Development Market Place 2007

• Development Market Place 2007

• Project Proposal by PFI at Global Development Market Place 2007

• Global DM2007 Finalists

Improving Results in Health, Nutrition & Population for the Poor

DM Proposal Number and Title

Proposal # 2393 : MOBILE EYE CARE CLINIC FOR THE TRIBAL PEOPLE OF INDIA’S NORTHEAST

2. Project Summary
Objective: To provide a quality eye care facility for Tribal communities in remote areas through a Mobile Eye Clinic and Wi-Fi wireless technology.

a. Rationale – why is the project necessary?

India has an estimated 15 million people visually challenged, 52 million people visually impaired and 270,000 cases of childhood blindness. Cataracts, glaucoma and diabetic retinopathy are prevalent. Nearly 70% of its patients live in rural India, where there is an acute shortage of ophthalmologists. The elimination of needless blindness, therefore, needs an innovative approach in ‘reaching as many as we can’ by reaching out beyond the clinic. Delivering eye care to the Tribal population is challenging due their remote locations and lack of a sustainable and quality healthcare infrastructure in those locations. Hence, this proposal presents a tele-ophthalmology system to connect a specialty base hospital with a remote Eye Care Van.

b. Innovation/Effectiveness

The tele-linked Mobile Eye Care facility is expected to cover more than 50,000 patients annually in tribal areas reaching a target of 100,000 patients in the 24 months of the project period. The project provides affordable and accessible advanced eye care to remote locations of Northeast India through economical mobile eye care facilities. It will procure a Mobile Eye Care Van with all the necessary equipment and long-distance wireless infrastructure (Wi-Fi) technology with off-the-shelf videoconferencing software and tools. The mobile eye care facility will also work with a network of specialists through a voluntary effort at the partner institute as well as the Govt. of Assam.

3. Problem Definition (Suggested limit: 400 words)

Globally, India shoulders the largest burden of blindness, estimated at 15 million people. Cataracts are the leading cause of blindness in India, but glaucoma and diabetic retinopathy are also prevalent. As more than 70% of the patients live in rural areas, the major challenge is to offer quality and affordable eye care with minimal infrastructure setup in remote and marginalized communities such as the tribal communities of Northeast India. Due to remoteness of the areas where the tribal people live, maintaining operational health centers in those places is difficult as health personnel tend to be urban centered. Experiments with a few models of eye care delivery including mobile vans and remote tele-medicine centres have created more challenges. These new challenges include hosting the mobile unit within local communities, and limited bandwidth and thus poor video quality in tele-medicine centres. Additionally, third-party network carriers and service providers are not interested in providing coverage to those areas as they are sparsely populated.

The Northeastern region of India, at the borders to Bhutan, China and Myanmar, comprises seven Indian states, 40 million people, and over 200 ethnic groups and languages. Poverty is far worse here than in the rest of India, as the people in this region have been largely excluded from the development in other parts of the country. The rates of blindness here is the highest in India, yet the smallest number of people are able to undergo surgery to restore their eyesight. This project therefore envisages blind people in the remote Tribal villages having access to eye care. And to accomplish this goal, one major regional super-specialty eye hospital will be wirelessly linked to a mobile eye care van equipped with surgery teams.

Other organisations like the Aravind Eye Hospitals in India has tested the Wi-Fi Technology but only as installed in fixed eye care clinics. Others, like Guwahati Medical College, the biggest hospital in the Northeastern region, have tested the field eye check-up vans. However, both the systems are not suitable for remote areas where we need to provide more than just diagnostic check-ups and at the same time can not afford to establish sustainable eye care clinics like South India. Therefore, the present project aims to set up an advanced mobile eye care clinics with superior diagnostic facilities and expert-consultations via a reliable Wi-Fi network.

4. Idea (Suggested limit: 500 words)

The current gap between eye care services and rural people’ needs could be best bridged by reaching out to rural people both physically and virtually through use of technology. The approach is to build an advanced eye care facility onboard a vehicle that that provides (1) high-quality eye care to underserved populations—particularly the children and the elderly who lack access to health care as a result of finances, transportation problems or cultural and language barriers, and (2) Long-distance (LD) Wi-Fi wireless technology to enable rural residents to have video consultations with doctors for remote diagnosis, and thereby eliminating the need for patients to travel long distance.

