A SYSTEMS MODELLING APPROACH TO AN ICT-SUPPORTED COMMUNITY HEALTH MODEL

Nomita Das
122 Connell Crescent
London W5 3BP
E-mail: nomita_das@rediffmail.com

Abstract

More than 2.5 billion people - over 40% of the planet's population- live in rural and remote areas of developing countries[1]. The potential of Information and Communication Technology (ICTs) and their consolidation with appropriate strategies and concepts to deliver to the needs of rural communities is enormous.

Key Words: Information and Communications Technologies, Community Health Model, Soft Systems Modelling, Information Network.

1.Introduction

The focus of the article is on the capabilities of locally appropriate ICTs in the fight against TB at the grass-root level in India. Parallels have been drawn wherever appropriate with national and international efforts of ICT-supported activities in healthcare, social and economic development. Each case has been carefully scrutinised to confirm the presence of the necessary elements which make it possible to replicate such initiatives in the context of TB management.

Although the focus is on India the principles drawn from the research may be applied to healthcare management in most developing countries who share similar economic and social set-ups. The author hopes this article will be of value to professionals and students engaged in public health issues and specifically in how ICTs may be employed in TB inflicted communities.

1.1 Methodology

Checkland's 7-stage Soft Systems Methodology (SSM),Figure 1,is used here as the defining framework[2]. Checkland's approach is a form of systems thinking which regards outcomes of a system as being the product of its interactions rather than as the sum of its parts. The methodology was specifically developed to deal with social or human systems and their transformation which are not easily modelled numerically. In this article Checkland's SSM is further supported with diagrammatic representation of sub-models wherever applicable and thought useful.

A model is a logical description of how a system behaves. Dynamic modelling (also known as simulation) involves designing a model of a system and carrying out experiments on it as it progresses through time[3]. This article uses a simulation technique to depict how the real-world activity or concept is mirrored by it. To close the gap between hypotheses and actual phenomena the explanation of the model is intertwined with reviews of real-life case studies. This demonstrates the replicability and ecological validity of the conceptual model.

1.2 Discussion

When we consider an ICT-supported community development project for a specific disease, namely TB, we have narrowed our focus tremendously from the huge healthcare sector but even this small physical area of work holds all the ingredients of its larger host and is well connected to the future survival of the latter. Therefore each small initiative may be regarded as a small clog in the massive healthcare machine and for the machine to perform effectively each of these clogs have to operate in an integrated fashion. Complete isolation of operations can be highly detrimental to the bigger public healthcare system. This is why a systems modelling approach is so vital and therein lies the potential of ICTs to provide that essential link and flow among operations.

The rest of the article now elaborates each stage in Checkland's 7-stage Soft Systems Methodology, from A-G, in the context of TB management, performing specific tasks relevant to each stage

Stage 1( A) Problem situation considered - B urden of TB in the village/block

The typical rural health infrastructure in India is a three-tiered system consisting of sub-centres for every 5000 population, Primary Health Centres (PHCs) for every 30,000 population and Community Health Centres (CHSs) for every 1,00,000 population. The burden of TB in rural India TB is enormous.

Stage 2 ( B) Problem situation - Lack of TB information and information flow between relevant stakeholders .

The lack of TB informationamong rural health professionals and patients has been a major obstacle in the fight against the disease. In 2001, Health and Development Initiative-India, conducted a survey to gauge the awareness level of health professionals in the state of Punjab about Directly Observed Treatment, Short course( DOTS), and to gain an insight into the process they follow while treating TB patients[4]. Some important conclusions drawn from the survey were:

• The knowledge of health professionals is woefully inadequate as regards the technical guidelines of the Revised National Tuberculosis Control Programme(RNTCP).
• 33% respondents have not heard of DOTS as a treatment modality for treatment of Pulmonary TB(PTB).
• 91% respondents did not even know the full form of DOTS.
• Only 42% respondents consider Sputum examination for Acid Fast Bacilli(AFB) as an appropriate tool for diagnosis of PTB.
• None of the respondents considered it essential to determine the HIV status of their patient before commencing treatment.

Most doctors are inclined to base their TB case management based on misbeliefs emerging out of a lack of standard sources of information.

