Meraka Telehealth:Project Chapter: Difference between revisions

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FMFI Telehealth Project in Tsilitwa, Eastern Cape Province, South Africa

Researchers:	Chris Morris (cmorris[@]csir.co.za)
	Ajay Makan (amakan[@]csir.co.za)

Background to the problem

The high unemployment rate in the Eastern Cape contributes to poverty. For example, 87% of the population in OR Tambo and Alfred Nzo district municipalities earn less than R800 per month. Poverty and the rurality of the Eastern Cape create a high dependency on public health services.

67% of communities live in rural areas in the Eastern Cape where harsh weather conditions, poor road and telecommunications infrastructure, and the lack of public transport have a direct impact on the delivering of healthcare services.

This situation is due to poor infrastructure and isolation of rural clinics. The workload is also increasing due to HIV/AIDS epidemic and thus the need for specialized advice or consultation or second opinion.

Lack of transport, bad roads makes referring of patients sometimes impossible thus treatment of patient in the community is the only option.

Lack of telecommunication, particularly in rural areas, makes proper referring of patients difficult and costs patients time and money to travel. Lack of access to training and Continual Medical Education (CME) severly limits healthworker development in rural areas and keeps healthcare workers away from the rural health centres.

A major challenge in the Eastern Cape is the drain of healthcare professionals from the rural communities to the more developed urban centres. Professional isolation from their peers contributes to the difficulty in attracting and retaining qualified staff in rural areas. Traditionally health professionals and managers have to travel long distances for meetings and knowledge transfer. This also results in high cost and loss of productivity.

Specialised care is very scarce in the Eastern Cape. There are only 2 dermatologists, 2 radiologists, 2 oncologists and no oral health specialists in the public service.

Due to the lack of telecommunications infrastructure in rural areas, wifi is seen as a potential solution to meet the needs of rural connectivity. However, the use of wifi in the 2.4GHz ISM band (which is license free internationally) is forbidden where it cuts across public boundaries and where the power emission of the antenna exceeds 100mWatts. So the challenge of this project is to pilot the use of wifi in order to demonstrate to government how low-cost technologies such as wifi can be used to meet the communication needs of deep rural communities.

The Tsilitwa Project

The tele-health application developed in Tsilitwa in 2001 formed part of the Department of Science and Technology’s Innovation Fund project entitled “Information and Communication Technologies (ICTs) in support of communities in deep rural areas”.

The community leader from Tsilitwa approached the CSIR in 1999 to draft a funding proposal after having visited a similar CSIR project at Lubisi. The request was for Information Communication Technology (ICT) to support health, education, agriculture and small business.

The project involved the two communities of Tsilitwa and Sulenkama that were geographically separated by a hill preventing direct access between the villages and requiring people to travel the 15km by a very poor dirt road where the public transport was unreliable. These towns are approximately 100km north east of Umtata. The two villages are typical of the former Transkei area and to this day have no electricity to homes, no running water, dirt roads and no telecommunications. The villages are spread out and people build mud-block houses with thatch roofs or corrugated iron. Some houses are constructed from brick with tile roofs. The population is mostly unemployed totalling approximately 2000 in each village.

The community facilities in Tsilitwa include a pre-fabricated clinic and technical school that, through the efforts of the headmaster, is electrified. The clinic ran on solar power until 2002 when it was electrified. The village of Sulenkama some 15km away has more infrastructure boasting a 200 bed community hospital called Nessie Knight with electricity (generator back-up) and 3 DECT telephone lines. The telephones do not usually work and the hospital staff rely on their personal cell phones to call Mthatha for an ambulance.

