HealthNet in Zambia

Healthnet in Zambia: The Technical Implementation of a Communications System for Health Workers

by Mark Bennett

Introduction: The Objectives of Healthnet

In 1985 Dr. Bernard Lown (co-president of the Nobel Peace Prize winning organization International Physicians for the Prevention of Nuclear War) conceived of the idea of an organization that would use micro-satellite "Star Wars" technology for peaceful purposes: the sharing of health information among professionals, particularly in developing countries. In 1989 this conception became reality with the founding of SatelLife, a joint east-west organization (based in both the United States and the then-USSR) dedicated to building north-south and south-south medical communication.

The objective of the project was strong and cohesive. It was known that information was one of the valuable commodities of which developing countries were most short. Lack of access to health information leads to replicated research; it leads to lack of awareness of simple but innovative cures or preventative measures; it leads to loss of life. This is especially so in Africa where the basic health infrastructure may be weak or underfunded, and where the disease AIDS is assuming severe proportions.

It was also known that traditional forms of communication were not always effective. The telecommunications infrastructure within Africa varies greatly from country to country. Throughout the region as a whole it is weak and expensive. To take Zambia as an example, an international telephone call to the UK costs on the order of US$7.00 per minute, and calls to neighboring countries (when possible at all) cost up to half of that. This is a high cost in comparison to a few cents for a packet of Paracetamol, or a few hundred dollars as the monthly salary for a doctor. In addition it must be remembered that telephone density is low in Africa (in Zambia it is around 0.7 phones per 100 people, less than one hundredth of the North American figure). Conventional mail is very slow (up to three weeks to a remote part of the country), and transportation may be poor and expensive. Libraries may have stopped getting recent medical journals because of lack of funds or foreign exchange.

For these reasons SatelLife adopted packet radio technology, combined with a low-earth-orbiting satellite that could act as a "postbox" to store and forward mail as well as distribute appropriate medical information. This technology was felt to provide a relatively low-cost solution to the communications problem, bypassing national telecommunications infrastructure problems and allowing communication on an equal basis among all countries interested in joining the project.

Zambia was fortunate to be one of the first countries within the subregion to install the equipment provided by SatelLife. This paper addresses some of the technical aspects of Zambia's experience in establishing its Healthnet link.

The Basic Technology

The satellite used by the Healthnet project is similar to that used by the amateur radio community. It is low-earth-orbiting (in an orbit some 850km from the earth), which means that only a small, low-powered transceiver and antenna are required. The cost of such satellites is relatively small - some one million US dollars to build and launch (perhaps 1/400th of the cost of a geostationary telecommunications satellite). The Healthnet satellite was developed by the University of Surrey in the UK. Being "sun-synchronous," it orbits at a speed of some 17,000 kph, and passes over each point on earth at least four times a day for an average of about 10 minutes per pass.

The 40kg satellite has 10MB of on-board memory, designed to store messages for approximately two days. In theory it is possible for a message sent by any earth station to be picked up at its destination within half a day. One pass should be sufficient to pick up perhaps 100k of data, although this has probably not been achieved in practice by many stations to date.

The satellite transmits a continuous signal denoting its presence. This signal is picked up by the receiving site, which responds, and handshaking initiates the communications session.

The basic equipment required on the ground is a personal computer (PC) - with hard disk, 12 MHz or faster, preferably with a math coprocessor - an amateur radio transceiver, and a terminal node controller with integrated radio modem. In addition, separate transmit and receive antennas, currently of the "egg-beater" design, are used. The cost of the whole groundstation is less than US$5,000 including the computer.

In some locations electricity supply may be a problem, but in theory it is possible to run the whole operation from solar power.

It will be appreciated that since the groundstation is communicating directly with a satellite, and particularly since it is transmitting rather than just receiving, permission has to be gained from the local licensing authority (normally the posts, telegraph, and telecommunications authority, or PTT) to operate the system within any country. While worldwide authority has been sought by SatelLife for use of the relevant frequencies, these must also be cleared within individual countries. In addition, certain countries may have concerns about whether the PTT itself is being bypassed or whether or not there are any security implications.