The Mobile Tele-Ophthalmologic Van (MTV) will be fully equipped with diagnostic tools and instruments to cover everything from preliminary vision screenings to comprehensive eye examinations. Patients can expect to find the same services onboard the MTV as they would in other practice settings. And while the eyewear selection is smaller than those found at a private practice, the MTV does offers a selection of eyewear. It’s the same equipment you can expect to find in any optometry practice, only ours moves from location to location to bring complete optometric care to specific groups of underserved patients. The MTV removes distance, time and affordability barriers that often separate patients from doctors.

The added technology in the MTV is a custom long distance, high-bandwidth, point to point Wi-Fi network that connects it to the main base hospital- The Regional Institute of Ophthalmology, Guwahati. Long-distance (LD) Wi-Fi is a fixed point to point wireless technology, like microwave links, that establishes a wireless network in remote rural areas that are sparsely populated and not covered by current wireless service providers. The original challenge was to use the Wi-Fi design for short-distance communication. However, to make it work over the long distances, it has a modified software (already tested at Aravind hospitals, India), known as the Wi-Fi Media Access Control (MAC) protocol. This is a unique wireless network that can handle high-speed communications over distances as great as 40 miles. To connect the MTV to the base hospital we will use an Intel and UC Berkeley designed point-to-point long-distance wireless infrastructure that combines a variation on IEEE 802.11 (Wi-Fi) technology with off-the-shelf videoconferencing software and tools that hospitals can use to maintain the network. The 802.11 networking standard, more commonly known as “Wi-Fi”, with modified Wi-Fi software with directional antennas and routers to send, receive and relay signals, the research team has thus far has been able to obtain network speeds of up to six megabytes per second (Mbps) at distances up to 40 miles (tested in south India validated at another project in Ghana). These speeds are about 10 times faster than dial-up speeds and carry 100 times as far as standard Wi-Fi technology.

5. Innovation (Suggested limit: 500 words)

Mobile eye care programs have very much been in use for a long time by various organizations around the world. There were many operational problems: sending vans to rural areas, and organizing local sponsors to host them. In addition, the vans could only visit a given area and only infrequently. Often these visits could not be followed up by specialists, ultimately limiting the services to the routine checkups, and thus leaving patients again to travel to the hospitals for even minor surgery.

Second, the mobile vans are generally running with just preliminary check-up facilities and no specialized care or consultations – only rarely would an expert be traveling to rural areas on such a mission regularly. Even as they are willing there are too many specialists to be taken along. Therefore, the alternative was to set up rural tele-medicine centers, like those being tried by the Aravind Eye Hospitals in South India. However both these approaches are not suitable for Tribal communities in Northeast India as they are spread over a larger area and without a reliable communication network to the base hospital.

The present project synthesizes the Wi-Fi technology tested in stationery clinics with a new method to mount the eye care facilities onboard. Through a wireless Tele-ophthalmology network, the remote Tribal communities therefore have access to experts in the nearby cities like Guwahati without leaving their villages. Additionally, it makes the eye care services affordable to them. Hence, the MTV project would deliver eye care services through an innovative combination of existing technologies, to a new geographic area, and a new beneficiary group with new partners in the network. The innovations are as follows:

• New beneficiary group: Marginalized Tribal communities so far unreached by specialized eye care facilitires.

• New geographic area: The tele-ophthalmologic mobile eye care system has not been tried in Northeast India, specifically in the remote Tribal areas.

• New combination of existing technologies: Modified Wi-Fi access protocols for mobile eye care vans.

The mobile eye care facilities tested earlier lacked expert back up from a base station and depended on the volunteer doctors traveling with the vans. The patients were referred to a major specialty hospital that was both expensive and difficult to travel to. The tele-ophthalmologic network, on the other hand, links stationery village eye care clinics only that are not financially viable for widely spread tribal villages with very limited local resources to sustain such facility. Moreover, its difficult to find health care personnel to run those centres in a remote area inhabited by Tribals. The MTV project attends both these barriers.

