July 2007

Ambient Wireless Networks for Sub-Saharan Africa’s Health System

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There is a need to provide connectivity and access to the much needed and poorly distributed health knowledge and expertise within the health system in Sub-Saharan Africa.  Connectivity and access through wireless networks could make possible communication between different levels of the health system, which in turn could ensure the coordination and cooperation between varied and distributed actors and infrastructure.

The poor healthcare system in Sub-Saharan Africa (SSA) is a matter of numerous policies and fora discourses, but with limited commensurate actions or impacts. For example, the picture of the HIV/AIDS epidemic on the African continent is extremely alarming with about 40 million patients living with HIV and AIDS. This has impacted on all fabrics of society and health systems in SSA, with resultant loss of health personnel due to high mortality rate. This massive brain drain within the health systems is also compounded by the internal rural-urban and external local-international migration of qualified health personnel.

In addition, the severe financial and logistical constraints within the health system in SSA have also reinforced this poor state. These institutional deficiencies and limitations call for the need to explore alternative models of tackling and managing the health systems in SSA. The exploitation of the potentials inherent in the effective, appropriate and contextual applications of information and communication technologies (ICTs) could provide an alternative or complementary model for overcoming these systemic constraints in the health sector. The use of ICTs for health system support is in line with the numerous national, regional and global development frameworks for employing ICTs for health system development.

A major global or intergovernmental example is the World Health Organisation (WHO)'s e-Health initiatives. WHO, as far back as 1998, have promoted the use of ICTs for health system development and has since adopted the term e-Health in the document titled 'Strategy 2004-2007 e-Health for Health Care Delivery' (eHCD) in 2003. The use of e-Health for Primary Health Care (PHC), especially in low-resource countries from SSA, was a specific focus.

Subsequently the establishment of  a Global Observatory for eHealth (Goe), which has on its plan to use e-Health for the development of the health system, mostly in the low and middle income countries as presented in the WHA 58.18 document, is a product of the WHO's commitment.  Two areas where e-Health can contribute to the health system in SSA are developing and building human health capacity, and in supporting and extending health services to the mostly rural, urban and geographically distributed population. The adoption and diffusion of e-Health within the health system in SSA could provide a means of maximising the skills and knowledge of the health workers located either locally within a country, region and internationally, and extend it to low level health workers situated in the rural and urban health centres. 

In order to leverage the inherent potential of using e-Health to develop health human resources development and to improve and extend health service delivery, the existing wireless infrastructure should be employed. There is a need to provide connectivity and access to the much needed and poorly distributed health knowledge and expertise within the health system in SSA.  Connectivity and access through wireless networks could make possible communication between different levels of the health system, which in turn could ensure the coordination and cooperation between varied and distributed actors and infrastructure.

Wireless/Mobile Network Scenario in Africa

The reality on ground in most SSA countries is the inevitability of the mobile/wireless technologies in providing communication access to millions of previously deprived and underserved people. This has led to the quiet acceptance of these ubiquitous technologies as the utopian answer to bridge the digital divide between the developed and developing countries. A very vivid manifestation of communication accessibility and connectivity of these technologies is explicit in the social democratisation and diffusion of GSM-based voice technologies.

For example, there are presently 2 billion GSM mobile phone subscribers in the world and the figure is rising.  This figure is aside from other established mobile/wireless voice communication systems like satellite, CDMA and the emerging Voice Over Internet Protocol (VoIP) through wireless IP networks.  This global trend has been replicated in the developing regions like SSA where as of November 2006; there were 177 million subscribers of GSM mobile telephony. What's more, some countries like South Africa and Nigeria have over 30 million users each, far outstripping the number of fixed telephones and even the mobile subscriber base in many European countries. In addition to this phenomenon is the sprouting of Community Internet Centres (CICs), also known as community telecentres or community access points, powered by the use of IP wireless networks such as GPRS, 3G, WiFi, VSATs, broadband satellite, DVB-RCS, and increasingly WiMax, for Internet access and connectivity.  This community shared access phenomenon is manifested as the use of one GSM mobile phone by many people through familial, public and private access points. This trend challenges the established notion of using the subscriber base as a measure of connectivity with a shift towards measurement of access, which is a reflection of actual mobile telephony usage and penetration in SSA.

The adoption and usage of mobile/wireless technologies in SSA and other developing countries has been driven mostly by voice communication, with data transmission limited only to SMS usage (and increasingly MMS) with GPRS already available in some SSA countries such as Uganda, South Africa and Nigeria.  The use of voice and SMS communication-based systems (notwithstanding their deficient data capacity) has transformed social networking in the SSA region, whose impacts are observed in building familial alliances, community mobilisation and enabling informal and formal business or commercial transactions. However, the lack of understanding or recognition of the potentials of the increasing bandwidth capacity of available and emerging wireless networks in SSA for leveraging the enterprise organisational processes of public and private institutions is retrogressive. The reasons for this might be but not limited to infrastructure scarcity, lack of knowledge, lack of coherent policy drivers, non-cooperative nature of telecom operators and lack of investment. 

