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Abstract:
Modern medical technology and medical experts do not provide significant services to rural population in developing countries due to acute shortage of both. The medical specialists are mainly concentrated to urban areas. Most rural health workers are less qualified but could improve their performance significantly, provided they get access to simple, reliable and affordable medical equipment for proper diagnostic purpose, and access to medical experts for consultation via telemedicine support. In this project, we plan to continue our work with ICT for creating an enabling Environment, building Human Resources and develop Applications and Content, for rural development, taking into account the importance of national contexts and population characteristics. We propose to deploy handheld, reliable and affordable medical devices for monitoring and diagnostic purpose, and to follow up treatment. These devices can be connected to a laptop with expert system and Internet connectivity for analysis by the health workers or for transmission of medical data to a remote team of expert physicians to establish dynamic linkages to existing knowledge, experience, processes and action. Mobile telemedicine system proposed in this project would be demand- and market-driven, with space for innovation and creativity for other rural activities, and should be attractive in any remote areas with limited economic resources and shortage of experts. The project is planned to be implemented in the district of Magura in Bangladesh, where with SPIDER funding, a rural ICT centre for education and training has been set up, and with Grameen phone initiative ten Community Information Service centres have been developed.

Keywords. ICT4D, Rural health care providers; smart medical devices, Telemedicine applications; Rural development in developing countries

1 Background:
Health care facilities in many developing countries in general are very inadequate and inefficient. While most of the developing countries have their major population living in rural areas, qualified medical doctors are not available to work in rural areas. Health care workers and paramedics are largely responsible for the rural medical care. Millions of people, especially women, children and elderly die each year due to insufficient health care, mainly due to lack of competent medical personnel. Having health gives a person the opportunity to escape poverty. At that same time, as people earn money, their health will improve. “Income is the best medicine for the poor.” Said, Dr.Yunus, Nobel laureate of 2006. An important question is: How to bring a rapid change for rural people in the developing countries that have no access to specialist health care? The answer is to empower the available health care workers with modern ICTs that include technologies designed to access, process and transmit medical information. This would enable rural health workers to send vital medical data to a medical specialist for second opinion. However, convincing evidence regarding the cost-effectiveness of mobile phones as a "telemedicine" intervention is limited and good-quality studies are rare in less developed countries. Although sophisticated medical technology is available on the market, there is an acute shortage of simple, reliable and affordable medical technology that could be used by the rural health care providers in the developing countries. Even in the large cities, where the number of medical colleges and private clinics are increasing rapidly, the health care sector is facing growing dissatisfaction among the patients due to lack of proper use, management and maintenance facilities, training and education of medical equipment. Moreover, available equipment is not appropriate or affordable to the local conditions (1-5). Improving the health of individuals and communities, and strengthening health systems, disease detection and prevention are crucial to development and poverty reduction. ICT has the potential to create impact in the health sector (6). In developing countries, the issues of acute shortage of qualified doctors and absolute lack of diagnostic medical technology can be met with the potentials of ICT (8-14). The above reasoning provides the motivation for this research proposal.

1.1 ICT activities in rural areas in Bangladesh supported by SPIDER:
Bangladesh can not reap the benefits of ICT if it is confined to selected households in cities and if we fail to take it to the doorsteps of general people throughout the country. The 68000 villages in the country can be a profitable region; and there are successful examples of Grameen Phone’s rural telecommunication initiative. Grameen phone has now undertaken a project to set up about 500 Community Information centres(CIS). Grameen Communication (GC) together with KTH has established a rural ICT centre at Nohata Girls’ college in Magura district with the funding from SPIDER, that was inaugurated in March 2006, by the Swedish Ambassador to Bangladesh in presence of SPIDER delegation and Bangladesh state minister of education (photos below).