6. Project implementation (Suggested limit: 1,000 words)

The mobile eye care van facility has already been tested in the region. The primary partner of the project, Guwahati Medical College, already has a mobile eye care van in operation. However the remote consultation access through Wi-Fi technology will be tested during this project in the first phase of the program. The preliminary findings of the operation shows the need to reach the remote communities, especially in the Tribal areas, with advanced facilities, equipment and access to specialty consultations with senior doctors and surgeons based in the major hospital.

The Telemedicine centre of Gauhati Medical College was started in January, 2003. Assam Electronic Development Corporation (AMTRON) acted as the nodal agency in implementing the project in Gauhati Medical College Hospital. The computer hardware and satellite antenna as well as the transponder time in INSAT were provided by Indian Space Research Organisaton (ISRO) free of cost. The centre has connectivity with several telemedicine centers of the country. Prominent amongst them are AIIMS, New Delhi, Narayana Hridalaya, Bangalore, Sankar Netralaya, Chennai, S.R.Medical College, Chennai, Trivandrum Medical College, Amritha Institute Of Medical Sciences, Cochin etc. The centre provides free tele-consultation for the patients of GMCH. A pilot project to link up with mobile centers temporarily set up in some remote rural areas is already taken up with ISRO.

The new technology of Wi-Fi access has been already been tested in South India where Intel and UC Berkeley researchers have built an experimental long distance, high-bandwidth, point to point Wi-Fi network to connect the vision centers to Aravind Hospitals (India). That will enable rural residents to have video consultations with doctors, eliminating the need for patients to travel to the hospital for routine eye care. The collaboration is part of the UC Berkeley TIER (Technology and Infrastructure for Emerging Regions) project, which is tackling the challenge of bringing the information technology revolution to the developing regions of the world. The prototype networking infrastructure was tested and validated at the first three vision centers deployed, at Bodinayakannur, Ambasamudram, and Chinnamanoor. At Bodinayakannur and Ambasamudram, the researchers replaced existing low bandwidth (33Kbps) wireless links with the new high-speed links. Intel and UC Berkeley researchers installed the links at two of the clinics, but the Chinamanoor link was largely installed by local technologists as the TIER team has trained local providers as well as hospital network administrators in order to ensure continuity. In May 2006, local technologists installed two new links, at Periakulum and Aundipatti, with no help from the TIER researchers. The goal is to have all future installations done locally. The first three vision centers established—at Bodinayakannur, Ambasamudram, and Chinnamanoor—screen about 1,500 patients each month. (Numbers are not yet available for the two other centers, which came online in May 2006.) Roughly 5-10% of patients—already nearly 100 people a month—experience significant vision improvement as a result of treatment, usually via cataract surgery.

7. Project Beneficiaries

It is estimated that out of approximately 31.4 million people living in North-eastern India, about 8.1 million are tribal people. Among four of the seven north-eastern states, tribal people are in majority. Arunachal Pradesh is made of approximately 24 major tribal groups, which constitute about 64% of its total population. In Tripura Tribal groups constitute 29%, and in Assam 12%. North East India represents a sort of ethnological transition zone between India and neighboring China, Tibet, Burma and Bangladesh. It is located between 22O north latitude and 29.3 north latitude and 89.7O east longitude and 97.8 east longitude. North East India has an overwhelming and almost incredible ethnic diversity. It is to be noted here that the overwhelming majority (89.86%) of the tribal population of the region is rural.


The base hospital (Guwahati Medical College) treats about 30,000 patients annually, coming from different parts of entire Northeastern region, annually of which about 3,000 patients are treated surgically. With the Tele-linked Mobile Eye Care Van we expect to extend the facilities to cover an additional 50,000 patients annually in tribal areas reaching a target of 100,000 patients in the 24 months of project period. The Mobile Eye Unit of the Guwahati Medical College is well accepted by the people and communities have whole heartedly hosted the facility in various locations indicates that a similar participation from the stakeholders/communities can be expected in case of the present project.

8. Results (Suggested limit: 800 words)

a)

b)

Health:

• More acceptable community based eye care services.

• Identification of vision problems among both school and non-school going children.