Regulatory Environment (South Africa)

It is important that the project team have a clear understanding of the regulatory environment in order to be able to use the research results as inputs for future policy. Regulation regarding WiFi

WiFi networks are allowed when:
- The network is deployed on a single site
- Signals may only traverse short distance; EIRP not to exceed 100 milliWatts
- No interference to users of other ISM equipment or other frequency bands may be caused
- The network must be confined to computer systems of the same user

For community based networks a license is needed; either a PTN (Private Telecommunications Network) or VANS (Value-Added Network Service) license. The latter is needed when the network is connected to the Internet, and Internet services are provided
Self provision has been an issue for long, but likely with the Electronic Communications Act (ECA), self provision will be allowed [need to check this]
The regulatory framework surrounding WiFi deployment nevertheless remains complicated, and due to quick changes of staff at the regulator, applications for licenses could take long.

In order for community owned networks to be legally pursued, the regulator requires such projects to obtain both a PSTN as well as VANS license and the deployment of facilities dictates that the telecommunications facilities must be that belonging to Telkom or the SNO. However, the issue of self-provisioning remains a grey area open to interpretation. Under the ECA a class license would be needed by FMFI partners for both infrastructure and services, but the use of WiFi is still hamstrung by the control on power levels and crossing public boundaries. It is suggested that the FMFI partners continue to lobby government for a regulatory relaxation for the use of WiFi across public boundaries in rural areas for use in non-commercial sectors such as health and education.

