1.8.1 Case 1: Development of A Low-Cost Automatic Field-of-View Scanning Microscope for Early Tuberculosis Detection Systems
0We developed a TB automatic detection system using commodity components. The system consists of an electro-mechanical digital microscope to record the FoV images of sputum samples, image processing software to detect and to count the number of the bacteria in the FoV, and a decision system to determine whether the patient is diagnosed as a positive TB or not.
Figure 1: The modified optical microscope that is capable of performing automatic FoV scanning.
The electromechanical digital microscope is actually a modified one from an ordinary low-cost optical microscope. We add a two-degree-of-freedom scanner made of two stepper-motors and a digital camera fixed in front of the microscope’s ocular. Figure 1 shows the modified-microscope, placement of the stepper motors, and the driver card with a simple microcontroller.
Figure 2: Two FoVs images of a sputum sample showing TB bacteria and its background
The image processing software and the decision system is now under-development. Figure 2 shows two different FoV of the sputum microscopic images. The staining of the samples shows contrast of the TB bacteria with its background. The image processing software should be capable of separating the bacteria from the background. Then, the segmentation and counting process can be conducted.
Conclusions and further directions
We have described a low-cost automatic FoV scanning Microscope for early TB detection systems. Some parts of the system, i.e., the FoV automatic digital microscope, have been constructed. Our next steps are to complete the prototype with processing software, performing laboratory- and field- tests, and benchmarking with manual sputum analysis.
 The Global Plan to Stop TB, 2011-2015: Transforming the Fight towards Elimination of Tuberculosis, World Health Organization, 2010
 R. Lumb and I. Bastian, “Laboratory Diagnosis of Tuberculosis by Sputum Microscopy,” The Handbook, Institute of Medical and Veterinary Science, Frome Road, Adelaide South Australia, 2005
1.8.2 Case 2: Picture Archiving and Communication System (PACS) and Teleradiology Development and Implementation
0Medical image becomes one of the most valuable assets in medical history and in supporting diagnosis process. Archiving and transferring medical image over telecommunication network is challenging, because of its size. It needs huge storage capacity to archive medical image in a health institution such as hospital. Our research since 2001 came out with effective compression method to compress the medical image in 16:1 ratio, yet maintaining the quality of image reconstruction over certain region of interest.
Figure 3: (Left) Application to manage medical image (right) Desktop Viewer
Figure 4: (Left) PACS viewer on Tablet PC (Right) PACS Viewer using large LCD touch screen
Our developed compression method was iterated for several years to meet the requirement from radiolog expert. We named our compression method as Scalable Fuzzy Vector Quantization (SFVQ). In the year of 2011, biomedical engineering of Institute Technology of Bandung cooperated with private company which works on health care area to develop commercial PACS. At the end of that year the beta version of commercial PACS product was launched. The product was implemented at to hospital, Agam General Hospital in West Sumatera and Cililin General Hospital in West Java. The product was design in a very simple user, yet powerful enough. However, there are many rooms for improvement.
The PACS product consists of three major components. The first one is the application to manage all medical images inside PACS. The second one is the application server to manage the interaction between client and storage server or persistence server. The last one is image viewer. We developed three kind of viewer, which are desktop, large LCD touch screen, and tablet PC.
We also develop on the PACS enhancement based on requirement and actual need. There is a need to have teleradiology session between small hospital which lack of radiolog and large computer where there are expert on medical image. Based on this need we expand the capability of our previous product into teleradiology supported PACS.
Figure 5: Teleradiology capability added into PACS
1.9 Kyrgyz Republic - E-Health Introduction in the Kyrgyz Republic - Experience and Further Steps
0Since its independence in 1991, Kyrgyzstan has seen periods of democratic progress and of authoritarian backlash. With the fleeing of two presidents (in 2005 and 2010) after popular uprisings against authoritarianism, corruption and human rights violations; coupled with regional disparities and the repercussions of the inter-ethnic violence of June 2010, the country is going through a difficult process of transformation. In June 2010 several serious inter-ethnic confrontations took place in the south of the country. About 420 people died and 2,000 were injured, while over 2,000 houses and 300 businesses were destroyed. As result of June 2010 referendum a new constitution has been adopted. The new Constitution defines the Kyrgyz Republic as a parliamentary republic (during the previous 18 years, the country was a presidential republic) thus making it the only country with a parliamentary system in Central Asia. Parliamentary elections held in October 2010 were contested by 29 parties, with five winning places in Parliament and three forming a new coalition Government. Presidential elections held in October 2011 resulted in peaceful transfer of power. However, peace and social cohesion cannot be taken for granted, as the root causes of conflict, including inter-ethnic mistrust and regional tensions, eroded credibility of state institutions, social exclusion and uneven access to economic opportunities remain to be addressed. Kyrgyzstan in the past has seen concentration of powers around the presidency, with state institutions not perceived to be efficient, transparent or accountable. There is still work to be done to support the Government to strengthen the rule of law, address justice issues, reduce the prevalence of human rights violations, improve redress mechanisms and increase the independence and capacity of the judiciary, media (both public service and independent), the civil service and local government. Civil society’s impact on decision-making still remains limited although its role has recently increased.