• Early stage vision restoration / improvement by treatment/surgeries/spectacle prescription to prevent otherwise unavoidable loss of opportunities.

• Reduction in eye diseases that are carried from polluted water, air and environment.

• Access to quality eye care facilities and quality public health facilities correlated with eye care.

• Rural eye care addressed both at the micro level (district and community) and at a holistic level, with genuine efforts to bring the poorest of the population to the centre of the national eye care programs.

Nutrition

• Increased community awareness about the causal relation between nutrition and vision.

• Prevention of unnecessary blindness in children and promotion of good community eye health and nutrition through education, training, and screening programmes.

• Establishment of a long-term perspective plan exclusively for rural eye care with special emphasis on awareness in nutrition and vision among mothers and children.

Population

• Empowerment of individuals through increased knowledge, awareness to maintain proper eye health and seek help when needed.

• Attitude change amongst the rural populace to encourage eye health and prevent eye diseases.

• Community ownership and participation in outreach eye care programs.

• Avoidance of harmful traditional practices that can unwittingly lead to blindness.

• Development of a ‘socio-cultural model’ to meet the needs of the rural population with a comprehensive method of eye care delivery addressing the existing inequalities among the tribal communities and rural population.

9. Measurability (Suggested limit: 800 words)

The project aims at increasing the actual number of eye patients treated in tribal / remote communities of Northeast India. Actual number of patients treated, checked as well as surgically operated upon by the Mobile Eye care clinic will be a major indicator of success. These numbers will be tabulated across social status, economic criteria, and affordability of access and then compared to the cost of self-financed services delivered. At the same time awareness generated through the eye care programme conducted in various locations will be another indicator of qualitative success. These indicators as listed below will be measured during the evaluation and monitoring stages every 6 months through suitable designed pre and exit tests.

Quantitative Indicators:

1. Number of patients diagnosed / checked

2. Number of operations done

3. Number of villages / communities / locations covered

4. Decrease in the number of eye infection in a target area

5. Number of referral cases

6. Number of vision restored

7. Number of spectacles distributed / prescribed

8. Number of doctors / surgeons / paramedics / community volunteers trained

9. Number of children checked

10. Number of patient treated at their place of residence

Qualitative Indicators

1. Increase in community awareness about the causes of preventable blindness.

2. Change in approach to the health care delivery in rural areas and to marginalized communities.

3. Consolidation of long-term perspective plan exclusively for rural eye care among health planners.

4. Attitudinal change amongst the rural populace that will encourage eye health and prevent eye diseases.

5. Community buy-in and participation in rural eye care programs.

10. Organizational Sustainability: Project Team and Partner (Suggested limit: 800 words)

Applicant Organization: Growth

State Rural Technology Promotion Council (SRTPC), set up by the Govt. of Assam vide notification no. IGN(E)/99/5 dated 7/6/99 as a joint venture. SRTPC focuses on Rural Technology Transfer, R&D in Human Development, and Information Technology based initiatives in rural areas focusing on population, health, labour, poverty issues, quality of life, education, social infrastructure, diversification of economic activities and migration. SRTPC is driven by a long-term vision of improving the pace of rural development, health service delivery and alleviating poverty in rural areas by using appropriate technologies and building technical skills and facilities. The organization’s strengths are the five features of its working approach:

• Council will work on a Public-Private Partnership (PPP) paradigm that will, in fact, be a “integrated collaborative network” of several institutions – Governent Departments, private institutions, NGOs, international organisations, training centers, universities, community based workers and civil society.

• The Council will carry out its functions by optimising ICT applications, particularly those that enable the creation and deployment of content databases based on learning objectives.

• The Council’s programmes are expected to be tailored to the realities of the people, imfrastructural and other opportunities of the region.

• The Council will be as much concerned with “adding value” to the ongoing programmes of the state and union governments in the areas of rural health.

• It will do so by joining the monitoring and evaluation mechanisms anf providing feedback on the achievements of the programmes.

To date the council has successfully undertaken following activities:

1. Development Research with training, monitoring, evaluation and dissemination of development information targeting socio-economic development of the rural poor.