A second interview was conducted by the Health and Development Initiative in 2001, with 25 private practitioners of Amritsar District in Punjab with the objectives to assess the load of TB patients in their practice settings, determine their current level of involvement with National TB Control Program (NTP) and explore the role for private practitioners in TB control[5]. The following messages were drawn from results of these interviews:

• The awareness of Private practitioners (PPs) was awfully low about NTP guidelines. Only 12% actually ask of Sputum examination for AFB in patient with a cough lasting for three or more weeks.
• The public health system seems to have consciously chosen to keep PPs out of the purview of the NTP. All the respondents had never been contacted by NTP managers to inform them about its guidelines.
• The opportunities for PPs to acquire knowledge about latest in TB control and management do not exist in the field. 64% of those interviewed never had an occasion to participate in a CME program on TB control.
• 80% of PPs do not maintain any record of patients under their treatment and all of them do not have any system to trace a defaulting patient.
• Only 16% of them have access to the Internet and expressed a preference to receive information via internet/ e-mail.

Both these surveys showed an appalling lack of TB information and the obvious desire of the respondents for means to fill these information gaps.

Stage 3 ( C ) Root definitions of relevant purposeful activity steps - "A proposed ICT-enabled framework to establish a community multimedia information hub primarily for TB related activities where all these activities will be supported by one or a combination of the multimedia present thus improving the TB information needs of the community".

Five elements of the root definition:

1. Customer(C)- All beneficiaries/stakeholders of the ICT project

2. Actors(A)- Project implementers representing the government, NGOs, private companies, voluntary sector, researchers and the local community among others

3. Transformation(T)- The present information gaps will be filled with the use of ICTs. Hence all TB-related information needs in the community will be changed from their current nature of distribution to be supported by one or other form of available ICT. In the long-run these communities working in isolation in their fight against TB will be connected with an ICT-supported network.

4. "Weltanschauung"(W)- Worldwide view which makes the (T) meaningful- ‘The potential of locally managed, cost-effective ICTs in transforming rural health is enormous.’

5. Owners(O)- Elements which could terminate the system- Funders, donors, politicians, bad policy making, resistance by the village community.

6. Environmental constraints(E)- The current telecom policy, national health policies on TB management, the current available locally viable technological know-how.

The root definition may be further stretched to incorporate a business model. Best & Maclay(2002), Table 1, have identified at least six broad categories that must be considered for economic self-sustainability especially in rural India[6].

Table 1: Nature and Level of Interactivity between Factors Affecting Rural Internet Sustainability

Source: Reproduced from Infor mation Technologies Group. Centre for International Development at Harvard.

Best&Maclay(2002) also believe that the varied interests of all the stakeholder groups should converge around such projects and for this a market approach or business model is required which is driven by the private sector and entrepreneurs[6]. Rural ICT projects are intrinsically concerned with creating demand. We are often dealing with populations who have never used a telephone before or who have no idea whatsoever about how an ICT framework would benefit their health needs. The solution to attitudes such as , "We have carried on just fine and don’t see how this will benefit us," is to create a demand for ICTs and this involves raising awareness about the potentials of ICTs. In this sense the role of the otherwise insignificant village information broker such as the storeowner, the ICT kiosk operator can be instrumental in educating the community. This is connected to the concept of ‘ICT intermediaries’, persons or organisations who are owners of ICTs and can thus act as ‘gatekeepers between cyberspace and the organic, informal information systems of those on the wrong side of the digital divide’[7]. Such a participatory approach also gives impetus to research that the demand for ICTs in rural India are driven by need and circumstance and not by income[8]. Even the poor are willing to spend on ICTs. This implies three things:

• ICT interventions may start by first addressing basic communication needs rather than advanced applications
• Telecentre services provided more cheaply than currently available will increase demand even more.
• The demand and willingness-to-pay combination indicates future economic sustainability of such projects.

