News and Events

Telemedicine: Stepping into the Future

Dr Mingma Sherpa, Director of the Logistics Management Division in the Department of Health Services, gave a presentation to the Support to the Safe Motherhood Programme (SSMP) team about his experiences with telemedicine while he was working as a medical doctor in Solukhumbu district, explaining how the Government of Nepal plans to take these techniques forward in the future.
 
1. What is telemedicine?
 
Telemedicine is the use of computer technology combined with broadband high capacity internet connection to enable expert health staff based at one, often central, location to provide professional advice and support to health workers in the field, in peripheral health facilities or district hospitals. Essentially there are two main possible modalities: video conferencing, which is live, or “store and forward”, which enables data and pictures to be sent to the adviser. For most purposes, store and forward is the most useful, since detailed data and X-rays, including pictures, can be sent for the adviser to study and use as a base for diagnosis. All that is required is a computer with the required software and reliable internet connection.
 
Simpler techniques, based on mobile or CDMA phones without a computer, are already increasingly being used to support health workers in remote areas. Each health worker carries a phone through which, by prior agreement, they can access a duty doctor based at a higher referral centre, such as the nearest district, zonal or regional hospital or in Kathmandu. They can receive practical advice on managing a complicated case and/or warn the hospital of the referral needed.  
 
2. The Solukhumbu Experience
 
As one of the remote mountain districts of Nepal, Solukhumbu suffers from the shortages of trained staff and access difficulties common to mountain areas. Seven years ago, the Solukhumbu team established “Rural Health Online”, to address these challenges. From a base in the district centre, the system can request advice from centres in Kathmandu and communicate with health posts around the district. Links have been established to Tilganga Eye Hospital in Kathmandu for advice on eye care and to other pre-arranged centres for advice on rehabilitation for the disabled, dermatology and maternity care support (for which a web partograph has been developed). The system is also used to facilitate emergency referral for cases that cannot be treated locally.
 
Solukhumbu Maternal and Newborn Care Project
 
Each month, Maternal and Child Health workers (MCHW) and Auxiliary Nurse Midwives (ANM) based at health posts and sub health posts send detailed records of all pregnant women they have examined, including new pregnancies detected, to the Village Development Committee Office, where they are collated and sent on the district centre. The ANMs and MCHWs refer complicated cases directly to the district hospital.  
 
Funded by the private donors, Himalayan Health and Environmental Services, a maternity centre has been established with a waiting home, where village women and their companions can stay prior to the birth. There is also a training hall for an ANM training programme established for local women with the School Leaving Certificate (SLC). Dalit and Janjati women from any mountain district are also encouraged to enrol. No fees are charged.
 
Women in Solukhumbu have benefited greatly from this project, as they all know about the maternity services available at the district hospital, that they are free and there is a waiting home, also free. They are well acquainted with their local MCHWs, from whom they can seek advice and help at any time. The MCHWs feel confident that they can refer cases to the district hospital, where they will receive good service free of cost.
 
Running the training course in Solukhumbu has benefited the district by (1) providing career opportunities to local young women and (2) ensuring there are trained nurses available to serve the district. Previously it was hard to get such staff, as women from other parts of the country did not want to work in Solukhumbu. Students from other mountain districts have also benefited.
 
Next Steps for Solukhumbu
 
From July 2008, further developments are planned, including a refresher training package on birth preparedness for MCHWs, provision of mobile/ CDMA phones (with support from SSMP) for all village based MCHWs and ANMs, to enable them to communicate with hospital staff for advice and referral, and a village based ultra-sound project. A small team of trained staff nurses will visit health posts on a regular basis carrying portable ultra-sound machines for providing antenatal ultrasound scans. Women identified as at risk of developing complications can be referred to the hospital for delivery. 
 
3. Government Plans
 
Two major initiatives are planned under the Government of Nepal programme:
 
Ø    Establishment of a central telemedicine unit at Patan Hospital, linked to 12 specialist centres in India, a network that is based in the city of Hyderabad. This scheme, including all equipment required, will be funded by SAARC with each SAARC country being connected to the “Super speciality Hospitals” in India through the Hyderabad centre.
Ø    Establishment of a Nepal network, based in Kathmandu Valley, with links initially to the district hospitals of 25 selected remote and disadvantaged districts. This will eventually be scaled up to all districts.
 
4. SSMP Support
 
SSMP is looking at ways to use the Solukhumbu experience to improve maternity care for women in other remote areas, linked to the development of a remote areas referral strategy. Initially, plans are being considered to issue health workers in remote areas of the 19 SSMP supported districts with mobile or CDMA phones, which they can use to directly contact district or other referral hospitals for advice and referral. This would improve immediate recognition and management of complicated cases and speed up referral. A further development would be the provision of computers and software for programme districts, to enable more focused and detailed advice to be provided through the CDMA phones.

01/08/2008 Ashima Shrestha SSMP