@@ Line 14: / Line 14: @@
 |}
-<br>
-== Telehealth Details ==
+== Background to the problem ==
-=== Project background ===
+The high unemployment rate in the Eastern Cape contributes to poverty. For example, 87% of the population in OR Tambo and Alfred Nzo district municipalities earn less than R800 per month. Poverty and the rurality of the Eastern Cape create a high dependency on public health services.
-The tele-health application developed in Tsilitwa, Eastern Cape Province South Africa formed part of the Department of Science and Technology’s Innovation Fund project entitled “Information and Communication Technologies (ICTs) in support of communities in deep rural areas”. The project was implemented between 2001 and 2003 and the CSIR was the lead organisation of a consortium comprising the HSRC, ARC, Naledi ya Africa and Renewable Energy (Pty) Ltd.
+% of communities live in rural areas in the Eastern Cape where harsh weather conditions, poor road and telecommunications infrastructure, and the lack of public transport have a direct impact on the delivering of healthcare services.
-This project’s aim was to develop and implement an innovative communications infrastructure that was independent of the State telecommunication utility companies, and to develop capacity within the community involved, with appropriate information content, to support sustainable development in rural areas.
+This situation is due to poor infrastructure and isolation of rural clinics.  The workload is also increasing due to HIV/AIDS epidemic and thus the need for specialized advice or consultation or second opinion.
-The project involved the two communities of Tsilitwa and Sulenkama that were geographically separated by a “koppie” preventing direct access between the villages and requiring people to travel the 15km by dirt road. These towns are approximately 100km north East of Umtata.  The two villages are typical of the former Transkei area and to this day have no electricity to homes, no running water, dirt roads and no telecommunications. The villages are spread out and people build mud-block houses with thatch roofs or corrugated iron. Some houses are constructed from brick with tile roofs. The population is mostly unemployed totalling approximately 2000 in each village.
+Lack of transport, bad roads makes referring of patients sometimes impossible thus treatment of patient in the community is the only option.
-The community facilities in Tsilitwa include a pre-fabricated clinic and technical school that, through the efforts of the headmaster, is electrified. The clinic ran on solar power until 2002 when it was electrified. The village of Sulenkama some 15km away has more infrastructure boasting a 200 bed community hospital called Nessie Knight with electricity (generator back-up) and 3 DECT telephone lines. The telephones do not usually work and the hospital staff rely on their personal cell phones to call Umtata for an ambulance.
+Lack of telecommunication, particularly in rural areas, makes proper referring of patients difficult and costs patients time and money to travel.  Lack of access to training and Continual Medical Education (CME) severly limits healthworker development in rural areas and keeps healthcare workers away from the rural health centres.
-=== ICT infrastructure ===
+A major challenge in the Eastern Cape is the drain of healthcare professionals from the rural communities to the more developed urban centres.  Professional isolation from their peers contributes to the difficulty in attracting and retaining qualified staff in rural areas.
+Traditionally health professionals and managers have to travel long distances for meetings and knowledge transfer. This also results in high cost and loss of productivity.
-==== Initial configuration ====
+Specialised care is very scarce in the Eastern Cape.  There are only 2 dermatologists, 2 radiologists, 2 oncologists and no oral health specialists in the public service.
-The ICT infrastructure implemented during the DACST funding included an MPCC at Tsilitwa and Sulenkama, PC network at the Tsilitwa school, a WiFi network connecting Sulenkama hospital and police station to a number of sites in Tsilitwa including the clinic, school and the MPCC. Each of these sites was connected in the network and voice communication was possible by means of VoIP. The Tsilitwa clinic was linked to the Sulenkama hospital with a web-cam to facilitate tele-consultation between the clinic sister and doctor at the hospital. In addition, external e-mail was piloted at the clinic using a GSM modem as cellular coverage was available in the area. The clinic sister was provided with a digital camera to capture pictures of patients with skin disorders or wounds. The images were then sent to a specialist in Umtata for diagnoses and advice.
+Due to the lack of telecommunications  infrastructure in rural areas, wifi is seen as a potential solution to meet the needs of rural connectivity. However, the use of wifi in the 2.4GHz ISM band (which is license free internationally) is forbidden where it cuts across public boundaries and where the power emission of the antenna exceeds 100mWatts. So the challenge of this project is to pilot the use of wifi in order to demonstrate to government how low-cost technologies such as wifi can be used to meet the communication needs of deep rural communities.
-==== New configuration ====
-In 2003 the CSIR were successful in winning funding from the World Bank Development Marketplace that funded the expansion of the network to other clinics around Tsilitwa. In addition, an application was made to the Universal Service Agency (USA) for sponsorship of a VSAT to provide internet and e-mail connectivity to the Sulenkama/Tsilitwa cluster. This is imperative to continue with the tele-dermatology already piloted at Tsilitwa through the use of GSM. (The GSM was piloted for a year and then discontinued due to high running costs). An MOU was signed between the USA, Department of Health and the CSIR for the implementation of the VSAT and ongoing support.
+== The Tsilitwa Project ==
+The tele-health application developed in Tsilitwa in 2001 formed part of the Department of Science and Technology’s Innovation Fund project entitled “Information and Communication Technologies (ICTs) in support of communities in deep rural areas”.