A fully  mobile community Internet access for community based home carers could be provided with WLAN enabled mobile devices that are in turn connected directly to community wireless networks on a real-time basis or ad-hoc basis, through mobile access points (MAPs) on bicycles or public buses, as in the DakNet project in India.

Wireless Enabled Integrated District Health Information System

The process and knowledge intensive nature of the health system demands a type of connectivity that has the capacity to carry large amounts of data and information from the distributed actors and structures within the health system, rather than voice-based communication only. As the district health system (DHS) is the unit of delivering PHC services in most of the SSA countries, there is a need to take an enterprise approach to the use of IP wireless networks for leveraging and supporting the organisational actors and structures. Structures in this aspect could mean the physical entities of health facilities such as community health posts or district hospitals. Also, the structures could represent the different health information management systems (HIMS) of different vertical health programmes; electronic health records (EHRs) and web-based teleconsultation platforms such as iPath.

The actors represent the different cadres of health workers at the levels of the DHS.  In the same vein, the integration and the interoperability of the different structures together could be achieved through the use of web tools and platforms. Web services are already matured for desktop applications, but the initiative of W3C in developing web tools for mobile devices especially for developing countries, is a pointer in the right direction and should be encouraged. Therefore, there is a need to recognise and identify the capacity and capability of these available IP wireless networks as a means of building an integrated district health information system (i-DHIS), as an appropriate means of providing the much needed connectivity and access regardless of the geographical context. This proposition of an integrated health information system (HIS) is in line with the vision of WHO-led global plan of building a continent-wide district-based Public Health Information Network for African Health, known as 'The African Health Infoway (AHI)'. 

The use of the IP wireless network to enable the i-DHIS has the potential to provide the much needed access and connectivity to the Internet through different end-user devices, such as mobile phones, handheld computers, laptops and PCs; within and beyond health facilities.  

Ambient Wireless Networks: A Proposed Model

The vision of the wireless IP enabled i-DHIS could be fully achieved through the concept of an ambient wireless network. This could be defined as the provision of Internet access through different types of wireless networks, regardless of your geographical context and nature of end-user device. This integration and interoperability can be used to provide access and connectivity to the different cadres of health workers within the health system in SSA.  This concept of ambient networks can either be classified as ad-hoc or continuous.

An ad-hoc ambient wireless network within an i-DHIS could involve a community-based health worker (CBHW) working within the community. He/She can be provided with Internet access through different types of fixed or mobile wireless shared access points.  These can be used to provide either voice or data transmission in either store and forward or real-time modes. The use of Public or Private Call Offices (PCO), the Gremeen Bank concept of Village Pay Phone (VPP), Community Telecenters, the DakNet model of community information kiosks connected through wireless IP networks, are all proposed models of fixed wireless community access points.

For example, low-cost, store and forward data access platforms like SMS, MMS, and voice access through voicemails can be provided through GSM-based public or private community access points.  These can be provided through the GSM-enabled 'Shared Access To Data' concept; a system of providing Internet access to multiple users from a single point either within the community or a health facility. In addition, the 'Shared Access to Voice' scheme; the deployment of a portable GSM-wireless box-phone, complete with solar charging accessories, to imitate a commercial public phone booth, can be adopted for voice communication. The deployment of these concepts through the Gremeen Bank-VPP model or CICs could provide an appropriate communication means for CBHWs in rural and urban regions of the developing countries.  E-mails and web services can be accessed through shared PCs, located in the CICs or Community Access Centres (CACs) such as in the Nakaseke MTC model in Uganda. The provision of real-time voice communication for CBHWs can be provided through 'Shared Access To Voice' model or through VOIP in CICs. 

A mobile-fixed or semi-mobile concept could be equipping CBHWs with mobile devices such as mobile phones, PDAs and wireless smart cards or USB memory sticks. These can be asynchronously connected to wireless access points, either within CICs as in the UHIN in Uganda concept, or community information kiosks, as in the DakNet model in India.  Connectivity can also be enabled by connecting the mobile devices through a wired connection to PCs via a secured website to a central repository within a health facility or community access points. Real-time multimedia and near real-time applications such as videoconferencing and instant messaging (IM) through the web can also be provided through PCs in the CICs for teleconsultation or interactive eLearning sessions, as in the iPath project. Public access points through community Internet digital screens, as in the Mindset Health programme in South Africa, can also be employed. The proposed 'FonePlus' concept from Microsoft can also be employed. This aims to make mobile phones to provide Internet access through connection to TVs that are widely available in most developing countries.

A fully  mobile community Internet access for community based home carers could be provided with WLAN-enabled mobile devices that are in turn connected directly to community wireless networks on a real-time basis or ad-hoc basis, through mobile access points (MAPs) on bicycles or public buses, as in the DakNet project in India. These mobile devices could then provide data and voice access through IP networks. The use of low-cost mobile end user devices such as One Laptop Per Child project (OLPC) and Simputer could make this possible.  Also a team of CBHWs on a community immunisation programme could employ the 'Shared Access to Data' model with an OLPC-like device for entering or accessing vaccination histories of patients on the field. The two shared access models could also be employed for use by a team of CBHWs, working together within a health post or health centre.