Local Infrastructure

Fortunately Zambia obtained a license to operate the station in a relatively short time, with generous assistance from the Zambian PTT, partly because of awareness of the humanitarian work that was to be done by the system. Despite initial fears, licenses have now been obtained in many other countries. Groundstations are now operational in Zambia, Kenya, Uganda, Tanzania, The Congo (where the African Regional Headquarters of the World Health Organization [WHO] is sited), and Mozambique. Zimbabwe is expected to link up shortly, and Botswana is also hoping to join the scheme.

It will be appreciated that although SatelLife has set up an infrastructure that is beginning to provide international communication where it did not previously exist, within each individual country there will also be a need to share the information and allow a variety of widely scattered users to gain access to the newly opened communication channels. It is possible for there to be several groundstations within a country, although this is an expensive solution and causes contention for the satellite time. Where telecommunications facilities are very poor, this is one option that will have to be considered, along with the use of "line of sight" terrestrial-based packet radio to link additional points to the main groundstation.

In Zambia the option chosen has been a Fido-based network, using computer-to-computer links through normal dial-up public telephone lines. The majority of institutions likely to require eventual link-up with the system have a telephone that is normally operational for the greater part of the time, and available for the few minutes a day necessary to exchange mail (Fido uses batch-based rather than interactive mailers, which maximize the use of poor or expensive phone lines and require the minimum human intervention). The sites also have an electricity supply for a sufficient time each day to operate the computer.

The satellite groundstation is located at the University of Zambia Computer Centre, which also houses a dedicated e-mail PC running FrontDoor Fidonet software (used for the university's own e- mail system). A standard modem within the groundstation computer allows satellite-based messages to be exchanged between these two systems. Presently there are two e-mail stations operational in the University Teaching Hospital (based in central Lusaka, some 8km from the main campus); two stations at the Ministry of Health; one at the Lusaka offices of WHO; one at the UNICEF offices in Lusaka; one at the Tropical Diseases Research Centre (TDRC) in Ndola (some 300km away); and one in Nkana Mines Hospital in Kitwe (370km away). These stations keep up regular contact with the satellite and with each other.

The project plan (being coordinated by a Healthnet planning team consisting of representatives from the university, WHO, UNICEF, CMAZ, and the Ministry of Health, which will ultimately assume responsibility for the system) is to begin with a pilot project in the Southern Province of Zambia, connecting some nine district hospitals to the network. These hospitals are of varying size (mission- and state-run), but all could be considered to be serving the rural community. The pilot phase will test the viability of extending the system to all 84 hospitals in the country. This work is being done in conjunction with a Ministry of Health plan to use unlinked computers in some provincial hospitals to collect management data.

The major tasks of the system to be implemented will be:

- improvement of local, regional, and international communication with others in the medical and health professions;
- improvement of health service administration, including planning, budgeting, accounting, manpower control, provision of health statistics, and vehicle control;
- improvement of distance education, including in-service training of doctors;
- provision of up-to-date literature, both local and international;
- assistance to hospitals and clinics in controlling the drug supply;
- facilitation of clinical consultations and referrals; and
- gathering and distribution of epidemiological information.

In connection with the literature facilities above, generous assistance has been received from the Health Foundation in Washington, which has provided a four stack CD-ROM system, along with a subscription to Medline on CD to attach to the PC in the University School of Medicine Library. The system will in turn be able to supply the network with some in-country literature requests. This effort has been complemented by AAAS, which has supplied further CDs, and by a link between the University Medical Library and a counterpart at the University of Florida that is able to supply articles by e-mail that are not yet available locally. An on-line database search facility through Fido has yet to be established, but is feasible once suitable software has been installed.

Successes and Failures

It has been possible for the University of Zambia to set up the groundstation and get it and the supporting Fido network operational without any staff having to come in from outside. The equipment was donated from SatelLife and IDRC, but no funding was available for staff. It should be possible to repeat this success in any other suitable and comparable situation.

This is a relatively new technology being operated, in the case of SatelLife, by a relatively new organization. It is likely also to be a transitory technology (the adoption of micro-satellite technology appears to be growing fast and may be absorbed quickly into the commercial sector). Thus there have inevitably been many learning experiences and problems encountered. Some of these are listed briefly below for the benefit of others who may be working in similar areas. They are divided into technical and human resource problems.

Editor: Ali B. Ali-Dinar
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