ICTworks

In February 2008, The Health Metrics Network (HMN) convened experts in Geneva after many months of focused organizational, advocacy and educational efforts in several countries.

The goal of the event was to test interoperability of core elements of a district-level digital health solution that would be repeatable across the dozens of countries in which HMN is currently working.

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Inveneo participated in this meeting and what follows is a brief discussion of four key ICT challenges identified by the HMN working group and how Inveneo is seeking to overcome them.

Power Challenges

Lack of consistent and affordable electricity is the single greatest challenge in designing a computing infrastructure for rural health informatics (or any other application for that matter). The vast majority of health facilities in remote parts of the developing world have no mains power and, where available, such power is usually extremely unreliable or so unstable that it poses a threat to unprotected electronic equipment.

Among off-grid health facilities that nevertheless have power, diesel generators are the most common source. But increasing fuel costs and on-going maintenance problems mean that generators are seldom run for more than a few hours a day (often only during medical procedures that require powered equipment) and are prone to abrupt and unannounced failure. Alternatives such as solar power are simply cost prohibitive when deployed to support standard computing hardware.

Pending the decades long process of extending stable, grid power to remote communities or the advent of an entirely new computing paradigm, the logical immediate answer to this challenge lies in low-power-consuming hardware. Fortunately, hardware now exists that is cost-effective to run on solar (or other renewable) or in partial-grid power.

For example, the Inveneo High-Efficiency Computing Station (PDF) draws just 17 watts of power, compared with 50+watts for a typical laptop, well over 100w for a new desktop and over 150-200w for an older workstation with CRT monitor.

Along those same lines, the Inveneo R4 Hub Server draws under 30 watts, compared with 200w or greater for many new servers.

Due to a number of factors, including increased energy cost, the market shakeup due to the proliferation of mobile platforms, increased focus on “bottom of the pyramid” opportunities, not to mention pressure from Inveneo and other integrators, chip makers are now paying more attention to power efficiency, which should increase availability of processors that can support cost-effective health applications in the developing world.

Efforts are also underway with DHIS2, OpenMRS and other health applications to minimize their system resource requirements and on other ways to improve overall performance on low-power, energy-efficient hardware platforms. This work is a prime example of where closer collaboration between hardware designers and those working on health applications can lead to better integration, repeatability and performance.

Environmental Challenges

The physical environment in most rural and remote settings is characterized by some combination of heat, dust and humidity, each of which is a challenge for standard computer hardware. High speed CPUs generate enormous amounts of heat that, if not properly dissipated, reduces performance or can render these systems inoperable.

Dust threatens sensitive electronics by shorting circuits and impeding airflow and heat dissipation. Humidity leads to condensation, corrosion and even mold, all of which can cause electrical problems and possibly shorten equipment lifespan.

Besides reducing power costs, power-efficient computing also helps to resolve these environmental challenges. CPUs with slower clock speeds generate less heat and, with appropriate thermal design, can be deployed without fans. This allows computer enclosures to be better sealed against these threats as well as vermin of various sorts.

Fewer moving parts also means greater reliability and lower overall operating costs. In exceptionally remote and/or hot environments, solid-state flash memory can be substituted for hard drives, which are prone to failure in extreme heat and are a common failure point requiring support.

Connectivity Challenges

Lack of affordable connectivity and bandwidth is the primary obstacle to several of the most promising health applications for rural areas, including tele-medicine and other real-time diagnostic support and training initiatives. Lack of internet access also complicates more basic efforts to collect and analyze health information.

For example, managing electronic medical records for peripatetic patients requires some means of accessing patient information from multiple locations. Similarly, accurate and timely health statistics are extremely difficult to compile in the absence of some form of connectivity, as is managing logistics or other key processes. Finally, lack of reliable connectivity complicates core IT functions, such as systems updates and virus control, thus increasing costs while reducing use value.

Once again, however, tools now exist to overcome these challenges for a growing portion of the communities in questions. The dramatic expansion of cellular networks across Sub-Saharan Africa means that affordable data services are now available for the first time in many areas.

Although most cell networks do not yet provide high-speed connectivity (at least not in rural areas), they can support a number of valuable asynchronous and low-bandwidth applications, like email, which are easy to use, powerful and sustainable. As these networks expand and are upgraded, they will provide crucial connectivity for a large number of rural communities and will be better able to support data-intensive applications.

Open protocols, such as WIFI, and durable off-the-shelf products offer an alternative, often complementary, approach. Work done at UC Berkeley in the TIER group’s the “WILD” project and elsewhere has adapted the core protocols for WIFI to allow increased bandwidth over long distances. And equipment maker Ubiquti has developed a comprehensive line of durable yet inexpensive WiFi antennas that Inveneo has certified as appropriate for rural wireless networks.

The technology relies on line-of-site, but for less than $1000 it is now quite simple to create a reliable broadband (6mbps) link over distances as great as 100-200km. Such links can be used to extend low cost Internet connections in urban settings to the near periphery at low cost or to share a VSAT connection to multiple facilities in more remote settings.

Even in the absence of Internet service, this approach can support high-speed networking among health facilities to deliver access to shared resources, tele-medicine, tele-training, VOIP telephony or other applications that require higher bandwidth.

Still, while connectivity options are improving, careful design for low-bandwidth and delay tolerance remain critically important. Only systems-level design that accounts for system resource as well as networking constraints can support this objective.

Human Resources and Other Non-technical Challenges

As important as these physical and infrastructural challenges are the many human factor and institutional obstacles to sustainable health information solutions in underserved areas. A partial list of these includes:

• Inexperienced computer users
• Lack of trained technical support
• Absence of defined, action-oriented health indicators
• Uncoordinated or absent governance mechanisms
• Inadequate oversight and/or incentives for health workers
• Widespread poverty and associated security risks

It’s worth noting that to succeed health information solutions for rural and remote environments must accommodate inexperienced computer users and novice administrators, not visa versa. This is true both for usability and resiliency. In settings where users may be encountering a mouse and keyboard for the first time, an intuitive and simple interface are critical – “less is more.”

Health Information Stakeholders Meeting: Kono District, Sierra Leone

One way to do this is to “lock down” the file system of the computers so that users cannot inadvertently delete system files or install viruses or other malware. If the system does somehow become mis-configured or infected, a simple on-off cycle will return the machine to its originally configured state.

Server software can include similar controls that streamline and simplify the process of configuring and managing workstations and system resources connected to a local or wide area network.

Conclusion

It is increasingly clear that information is the lifeblood of a healthcare system. Accurate, timely and accessible health information strengthens literally every part of the system, from policy making, to clinical treatment, to logistics and training. In contrast, inefficient health information systems suffer from an informational anemia that weakens the entire system.

Sadly, all too many health systems in the developing world still suffer from the equivalent of information shock; a system-threatening condition characterized by the inability to generate, access or act on even the most essential health information.

Success or failure of ICT deployments in rural healthcare depends on access to affordable, integrated solutions that are both sustainable in low resource settings and customizable to local conditions. Inveneo is actively developing and deploying such systems specifically to address this need.