2. Human Development research focusing on population, labour and poverty issues relating them to quality of life, education, social infrastructure, diversification of economic activities and migration.

3. Natural Resource Utilization and Management through interventions like Participatory Irrigation Management, Watershed Development Programmes, Joint Forest Management and Protected Area Management. Examine economic viability, equity and institutional mechanisms and explore the inter-relationship between community based management, the government and NGOs.

Regional Program: SOUTH ASIA DEVELOPMENT GATEWAY

Through a partnership alliance with country development gateways and in collaboration with the Development Gateway Foundation (DGF), the State Rural Technology Promotion Council (SRTPC), Assam (India) has taken the lead in initiating South Asian Regional Development Gateway (SARDEG) to overcome the development communication gap in the region and utilize the new forces of ICT to promote social and economic growth in the region.

SRTPC has also collaborated with the United Nations Economic Commission for Africa (UNECA) and supported UNECA’s activities at the international level by providing technical expertise. It has been involved in various UN projects in Asia and Africa and worked in countries like Cambodia, Rwanda, Ethiopia, The Gambia, Ghana, Uganda, Kenya, Sudan, Egypt, Tanzania, and Sierra Leone. Its latest missions include e-Government Strategy for the Gambia (Published by UNECA) and National ICT Policy called NICI Policy and Plans for The Gambia, Regional ICT Strategy for COMESA (Common Market for Eastern and Southern Africa), and the Regional e-Government Framework for the East African Community commissioned by UNECA.

The Council has an Executive Board that is guided by a broad advisory board in various sectors like ICT and Health. The Council’s accounts are audited following the government departmental audit procedures. The council is major part of the government’s technical organ employing more than 500 Engineers, specialists, project managers, policy developers and other supporting staff.

The council has regularly held rural health care camps and experimented with tele-medicine programmes. On the information technology side the council has all the necessary expertise and engineers and it will be supported by the government owned Guwahati Medical College on the ophthalmic specialty side. Together it will be a joint team of highly experienced engineers, doctors, surgeons and project mangers that will ensure the successful implementation of the project.

Project Team:

Name	Designation	Position in Team
Dr Baharul Islam, PhD	Chairman & CEO	Team Leader
Dr. C.K. Baruah, MS	Director-cum-HOD	Lead Surgeon
Dr. P.K. Goswami, MS	Professor	Surgeon
Dr. (Mrs.) Deepali Deka, MS	Professor	Surgeon
Dr. (Mrs.) Anamika Saikia, MS	Asso.Professor	Surgeon
Dr. Deepak Bhuyan, MS	Asstt. Professor	Surgeon
Dr. (Ms.) Shubhra Das, MS	Asstt. Professor	Surgeon
Dr. (Mrs.) Jyoti Bhuyan, MS	Asstt. Professor	Surgeon
Dr. (Mrs.) Kabita Borah Baishya, MS	Asstt. Professor	Surgeon
Dr. S.K. Bhuyan, MS	Asstt. Professor	Surgeon
Dr. N.K. Bora, MS	Asstt. Professor	Surgeon
Dr. (Ms) S. Sarma, MS	Asstt. Professor	Surgeon
Dr M M Alam	Registrar	Coordinator (Network)

Main Partner Organization:

The Regional Institute of Ophthalmology, Guwahati Medical College, Guwahati, was established in the year 1985, under the National Programme for Control of Blindness. It is a premier Ophthalmic Institute catering to the needs not only of Assam but also of the entire North-East Region. Other NE states like Meghalaya, Mizoram, Manipur, Nagaland, Arunachal Pradesh, and Tripura refer their eye patients to this institute for advanced diagnostic and treatment facilities. It treat around 30,000 patients annually. A number of projects are going on in this Institute, viz.,

• Screening of Diabetic Retinopathy

• Small Incision Cataract Surgery

• Posterior Capsular Opacification (Cataract ) in young children,

• Use of Antimetabolite in filtration surgery

• Retinoblastoma Study

• Survey of Visual Impairment in School Children

• Use of Mitomycin C in Complicated D.C.R.

• Anterior Suspended Flap D.C.R.