Figure 2 is a conceptual model of such a business backdrop, showing a combination of government policy, the legal and regulatory systems and financial institutions. Here,

Customer =Patient,rural health worker

Figure 2:Business Model for Engagement of Stakeholders

Stages 4 and 5 (D&E)- Conceptual models of the systems named in the root definition, and, Comparison of the model and the real world - TB information needs assessment and all information in (D) assessed in light of real-life case studies

Communities vary greatly in their socio-economic and cultural structures and therefore information needs, and the design of the most relevant community networking model will vary from place to place and over time for a given area. It is also important to remember that the information needs analysis may show that ICTs may not be extensively required to fulfil the information needs of the people. Therefore ICTs may have to be incorporated in a complementary role to the existing structure and not totally replace it[6].

Crowder(1991) sums up the importance of a participatory and systemic approach by stating that to be effective it is essential to look beyond the technologies "to the social and economic systems in which the media function and how these systems influence media access, exposure and impact".[9]. Therefore when selecting a location for an ICT-supported TB project, pre-conditions/pre-feasibility considerations include–

• prevalence of TB in that region
• the level of potential demand for communication and information services from a large number and a wide range of users.
• Investigating the existence and proximity of the proposed framework to organizations and institutions that can play roles in using, supporting, maintaining or operating the ICT centre. Example, health centres, community centres, religious centres, government offices, radio and television stations.
• Ease of access to potential users ( near public transport or within walking distance); the availability of an existing structure( school building, library) or a new structure which is suited to use as an ICT centre; access to electricity and connection to telephone lines(terrestrial or satellite link). Ref HIN India.

Once the location has been agreed on the next step would involve assessing local information needs and skills of the relevant stakeholders with regards to TB management. For sake of brevity, Figure 3, focuses on the information needs of the rural health worker only. This approach may however be used as a guideline to include any and all stakeholders.

Figure 3 , Sampling procedure. Adapted from Health InterNetwork-India 2002

It is important at this stage to establish a baseline of the current information usage. Here we could define ‘information gap’ as the observed disparity between the established baseline and the information the stakeholders demand.

An information needs assessment could focus on the following areas:

• Current access to information in terms of speed, ease and relevance.
• Existing levels of health information among beneficiary groups with respect to tuberculosis
• Beneficiaries’ perception about the types of information they needed

Research has shown that with the available technology a village in India can be connected to the Internet and other multimedia devices for under US$1,000 in capital costs and ongoing recurrent costs of US$60 per month[10]. For a conceptual model of a multimedia rural telecentre supporting TB information needs, a model like Figure 4 may be considered:

LSP-Local Service Provider

Figure 4- C onceptual Model of a Multimedia Rural Telecentre

Channelised flow of information is important. Therefore data from three locations may be compared; e.g, hospital records showing cases of TB, the dispensary showing how much medicine was sold and the school showing how many children were sick from TB during the same period as shown in Figure 5

HOSPITAL SCHOOL DISPENSARY

Figure 5: Channels of Information Flow

This bottom up exercise involves local participation to access information at the kiosks via the Internet or other device. The kiosks or ‘information hubs’ may be situated in communal buildings, temples, or even a local shop.

We now look at some of the ICTs that may be used in a community model. Each ICT chosen is further substantiated with real-life examples of how it is being used in similar activities worldwide.

1.2 i The Community Radio Tower/Centre

The radio is the most widely used communication device in rural India. One major reason for its popularity is low costs and portability. As opposed to a community telecentre which typically requires an investment of US$50,000 to US$100,000, a community radio centre can be launched for less than $10,000[11].Therefore the radio as a means of dissemination of TB-related information is a powerful option.

Uganda has a high maternal mortality rate estimated at 506/100,000. The Rural Extended Services and Care for Ultimate Emergency Relief (RESCUER) project was launched in March 1996[12].A study was carried out in July 1999 to investigate the effect of ICT, namely radio, on maternal health care in the project area. The VHF radio was the type of ICT selected to be used in the project. This included fixed base stations at the health units, mobile walkie-talkies with the Traditional Birth Attendants (TBAs) and vehicle radios in the referral hospital ambulance and the District Medical Officer's vehicle. The VHF radio is solar powered hence avoiding the common electric power shortage or surge problems. The RESCUER project was designed to link up rural community health providers with the formal health system such that when an obstetric emergency occurs in a village, a TBA uses a walkie-talkie to call for assistance from the nearest health unit. Advice on what to do is immediately relayed over the radio system. If the TBA cannot manage the case, transport is dispatched from the health unit with a midwife to collect the patient. If a case cannot be managed at the health centre level, the hospital is called and an ambulance is sent to transport the patient to the referral hospital.

