project Leader:
Dr. Mohan Raj Pradhan

Amount and Duration: US$ 30,000 / 24 months

Commencement Date:
June 2004

Project Proposal
Project background and justification

In Nepal, there is acute shortage of doctors. The total numbers of allopathic doctors are 4000 and majority of them are staying in capital and other major cities. The public and doctors ratio is approximately 6000: 1. Health workers in rural health care, who serve most of the population, are isolated from specialist support and up to date information.

The advent of ICTs has unleashed new opportunities to the delivery of health services. Telemedicine may in fact have a more profound impact on developing countries than on developed countries.

In Nepal, top ten OPD diseases are related to communicable and infectious diseases. These types of diseases can be diagnosed and managed with the help of images and physical examination to patients is not needed. Further, simple change in health habits can help to reduce the burden of these diseases, which can be provided through tele-education.

As we learn more about distance medicine, we will also learn more about the diversity of disease, healthcare systems, and outcome expectations in Nepal. There is a temptation to introduce western technology into health systems that are naïve with respect to Western approaches to health care. Without considering the sustainability aspect, telemedicine could have a negative impact on the continuity of the system. And unless we understand the technological and cultural readiness our country and its health care practitioners, much effort can be expended with little gain.

An economical solution to support health care in remote areas is email, based on store and foreword principal. Email has many advantages in Nepal. It is cheap, hardware and software requirements are simple, and the information does not have to be transmitted in real time. These allow sending e-mail attachments such as image files, permitting a form of low cost telemedicine. Modern digital cameras are small, robust, easy to use and cheap. Low cost telemedicine with still images can be applied in the area of Radiology, Pathology and Dermatology. The modern digital camera can create high-resolution images that are adequate for diagnosis. These techniques may not provide the quality of data we expect in modern hospitals. However, if used by health care workers trained to follow simple photographic and email procedures they can improve specialist access in remote areas.

In Nepal, connectivity and training remain the biggest challenges for implementation of telemedicine centers. It is important that local health care workers take a lead in developing and operating telemedicine projects. Initiatives to train healthcare workers in the use of ICTs are also essential. We should emphasis low cost techniques, as a pilot project to gain experience.

Project objectives

Test the potentiality of telemedicine based on store and foreword principle for still images captured through digital camera in the areas of pathology, dermatology and radiology.

Specific objectives of the project will be:

f. Establish a pilot network of telemedicine in three areas of Nepal: Butwal (Western region), Jhapa (Eastern region), and Bhaktapur (Central region).

g. Trial run the efficacy of image captured through digital camera for diagnosis and management of cases in the field of pathology, dermatology and radiology.

h. Develop Internet based computer program for uploading the cases captured through digital camera.

i. Use e-mail for uploading images for diagnosis and management of patient.

j. Internet based referral system through telemedicine for providing community health care in remote areas to reduce the burden of communicable and infectious diseases.

3 Project beneficiaries

Patients from a population of 1395546 (Bhaktupur, Butwal and Jhapa)

Under-served communities in the rural and urban areas of Butwal, Jhapa and Bhaktapur and primary health care project of Bhutanese refugees in Jhapa in Morang districts

Health workers at Siddhi Memorial Foundation, Bhaktapur, Siddhartha Children and Women Hospital, Butwal and AMDA-Hospital, Damak

4. Project Sustainability

As it supports the day to day activities of the above mentioned hospitals, the operating cost may be covered through charges from consultation. The cost may be as follows:

Phase 1 : There will be no fees for the 1st year (demand creation and marketing)

Phase 2: 2nd year - 50c * 20 patients x 30 days = US $ 300

5 Project Methodology

5.1 Review the existing methods of telemedicine based on store and foreword principle in adopted developing and developed countries.

5.2 Compare study of similar experiences in India, Nepal, Bangladesh and other developing countries.

5.2 Design, develop and implement the free ware software packages like ipath software, software for radiology and software for dermatology.

5.3 Design and develop customized software for telepathology, radiology and dermatology based on store and foreword principle

5.4 Software will be developed for online consultation through web, chatting and uploading in the web through e-mail. The e-mail message goes to server side and automatically uploaded in the server with description of the case.

5.5 From the rural health worker side, e-mail will be sent for the captured picture but from the hospital side, web will be used for the diagnosis of the case.

5.6 Evaluate the suitability of image sent through telephone line for diagnosis and management of case.

5.7 Design and develop training module for users of proposed telemedicine system to adopt effectively use of telemedicine using the existing infrastructure of Nepal.

5.8 Specification of Equipment needed for the project

a. Computer Specification:

Processor: Intel Pentium 2.0 GHZ
Memory: 256 MB
Hard Disk: 40 GB
Modem: 56.6 K bps

b. Software specification:
Operating system: Linux Redhat
Web server: Apache
Database: MySql
Software: Perl software

c. Digital Camera: Nikon Cool Pix 4500

d. Simple Olympus Microscope

6. Project time-line

Description of Activity

i. Equipment Acquisition, Shipment & Distribution to end users
June to Dec 2004

ii. Developing format for recording report captured through image
June to Dec 2004

iii. Development of software for diagnosis and management of cases captured through images in web and e-mail.
June,2004 to May, 2005

iv. Functional Tests of different forms to be used in Dermatology, Radiology and Pathology cases

May 2005 to July, 2005

v. Training

Aug to Nov, 2005

5.1 Draft training materials for Siddhi Memorial Foundation, Amda Hospital, Jhapa, and Children and Women hospital, Butwal

a. Discuss training modalities and strategies with other partners to coordinate roles and encourage dialogue/interaction between HealthNet Nepal and trainees

b. Train partners on capturing images, filling cases in forms, using Internet and e-mail

vi. Collection of cases through by capturing images for radiology, pathology and dermatology

Dec 2005 to May 2006

vii. Monitoring and Evaluation

Dec. 2005 to May 2006

7.1 Design user satisfaction survey for both paper and images sent through Internet

7.2 Develop evaluation framework and collect baseline data

7.3 Conduct user feedback survey on diagnosis captured through images

7.3 Collect evaluation data based upon framework

7.4 Interview health workers and document their feedback

7.5 Review user feedback

7.6 Make preliminary evaluation of data and host internal evaluation meetings

7.7 Host external meetings to share project design and preliminary outcomes of the project

7.8 Modify reporting forms and protocols based on preliminary evaluation and remap databases

7.9 Train partners based on the review

viii. Reporting

Oct 2004 to June, 2005

Quarterly report to IDRC
Quarterly financial report to IDRC
Final narrative and financial report to IDRC

7. Project Outputs

As a result of the pilot, the output will be:

• Develop telemedicine system based on store and foreword principle suitable for Nepal
• Create a pool of health professionals at HealthNet Nepal, implementing partners who are trained in use of in the use of digital camera and related equipment for capturing images suitable for diagnosis and management of cases.
• Plan a possible collaboration with the Ministry of Health to implement telemedicine system in remote areas.
• Use of the technology for other organizations at Nepal for diagnosis and management of cases captured through images.

8. Project Monitoring and Evaluation

This pilot will be reviewed by HealthNet Nepal and IDRC to determine its usefulness, timeliness and adaptability to the remote areas of Nepal. There are many applications for this technology. Aside from the uses for the HealthNet Nepal and its partners, this technology can have global implications on telemedicine for still images. This will also develop Nepal's capability to develop new technologies to provide telemedicine appropriate for developing countries.