• Correlation of I.O.P. with Corneal thickness

• Clinical study on Dry Eye

• Ocular Disorder in School Going Children in Urban and Rural Areas

• Ocular Morbidity in Head Injury

The RIO, Guwahati will provide all the necessary technical expertise on the eye surgery, maintain the duty roster of tele-ophthalmic consultations and monitor the follow-up referrals at the RIO Base hospital. It will host and support the project with necessary evaluation studies in its PG programmes.

11. Team leader (Suggested limit: 300 words)

Dr. Baharul Islam a senior Telecom and Information Technology expert who has worked with UN Economic Commissions for Africa (UNECA), Asia and the Pacifc (UNESCAP) since 2003 will be the Team Leader for this project.

Dr Islam has long standing experience in Information and Communication Technologies (ICT) sectors and executed many ICT for Development (ICT4D) projects across the continents. As the Chief of the Rural Technology Promotion council he is in a position to marry diverse sectors like Ophthalmology and Telecommunication with the three major roles – project manger, technology expert and coordinator of telecom regulatory authorities of the government. His background includes supervising rural ICT deployment programs like community information centers (CIC) in the Asian countries. A recent work of Dr Islam includes a scrutiny of the ICT devolution for the rural usage in the region on behalf of the UN. The major plus points in putting Dr Islam in lead role are :

• Experience in ICT For poor / rural areas – International exposure in India (Asia) and Africa.

• Strong academic background in both technology and telecom side as well as in ICT policy and legal issues.

• Supervised major international projects on multinational level with multi-donor funding.

As far this project is concerned we had to make a difficult choice between the a ICT lead person or a medical expert as the leader. We decided to put Dr Islam on the lead as the ICT implementation and coordination side plays a greater role in the success of the idea. However, Dr Islam will work closely with the main partner on medical side lead by a very senior Ophthalmic surgeon Dr C K Barua, Director of the Regional Institute of Ophthalmology, Guwahati who will lead the team on medical side.

12. Risk Evaluation (Suggested limit: 400 words)

The potential risks in this project are three dimensional:

1. Operational: The Aravind Eye Hospital operated Wi-Fi access and VSAT connected Ophthalmic centres in South India in more or less plain areas whereas we have to consider the transmission problems in the hilly region of the Northeast. To address this we will identify plain tribes areas for a pilot project in addition to a hilly region. As the technology of connecting the MTV with base station stabilizes we will move towards hill tribes areas. However, the project will still cover the target beneficiaries ie, the Tribals in the region to the projected number.

2. Managerial: The joint operation of the project involves technology management by telecom engineers while the medical management remains with doctors in the team. There is potentially some risks of management issues. We can resolve this issue by proper orientation of the doctors in ICT and the ICT specialists in eye care.

3. Financial: The cost of operating the MTV for Tribal people will be more than the revenues gained from charging other patients for paid services. On the other hand, moving the MTV further into services for the largely urban centered ‘paying patients’ might make it difficult to help Tribal people. Therefore, address this challenge in deciding the routes (via some “revenue generating stops” on way to Tribal areas) and target stations/destinations, an optimization will be performed through some preliminary exercises and operations. In fact, we have kept this kind of ‘resource mapping’ exercises in the 13-18 months period of the implementation plan specifically to resolve this issue.

13. Growth Potential (Suggested limit: 600 words)

Lack of specialized eye-care facility is a major problem for the rural population in India and it is a major challenge across many South Asian countries. Both the advanced mobile eye care van and the Wi-Fi communication technologies can be replicated in similar locations and regions elsewhere with technical blue-prints and operational models from this project. With satellite uplinking facilities, the training / operation can be transmitted in real time to other medical institutions in the region. With the basic model of the mobile van and Wi-Fi communication architecture developed by the project, it can be easily scaled up for other regions / countries at a much lesser initial efforts and costs. With the basic central hub of communication permanently set up at the regional institute the number of mobile facilities can be increased with minimal connectivity and equipment costs for each additional van.
If the first deployment and operational run of the MTV in Tribal areas breakeven as expected, (as happened in South India) the project will meet the prerequisite for sustainability. However, the challenge is to reach the breakeven point faster than three years (Aravind Hospital) – in 24 months to be precise. It is