The increased number of deliveries under trained personnel and increased referrals to health units led to a reduction in maternal mortality from 500 per 100,000 in 1996 to 271 in 1999. The RESCUER project therefore caused a change in the health seeking behaviour and reproductive outcomes in its pilot phase, which led to its expansion to other districts.

1.2 ii Handheld computers - Information collection is the first step in a project. This is often time-consuming, plagued with errors in data collection and transcription, expensive, and inevitably followed by delays in the receipt of a final report.In order to test the concept of using the PDA to conduct surveys, SATELLIFE and the International Services section of the American Red Cross (ARC) in the summer of 2001, got involved with their ongoing Measles Initiative aimed at vaccination of children across Africa[13]. It was hypothesized that a survey could be done quickly and accurately and with a large sample size. Measles kills nearly a half million children in Africa every year. The cost and logistics of collecting data to assess the magnitude of the problem is often too high for many programs to afford. During trials the stored data was transferred from the PDAs to a laptop computer using the synchronizing software and cradle supplied with the PDA. Transferring the data into the database required approximately thirty seconds and no errors were encountered during the process. A complete report was delivered to the Ministry of Health by the end of the same day. The speed and ease of gathering this epidemiological data was unprecedented. Thirty paper surveys done in conjunction with the PDA survey took approximately 30 minutes to enter into a database, a rate that would have taken over 40 hours to enter the PDA surveys by hand.

1.2 iii Short Message Service (SMS) technology- This case-study showcases the use of SMS technology to manage tuberculosis in Africa. A similar effort is possible in India due to its recent boom in mobile telecommunications services.

Cape Town has one of the world's highest incidences of TB[14]. TB patients must strictly follow a difficult drug regime of four tablets five times a week for six months. Non-compliance with the drug treatment has exacerbated the high occurrence of TB and has created difficulties for the local healthcare service. Precious medicines are wasted and non-compliance causes the TB virus to become increasingly drug resistant. Dr. David Green, a qualified medical practitioner and consultant in Cape Town , through his company The Compliance Service, uses SMS to alert TB patients to take their medication. The initiative which started in 2002 has led to a significant increase in the recovery rate of patients. Names of TB patients are entered onto a database. Every half an hour the computer server reads the database and sends personalised messages to patients, reminding them to take their medication. The technology being used is extremely low-cost and robust: an open source software operating system, web server, mail transport agent, applications, and a database. Of the 138 patients involved in the pilot, there was only one treatment failure. The WHO has cited the project as an example of "international best practice".

1.2 iv Telecommunication and Telephone based technologies - Rural telecommunications form the backbone for an affordable and effective communication network in rural areas. Rural telecommunication systems can range from very basic pay telephones on the walls of village stores, to digital wireless cellular telephones and sophisticated community Internet systems. Transmission of voice and data can use a variety of tools, including wooden telephone poles and copper telephone lines, analogue radio transmitters and receivers, low earth orbit satellite systems (LEOS), wireless local loops or fibre optic cables[15]. The basic telephone network or public switched telephone network(PSTN) may be used for a wide range of communications[16].

• Point-to-point telephone calls- interconnection between terrestrial, mobile and satellite systems: health services depend heavily on this type of communication
• Paging- Using the telephone services to transmit text messages to receiving units. This technology is increasingly being used with mobile services.
• Voice mail - In addition to forwarding messages to a central telephone number this system also allows the user to call their own voice-mail box from a land line to pick up messages.
• Fax- A good option in slow Internet connection areas.
• Audioconferencing and picture phone- for live discussions and transmission of images.
• Computer-mediated communications for accessing e-mails, the internet and dynamic/static image transfers including live discussions

1.2 v C able television- In rural India there are at least 10.5 million cable subscribers making up 32.5% of the country's total subscription base. Clearly there has been a growing willingness to pay for cable television in rural India and this itself brings out the potential of cable television to provide health education[6]. Doordarshan is the national broadcaster of the Broadcasting Corporation of India. In May 2002 Doordarshan launched a campaign to create awareness on diseases like TB among others. The television spots and health magazine programme called Kalyani, are aired in the capital cities of some of the poorest, most illiterate and disease-prone parts of the country. The programme also has a live phone-in programme.