ICT provide powerful instructional tool and will become more so. But their potential will not be realised without active involvement of the teachers, and for that they need training in the use of ICT. With the support from SIDA, SPIDER and KTH, Grameen Communication organized several seminars, workshops and training programme at that rural ICT centre addressed to the rural science teachers from high schools and colleges so that they could increase interest for science education among the young students (11,12). Teachers are the key change agents in education and play the crucial role in deployment of ICT in class room. Workshops for rural health care providers were also organised, where some diagnostic medical devices and benefits of telemedicine systems were presented (photos below).

This kind of work would function to reduce the digital gap by improving Internet access and developing rural capacity in the rural areas (13-14). A pool of health professionals are going to be trained during July 2007, to use PC, digital camera and some basic medical devices for diagnostic purpose. The seminar and workshops at Nohata rural ICT centre, resulted in a growing list of staff willing to be trained, indicating increasing awareness of the potential of ICT.

1.2 A telemedicine compatible medical device developed through a SIDA funded research project:

Telemedicine compatible medical sensor system has been developed for application in the rural areas in the developing countries. The device can detect pulse rate and ECG that can be displayed on a laptop and can be transferred to medical specialists as attached file to an email. The present system can further be developed and its functionality can be increased by adding multiple sensors to develop mobile telemedicine systems for prediction, detection, diagnosis, monitoring and prognosis of disease and for support and guidance of therapeutic interventions. A medical doctor and a Biomedical Engineering master student, Kamal Ahmed from KTH is currently working to develop low- cost telecommunication systems specially designed for rural primary healthcare personnel in developing countries (. He will be working in Bangladesh during July-August 2007, with testing and evaluating a simple telemedicine system connecting the rural doctors at SPIDER funded rural ICT at Nohata, Magura with a medical specialists, coordinated by Professor Saiful Islam at the Medial University in Dhaka, BSMMU. During the field test, the women and girls will be instructed to use the telemedicine system. Information collected from other ICT projects, reports and documents, site visits, interviews and questionnaires suggest that ICTs can be used as tools that enable desired changes in the performance of institutions and markets, in the livelihoods of poor people that can lead to poverty reduction and sustainable development.

2 Aim of the project:
The purpose of the proposed project is to add values and increase functionalities of the ICT facilities for rural development for enhancing rural health care facilities. The plan involves:

1. Further development of the reliable and affordable telemedicine compatible medical devices for remote and rural application. It is planned to be conducted keeping the major features of the devices in mind, such as; portability, robustness, scalability, data storage and transfer capabilities, display of parameters/waveforms monitored, cost, etc. Modification of the earlier developed telemedicine communication platform for rural application for medical data collection, storage and transmission is also considered.
2. Capacity building involving mostly female health workers with appropriate education and training modules for effective use of ICT for rural development. This would include developing curriculum and methods to employ ICT for rural development, considering users’ background as well as entrepreneurship and business model issues adapted to the local environment. Organisation of seminars, workshops and establishment of pilots would involve mostly female rural health care providers, rural doctors at primary health centres as well as medical specialists from district and referral hospitals.
3. Develop and validate methodology to evaluate efficiencies and cost effectiveness of the mobile telemedicine system for rural health care and ICT modules for rural development in the developing countries.
4. Publish documentation and learning material related to the system and its use openly on a dedicated website to increase ICT4D awarenes

During the work in this project, it is also planned to study:

• How can ICTs contribute empowering agricultural activities to local economic development and social development in communities with low income levels?
• What capacities, measures and resources are required to successfully employ ICTs for social and economic development?

The long term objective of this work is to facilitate efficient use of ICT to promote good health, to prevent and treat major diseases, and to deliver health care, and empower the farmers with modern agricultural knowledge. The long term goal of this work is to develop a telemedicine system suitable for rural primary health centres in developing countries, taking into account of health problems and infrastructure in the rural areas in the country.