-At the beginning of 2004 the Department of Public Works embarked on a building programme in OR Thambo District Municipality for the construction of new clinics. At the project site in Tsilitwa this meant the demolishing of the old clinic and the transfer and re-installation of WiFi equipment to the new clinic. This move resulted in a whole new set of challenges being presented to the project team and the re-design of the existing network to focus on connectivity for health to a number of clinics in the area. The new network design was based on the installation of the VSAT at Nessie Knight hospital, Sulenkama and WiFi connectivity to the new clinics at Tsilitwa and Kalankomo. In addition, the WiFi network was to be extended to the new clinics at Guru and Mahlungulu provided line of sight conditions prevailed.
+The community leader from Tsilitwa approached the CSIR in 1999 to draft a funding proposal after having visited a similar CSIR project at Lubisi. The request was for Information Communication Technology (ICT) to support health, education, agriculture and small business.
-After having erected the RF equipment to the new clinics the link between Tsilitwa clinic and the “koppie” and Tsilitwa to Kalinkomo clinic was successfully tested. The team then needed to test the line of sight to Guru clinic. The link prediction using the GISRAP software developed by the CSIR indicated there was possible line of site but this was subject to on-site evaluation. A 10m mast was erected at Tsilitwa with directional antenna pointing to the “koppie”, Kalenkomo clinic and Guru clinic.
+The project involved the two communities of Tsilitwa and Sulenkama that were geographically separated by a hill preventing direct access between the villages and requiring people to travel the 15km by a very poor dirt road where the public transport was unreliable. These towns are approximately 100km north east of Umtata.  The two villages are typical of the former Transkei area and to this day have no electricity to homes, no running water, dirt roads and no telecommunications. The villages are spread out and people build mud-block houses with thatch roofs or corrugated iron. Some houses are constructed from brick with tile roofs. The population is mostly unemployed totalling approximately 2000 in each village.
-After it was determined that there was no line of site using the CSIR WiFi equipment between Tsilitwa and Guru it was decided that the link would be tested using “non-line of site” equipment manufactured by Alvarion. This operates in the 5.8GHz frequency and has unique signal propagation characteristics. The mast had to be taken down at Tsilitwa and a different antenna was erected for the Alvarion equipment. The alignment of the antenna to Gura was done using a GPS. This gives approximate directional information only and panning of the antenna is required. Despite these efforts no link could be established between Tsilitwa and Guru clinic and the antenna for the Alvarion equipment was dismantled.
+The community facilities in Tsilitwa include a pre-fabricated clinic and technical school that, through the efforts of the headmaster, is electrified. The clinic ran on solar power until 2002 when it was electrified. The village of Sulenkama some 15km away has more infrastructure boasting a 200 bed community hospital called Nessie Knight with electricity (generator back-up) and 3 DECT telephone lines. The telephones do not usually work and the hospital staff rely on their personal cell phones to call Mthatha for an ambulance.
-The network then only included Nessie Knight hospital at Sulenkama, the “koppie”, Tsilitwa clinic and Kalankomo clinic. Guru and Mahlungulu clinics could not be connected to the network. At this point the question was asked what could be done to provide connectivity to the clinic. The antenna mast had been previously erected and enclosure box fitted to house the WiFi equipment. The decision was taken to complete the installation by installing the power cabling, trunking and LAN point with the idea that we would provide a PC for the clinic. This would at least introduce the clinic staff to e-Health and connectivity might be provided by some other means, such as 3G, at a later stage.
+== Regulatory Environment (South Africa) ==
-=== Regulatory environment ===
+It is important that the project team have a clear understanding of the regulatory environment in order to be able to use the research results as inputs for future policy.
+Regulation regarding WiFi
+*WiFi networks are allowed when:
+**The network is deployed on a single site
+**Signals may only traverse short distance; EIRP not to exceed 100 milliWatts
+**No interference to users of other ISM equipment or other frequency bands may be caused
+**The network must be confined to computer systems of the same user
-A continuing concern for the project was the issue of a license for the use of WiFi. It has been interesting to note the changes taking place in the regulatory landscape with respect to WiFi and at the African WiFi conference in 2004, a representative of ICASA indicated a willingness to assist with facilitating the use of WiFi in tribal lands.
+*For community based networks a license is needed; either a PTN (Private Telecommunications Network) or VANS (Value-Added Network Service) license. The latter is needed when the network is connected to the Internet, and Internet services are provided
+*Self provision has been an issue for long, but likely with the Electronic Communications Act (ECA), self provision will be allowed [need to check this]
+*The regulatory framework surrounding WiFi deployment nevertheless remains complicated, and due to quick changes of staff at the regulator, applications for licenses could take long.
-The CSIR met with the regulator and issues of tribal and contiguous land and municipal PTN licenses were discussed. The CSIR are currently developing a strategy for use of WiFi in the Eastern Cape that includes lobbying the regulator for a license exemption for research purposes...
+In order for community owned networks to be legally pursued, the regulator requires such projects to obtain both a PSTN as well as VANS license and the deployment of facilities dictates that the telecommunications facilities must be that belonging to Telkom or the SNO. However, the issue of self-provisioning remains a grey area open to interpretation. Under the ECA a class license would be needed by FMFI partners for both infrastructure and services, but the use of WiFi is still hamstrung by the control on power levels and crossing public boundaries. It is suggested that the FMFI partners continue to lobby government for a regulatory relaxation for the use of WiFi across public boundaries in rural areas for use in non-commercial sectors such as health and education.