1.2 vi Other Common ICTs- The term ICT is very broad and may well cover even the newspaper, the poster on the wall or the newsletter. The objective is to give people a wide choice of communication media and the emphasis is on locally relevant and contextually appropriate services. The high illiteracy rate, the rich oral tradition of the village folk point towards an integrative multimedia approach and the potentials of the video and even audiocassettes should not be underestimated[17]. The emphasis is not on technology but on feasible ways to enhance the community's information and communication capacity through the use of ICT.

For purposes of standardisation, interoperability and information sharing each centre may follow the same general procedures according to a detailed training and operations manual, using the same word processing and e-mail applications.

Stage 6 (F)- Changes:systematically desirable, culturally feasible- Criteria for success and general guiding principles drawn

The idea is not to dump the necessary ICTs and leave. Policy makers need to ensure continuity and sustainability of projects. The bottom line is to be cost-effective both to the local provider and the user. Recovery of costs from multimedia telecentres ensures sustainability Lobbying for national policy changes to subsidize universal Internet access takes enormous amount of time especially in a multi-layered bureaucratic system like India[18]. In the medium term, costs may be controlled by other measures as stated below:

• Working out monthly contracts rather than hourly rates with the Local Service Provider
• Reducing printing costs by storing materials on the computer and allowing interested villagers to read them
• Transferring unused PCs to centers needing them rather than purchasing new equipment

Another method is cross-subsidisation. In September 2000, China's State Council issued Article 44 of its ‘Telecommunicatins Regulations and Rules' stipulating that telecom providers must fulfil an obligation where in principle the proposal was to levy a small service charge to every Internet use with the money raised being used to fund present and future Internet Information Centres in designated poor areas. The UNDP has been working on similar lines in ICT projects in rural China[18].

Stage 7 ( G) Action to improve problem situation -Integrated involvement at national, state, district, block, village and community level

Projects implementers in Pondicherry in South India have trained volunteers to use a digital camera to take pictures in and around the village, in their homes, of people being trained, of people accessing the Internet, of children accessing kiosks. These pictures are then mounted on PowerPoint presentations and shown to the village folk . Through such a system without realising it people get trained in basic computer skills and also learn to read and write in a familiar context. Methods such as these have shown that the illiterate sometimes pick up basic ICT skills without even learning to read and write[19]. The idea is to build local familiarity.

At the wider level the flow of information may take place between villages, between villages and the local government, between the local government and state/central bodies. The local self-governance in rural India is a three-tiered system consisting of the District Council, the Block Council and the Village Council. The village folk directly participate in the lowest tier i.e. the Village Council. National and State governments provide financial resources to these Councils for village-based plans. This has already resulted in better participation[20]. The problem is the lack of information flow from the upper tiers to the people or vice versa in rural India. Figure 4 below, demonstrates how ICTs can facilitate connectivity between all the concerned parties starting at the grass-root level and going up the hierarchy to the national level.

Figure 4:The Information Network

The Information Netwok may be connected to any number of village centres such as the rural dispensary, the local hospital, community training centre, primary schools and even to medical centres, supporting agencies at the district/state level.

1.3 Summary

This article has explored ideas and concepts for tuberculosis management in the Indian context using a system modelling technique to develop the principles of the potential value of adopting such a participatory approach to showcase how various stakeholders need to be involved and stay connected for an ICT-supported community initiative. This has been further supported by a s election of "good practice" cases with the aim of promoting sustainable community development through the local appropriation and application of ICTs.