3 Methodology and plan of work:
The project addresses the local conditions, based on the experience that has been already accumulated, and enhancing the facilities created through earlier SIDA and SPIDER funded projects in order to create opportunities for the rural people to benefit from the potentials of ICT. Mobile telemedicine system proposed in this project would be demandand market-driven, with space for innovation and creativity for other rural activities, and should be attractive in any remote areas with limited economic resources and shortage of experts (17,18). To develop tools for transforming information, experience & skill to useful knowledge for rural development, the method has three components:

3.1 Creating ICT environment and development of the mobile telemedicine system:
For transforming information, experience and skill into useful knowledge to make the best use of the new opportunities offered by ICT, our plan is to upgrade the rural ICT centres with additional equipment and software, internet connectivity, telemedicine compatible diagnostic devices (Digital thermometer, Blood pressure measuring device, Stethoscope, ECG, Blood sugar detector, Digital camera etc). Mobile telemedicine system will be modified, enhanced and implemented based on the experience acquired from these previous telemedicine projects and systems. Development of communication system will focus on free Open Source software and identifying technologies most suitable for efficient diffusion to developing countries.
The bulk of the technical development work will be conducted in development projects involving senior master level students that are interested in industrializing the results of the project, supervised by the research team members from KTH and IIIT as thesis projects.

3.2 Capacity building, Education and Training:
There are two target groups for the capacity building activities in the proposed project: a) Technical developers and maintainers: They can ensure proper operation, utilisation, management and maintenance of the ICT services and mobile telemedicine system. The education and training of the technical developers and maintainers will be organized using pedagogical methods appropriate for local conditions and capabilities. b) Rural health workers: They will be the users of the mobile telemedicine system, members of the local community (both men and women), community health workers, nurses, students, and staff of health training institutions and colleges, and they will require education and training in the local settings as users of the telemedicine system. They will have to acquire a solid foundation for reliability of medical data acquisition and security aspects of transmission of medical data. KTH, IIIT and BSMMU will design and develop curriculum and instructional material based on suggestions and experience from other related projects. In collaboration with key stakeholders the materials will be contextualized and adapted to meet the international quality and standard, as well as requirements of the local situation. A next step would be to identify the appropriate and effective methodologies in delivering the ICT knowledge and developing skills, considering the multi-disciplinary character of the subjects.

Participants will be trained in evaluating the cost-effectiveness and relevance of ICT
tools. The courses will mainly focus on preparing participants to train colleagues and
serve as ICT resource personnel in their home institutions. Participants will be introduced to a variety of learning styles, instructed in the use of multiple facilitation techniques, and given the opportunity to create. The curriculum and materials for ICT trainers would be provided for a nominal fee. An instructor for the ICT Trainers’ course would be available at no cost for the participants.

3.3 Pilot establishment (application and content development):
The pilot establishment activities include development of skill and capability of offering education, training, involving rural primary health centres as well as district and referral hospitals using relevant ICT systems. Entrepreneurship and business model issues adapted to the local environment and users’ background would also be included. A draft proposal for a rural health care pilot establishment programme is given below:

1. Medical Equipment: Function, Operation, Procurement, Management and Maintenance
2. Basic understanding of the use of computers: Learning Word, Excel and Power Point
3. Internet Fundamentals: Introduction, World Wide Web Concepts, E-Mail Concepts, Composing and Sending Messages, Listing, Viewing, Replying to, and Forwarding Messages, Organizing Messages with Folders
4. Diagnostic decision support tools: Diagnostic quality and clinical management prompted by use of the system.

While working with the establishment of pilots, some important aspects to remember are:
Available experience: Rural women are able to take advantage of new technologies. Often women also require specific health information. Therefore, the participation of women both as managers, pilots and users of ICT should receive specific attention.

Sustainability: Unless the local communities have a sense of ownership of the knowledge management centres, it will be difficult to sustain them. It is only a user driven and managed system that will be replicable and capable of developing a selfpropelling momentum. For sustainability of the rural ICT centres, we are considering revenues from: Grants, Public subsidies in-kind (equipment, volunteers), Community support (rent free building), telemedicine memberships fees, and revenues earned from core business such as :Connectivity (Phone, internet, web pages), Direct computer access to users, Office services (information, consulting) and Telemedicine and also Tele banking.