Kyrgyzstan has a GDP per capita of US$2200 (2010) and is classified as one of two low-income countries in the Europe and CIS region. The economy grew 3.9% per annum in 20002005 and 3.7% in 20052010. In 2011 the economy grew 5.7%. Poverty fell from over 62% in 2000 to 32% in 2009, but after the 2010 events it rose back to 33.7% that year, with an increasing proportion of the poor being female. Foreign debt is $2.803 billion as 2011, about 47% of GDP, while the budget deficit for 2012 is planned to be about 5.7% of GDP. There is a large informal sector, particularly in services and agriculture. Meanwhile, 26% of households have at least one member working abroad. Remittances had risen to US$1.7 billion by 2011, slightly over 30% of GDP.
With a human development index ranking of 126 out of 187, the Kyrgyz Republic is in the lower half of the medium human development countries. It raises seventeen places in the inequality-adjusted human development index. The country is 66 of 146 countries in UNDP’s gender inequality index. The country’s 2010 MDG report indicates that the country is unlikely to meet the MDGs for child and maternal mortality, tuberculosis, sanitation, and gender equality, although it is on track on extreme poverty reduction, access to basic secondary education, and access to improved water sources.
Life expectancy is 73.5 years for women compared to 65.3 years for men, and female literacy is high 97.7% (in the 15-24 age group). But despite progressive legislation on gender issues, women remain vulnerable to rising unemployment, a weak social protection system, and increased influence of patriarchal traditions in social relationships. Gender inequality, social and financial discrimination, and the additional unpaid work carried out by women mean that nearly 70% of the poor are now female. The continuing high prevalence of bride kidnapping in rural Kyrgyzstan remains a serious concern, and nearly 83% of women suffer domestic violence. In the government formed after the October 2010 elections, there were no female cabinet ministers until a lone woman minister for social protection was appointed on 7 April 2011. In those 2010 elections, representation of women in parliament fell from 30%to 20.8%, while in local councils it is now only 12%.
About 32% of Kyrgyzstan’s population is between 15 and 25 years of age. Young people do not have full access to education, employment, health care, family decision making, and entrepreneurship. With inadequate educational training and poor economic prospects, many young people turn to crime and drugs. Young women, especially in rural areas, are particularly vulnerable to gender-based violence.
The country has prepared a medium-term Country Development Strategy (20122014) in the context of a macroeconomic outlook that looks challenging, but with potential for directing the economy on sustainable development. The Strategy focuses on creating conditions for attracting foreign investment, reform of state regulation aimed at eliminating bureaucratic barriers and expanding economic freedom of business entities, as well as on launch and implementation of 40 national projects in the medium-term. All these fundamental factors will be crucial for long-term sustainable human development and achievement of the MDGs.
1.9.2 Situation Analysis in the Healthcare System of the Kyrgyz Republic
Heart diseases are one of the leading causes of death and a major cause of disability. The importance of cardiology service is emphasized by the fact that cardio-vascular problems account for 50,3% in 2011 (48.3% in 2010) of all death cases in the Kyrgyz Republic.
The second alarming issue is the level of maternal and child mortality.
Child (infant) mortality is the crucial characteristic of national health. The child mortality rate is 20,7 per 1,000 born alive in 2011 (22,8 in 2010) and the structure looks as follows: the main share belongs to perinatal period conditions (65,2% in 2011, 63,1% in 2010, 60.0 % in 2007 and 60.9% in 2006), respiratory apparatus’ diseases - pneumonia (12,3% in 2011, 14,9% in 2010, 16.7% in 2007, 17.5% in 2006), inborn anomalies (12,3% in 2011, 12,6% in 2010, 11.3% in 2007 and 11.2% in 2006) and infectious and parasitic diseases (5,3% in 2011, 4,5% in 2010, 6.8% in 2007 and 5.7% in 2006).