In summary, Table 3 is a typical list but by no means an exhaustive one of TB-related activities that such an approach could support within the community:

References

1. Chan E. Why should we commit to rural technology funding-Supporting Rural Technology Projects: Issues and Strategies.2001; Available from: URL: http://www.techfunders.org/paper_ruraltech_chanthompson_030103.pdf .Accessed March, 12, 2003
2. Checkland P. Soft Systems Methodology in Action. New York: John Wiley & Sons; 1999. ISBN: 0471986054
3. Simulation Defined.2003.[1 screen] Available from: URL: http://www.imaginethatinc.com/sols_sim_def.html. Accessed August 22, 2003
4. TheCommunication Initiative. Impact Data - Survey of Health Professionals to Gauge Knowledge of TB and DOTS – India.2001 ;Available from: URL: http://www.comminit.com/id2001/sld-2875.html Accessed August 22, 2003
5. The Communication Initiative. Planning a Role for Private Practitioners in TB Control: Obstacles & Opportunities. 2001;Available from: URL: http://www.comminit.com/st2001/sld-3395.html. Accessed August 25, 2003
6. Best ML, Maclay CM. Community Internet Access in Rural Areas-Solving the Economic Sustainability Puzzle. The Global Information Technology Report 2002-2003.Readiness for the Networked World. Oxford University Press Inc, USA;2003 ISBN: 0195161696
7. Roman R, Colle R. Digital Divide or Digital Bridge, Exploring threats and opportunities to participation in telecenter initiatives.2001; Available from: URL: http://www.techknowlogia.org/TKL_active_pages2/SearchCurrent/main.asp. Accessed August 25, 2003
8. Blattman C, Jensen R and Roman R.Assessing the Need and Potential of Community Networking for Developing Countries:A Case Study from India.2002;Available from: URL:www.edevelopment.media.mit.edu/SARI/papers/CommunityNetworking.pdf. Accessed August 30,2003
9. Crowder LV. Is There a Communication Media Bias in Development Projects?. Journal of Applied Communication,1991; 75(2)
10. Morven D, Khan B, Padhi A and Goyal G.Developing a Sustainable Business Model for SARI. Report to the SARI project.Delhi:. McKinsy&Company;2001.
11. Mantell K. Solar vs Wind up in Radio Power Contest,Communication Initiative.2002; Available from:URL: http://www.comminit.com/st2002/sld-5635.html Accessed July 23, 2003
12. Musoke GNM. Maternal Health Care in Rural Uganda-Leveraging Traditional and Modern Knowledge Systems. 2001; Available from:URL: http://www.worldbank.org/afr/ik/iknt40.pdf. Accessed August 25, 2003
13. Galblum A. Health information project: Using handheld computers for surveys.International Institute for Communication and Development(iIICD).2002;Available from:URL: http://www.iconnect-online.org/ Accessed August 24,2003
14. ICT-Enabled Development Case Studies Series. Africa - An initiative of IICD and bridges.org. 2002; Available from: URL: http://www.stoptb.org/material/news/press/IICD_030123.htm Accessed August 23, 2003
15. Shariff MS. Technology Trends in Rural Communications.Arab Centre of Excellence.2001; Available from:URL: http://itu.org.eg/coe/rural/Doc16-technology% 20trends%20in%20Rural%20Communication%20sami%20sharif.ppt. Accessed August 12,2003
16. Overview of Information Technologies and Telecommunications.2000;Available from: URL: http://www.med.monash.edu.au/mrh/resources/telehealthreport/tele27.htm Accessed July 11,2003
17. Fraser C, Estrada RS. Communicating for Development.London: I.B.Tauris;1998.ISBN: 1860642381
18. Ulrich P.Future Sustainability:If Revenues are Not Enough,Lower the Costs.China's Rural Internet Information Centres-A Project to Reduce Poverty through Access to ICTs in Rural Areas,UNDP(China).2003;Available from: URL: http://www. developmentgateway.org/node/133831/sdm/blob?pid=3483Accessed August 18, 2004
19. Fergusson J. From Beedees to CDs: Snapshots from a Journey through India's Rural Knowledge Centres. International Institute for Communication and Development- IICD Research Brief. 2003; Available from: URL: http://www.dgroups. org/groups/c3net/index.cfm?op=dsp_resource_details&resource_id=1618 Accessed August 23, 2003.
20. Strengthening Rural Decentralization using Information Technology Orissa and Chhatisgarh with Corporate partnership. UNDP Report .2002; Available from:URL: http://www.undp.org.in/orissa/dnr_profile.htm. Accessed May 3,2003