4 Account of available resources:
The project team led by the coordinators, Islam, Mridha, Nazneen and Srinivas is composed to facilitate a ultidisciplinary problem-oriented approach. The expertise of the team includes medicine, including doctors with local clinical experience, biomedical engineering, medical electronics, sensor techniques, computer engineering focusing on embedded systems, computer science and telecommunications and business management. The service technicians from the Grameen phone (GP) will contribute with technical support, management and maintenance of the rural ICT centres. There is large pool of students with different backgrounds to recruit from for the development work for their real world based project and thesis work. The synergetic ICT development work performed by this group could provide new technological directions for diverse interests and innovative research on application of ICT systems for rural development for application in health, education and entrepreneurial work in the developing countries (13, 14, 20).

The collaborating team has a history of working cooperatively and solving problems, has open and clear communication, and has a plan for continued focus on the desired outcomes and sustainability. The collaboration has identified impacts, and conducted a needs assessment to establish its goals. The history and environment surrounding leadership and decision making is positive in this team work. Political climate in the country may be at times difficult though in the rural areas as a whole it is peaceful. The collaboration has access to local available resources such as, environmental, in-kind, financial, and human. The applicant has policies and regulations that allow the collaboration to function effectively and efficiently. The leadership in the team facilitates and supports team building, and capitalizes upon diversity and individual, group and organizational strengths, and understands the community, including its people, cultures, values, habits, and traditions.

5 Risk factors:
There are certain risks involved such as, frustration regarding unreliability of electricity, risks of mischief within the rural community, security risk for female health workers, inappropriate use of equipment, political disturbances, conflicts between the partners, departure of key people in the project, lack of technical support for management and maintenance. Reliance on foreign organisations may provide a short lived stability to the situation. However, the partners involved in the project have a long term working relations and have earlier worked with the similar projects in Bangladesh. Besides, the local conditions and the stakeholder are well known from working with previous projects. The partners also have a good working relations with the relevant authorities in Bangladesh government as well as NGO like Grameen, to work together to best use of the potentials of ICT, support achieve project goals to improving the quality of rural life.

Multiplier effects: The mobile telemedicine system developed within the SPIDER project can, on a continuous basis, be used for not only at the co-operating rural health centres, but also at other primary health care centres in Bangladesh, and other developing countries. Rural health centres, hospitals, schools and colleges, will recruit the participants, who complete the rural development training programme. Their knowledge and experience will thus be utilised in many aspects. Finally, many R&D-projects on ICT for rural development could be initiated based on the results achieved from this project such as, the rural eagriculture could potentially benefit from similar settings as shown below. An important project objective is to enable farmers to harness the benefits of information and communications technologies to promote economic development and social well-being. The farmers in the developing countries, who have long suffered from lack of market price information and poor access to buyers and sellers, would by provided transparent and timely market information who are both buyers and sellers.

Sustainability: The ICT for rural development programme, developed within this proposed SPIDER project is planned to start in August 2007, and completed in December 2009, and later on a permanent basis, at the co-operating institutions like Grameen Commuication and Nohata University of Health and Agricultural Technology, NUHAT, that is at present under development (www.nuhat.org).

Publications and other outputs: Seminars, Newsletter, Internet web pages and discussion forums will serve to publish the outcomes for awareness creation and also aimed to sensitize policy makers to the potential value of information and communication technology (ICT), thereby promoting investment in ICT equipment and training. The project can enable to increase visibility of the rural health care providers within the international development community, and consolidate their roles as key players in expanding the use of ICT for better health in developing countries.

Impact: The project’s impact would be; reduced disease and illiteracy, fewer people in poverty and greater gender equality, enhanced efficiencies in the agricultural production sector and market. Therefore, the project would make significant contribution to achieve Millennium Development Goals, and SPIDER objectives to support developing countries in the promotion and deployment of ICT for better access to information, knowledge and communication.