However, the concept of continuous ambient wireless network could provide a more integrated and seamless platform for the interconnectedness of the different actors and structures within the i-DHIS. This concept could ensure that the vision of the AHI becomes a reality within a relatively short period of time. This could also ensure that Internet access and connectivity are provided to the actors within the levels of the DHS. For example, in the case of a CBHW illustrated above, instead of ad-hoc wireless Internet access, a CBHW empowered with a suitable mobile device such as OLPC can have Internet access through a WiFi network within the community health post. And the device can shift seamlessly to a GPRS/3G or long distance WiFi network, while working within the community during home-based care visits. This could provide an advantage of real time and instant access to the i-DHIS database.

From a different perspective, a continuous ambient wireless network could also enable a seamless integration of the structures within the i-DHIS, thereby ensuring that information is shared and updated on a timely basis. For example, the timely aggregation of data from EHR and HMIS would provide a timely access to information on matching health needs with logistical supply. Also, access to the i-DHIS can be provided through web services to a doctor, located at a district hospital, through a WiFi Local Area Network (WLAN) enabled PC, and the same access can be provided to a CBHW at the community level through WiFi/GPRS/3G enabled mobile devices like OLPC or Simputer. Hence, continuous ambient wireless networks could provide a means of using appropriate ICT tool to provide Internet access at different levels of the DHS.

The concept of continuous ambient wireless network could provide a more integrated and seamless platform for the interconnectedness of the different actors and structures within the district health information system (i-DHIS). This concept could ensure that the vision of the African Health Infoway (AHI) becomes a reality within a relatively short period of time.

Taking this concept further, clusters of i-DHIS within each SSA country can further be interlinked and connected together with each other through the use of Wide Area Networks (WAN) like WiMax, WiFi, 3G and satellite technologies, either used singly or in combination. The interconnected i-DHIS could then provide a basis for building the continent-wide health network vision of AHI. This interconnection can then be achieved through the use of broadband satellite networks or through the ongoing New Partnership for Africa's Development (NEPAD)'s fibre-optics broadband backbone presently under construction. Likewise, the India Space Research Organisation (ISRO) and the European Space Agency (ESA) have also indicated their intention to offer their satellite wireless networks to support the development of e-Health in Africa. The recently launched communication satellite by National Space Research and Development Agency (NASRDA) can also be employed towards this purpose.

Technically, this vision of continuous ambient wireless networks is feasible as the International Telecommunication Union (ITU) under the Next Generation Networks (NGN) is already providing leadership on standardisation for interoperability and integration. ITU has also carried out some pilot studies in the use of IP wireless networks for e-Health purposes.  Furthermore, the European Union (EU), through the Information Society and Technology (IST) programme, has developed protocols on how different wireless networks can be made to be interoperable so as to create a seamless and integrated information network for data and voice communication under the ambient network project.

Summing Up

The achievement of this vision could provide a means of building integrated health systems in Africa.  In addition, the use of ambient wireless networks concept could provide a means of improving the health system through an integrated and networked health management information system. Also, medical processes can be extended to rural and isolated regions of SSA through wireless telemedical and telehealth services. The recognition of this vision could provide a cost-effective and appropriate means of achieving the WHO's goal of 'Africa Health Infoway.' However, in order to achieve this vision of ambient wireless network enabled i-DHIS, there is a need to explore and exploit the Public-Private Partnership (PPP) clause of the target #18 of MDGs. Of particular importance is the need of the private wireless operators to be ready to share their infrastructure with public and community access networks.  

Acknowledgement to Dr Jim Briggs of Centre for Healthcare Modelling and Informatics, University of Portsmouth, UK and Dr Patricia Mechael, mHealth Consultant to WHO for their valuable contributions to the structure of this article.

References:

1.http://whqlibdoc.who.int/hq/1998/WHO_DGO_98.1.pdf
2.http://www.who.int/entity/eht/en/eHealth_HCD.pdf
3.http://www.who.int/goe/en/
4.4. http://telemed.ipath.ch/ipath/
5.http://www.w3.org/2006/07/MWI-EC/cfp
6.http://www.gsdi.org/SDIA/docs2006/dec06links/health-infoway.pdf
7.http://www.grameenfoundation.org/what_we_do/technology_programs/village_phone/
8.http://www.firstmilesolutions.com/
9.http://www.gsmworld.com/developmentfund/projects/index.shtml
10.http://www.cta.int/afagrict-l/telecentres.htm
11.http://pda.healthnet.org/
12.http://www.mindset.co.za/
13.http://www.engadget.com/2006/01/30/gates-proposes-cellphones-as-alternative-to-olpc/
14.http://laptop.org/
15.http://www.simputer.org/
16.http://www.itu.int/ITU-T/studygroups/com13/index.asp
17.http://www.itu.int/ITU-D/fg7/
18.http://www.ambient-networks.org/

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