The major causes of such deaths are wrong diagnostics and incorrect prescriptions. The registration of child deaths at home shows that children die during the first five years of life because the parents are unable to properly evaluate the health status and do not know how to help. During the recent years the ratio of child’s hospitalization caused by pneumonia has been high and made 36% for children up to five years, being one of the main death causes for children under 14.
In the last few years the maternity mortality rate has increased and in 2011 it made 49,3 per 100 000 live births (50,6 in 2010, 62,5 in 2007, 53,0 in 2006 and 60,0 in 2005). The leading place in maternal mortality increase was taken by the Talas region -87,0 per 100 000 live births in 2010 (61,3 in 2009 and 38.5% in 2006), the Naryn region – 83,5 per 100 000 live births in 2010 (135,6 in 2009), the Issyk-Kul region – 70,4 per 100 000 live births in 2010 (72,0 in 2009), Osh region – 59,8 per 100 000 live births in 2010 ( 117,4 in 2009). Rural areas take the first place in terms of death cases among women (86.8%). The major cases of such deaths are wrong diagnostics.The maternity mortality structure shows that 75.0% of deaths happen during pregnancy and childbirth. The first place of the mortality rate is taken by haemorrhages – 52.2% (in 2007 – 34.4%), the second by hypertension disorders - 22.4% (in 2007 – 34.3%), septic complications account for 10.4% (7.8% in 2007).
Although the prevalence of HIV is still low, the country has registered sharp increases in the number of persons living with HIV, and suffers one of the fastest rates of increase of reported HIV infection in the world. As of end 2011, there were 3111 registered HIV cases in the country, although WHO estimates suggest the true figure may be two or three times higher. Children now make up 8% of HIV cases in the country, following an outbreak in hospitals in the south of the country in 2007 and mother to child transmission. Because of women’s vulnerability to HIV, sexual violence, inequality in decision making on contraception and sexual life, and poor sex education, the number of females registered as living with HIV increased by 75 times between 2001 and 2011, compared to 17 times for males. Despite progressive legislation, implementation mechanisms are weak and people living with HIV face continuing stigmatization. At over 12 cases per 100,000 people, tuberculosis prevalence is also high and rated as an epidemic. Much of the tuberculosis is multi-drug resistant, and the disease is particularly prevalent in the penal system because of overcrowding, poor ventilation, malnourishment and inefficient treatment. Meanwhile, an increasing proportion of tuberculosis cases are being registered among women and children. The prevalence of malaria, although still low, is increasing, particularly in southern parts of the country.
1.9.3 Objectives and Strategies
During the implementation of the National programmes on the healthcare reforms in the Kyrgyz Republic: “Manas” (19962005) and “ManasTaalimi” (2006-2011) the legislative base for the new health care system in the Kyrgyz Republic were established. The following new laws were adopted by Kyrgyz Parliament: on “ The unify payer in the healthcare finance system” (2003), “ About healthcare organizations in the Kyrgyz Republic” (2004), “Health protection of the citizens of the Kyrgyz Republic” (2005), “ Public health care in the Kyrgyz Republic” (2009), amendments to the laws on “About the main principles of the budgetary law in the Kyrgyz Republic” (2000), “ Local self governance and local governance administration in the Kyrgyz Republic”(2000), “Medical insurance of the citizens of the Kyrgyz Republic” (2003).
Every year, starting from 2001 the Government of the Kyrgyz Republic approves the Governmental Programme on State social guarantee provisioning free, preferential and paid terms of the healthcare services depending on the citizen’s social status and medical insurance conditions. From 2006 the health care reforms performs under the Sector Wide Approach (SWAP).
The current National Programme of the health care reform “Den Sooluk” for 20122016 is a logical continuation of the previous national programmes focused on the 4 programme’s directions:
Maternal and child health care;
The special focus in this programme was taken on the deployment of the ICTs in healthcare system from the view of standardization of the medical information systems and development of the unified telecommunication infrastructure. The implementation of the e-health services recognized as one of the main priority and includes the creation of the national e-health network for e-learning and tele-consultations.
Kyrgyzstan, as a country with difficult mountainous terrain needs the e-Health services because people in remote and rural areas have inadequate access to medical aid and health care. They have to travel for many hours to reach the nearest hospital or clinic. But to be effective, e-Health requires appropriate regulatory, legal and policy frameworks in both the telecommunications and the health sectors. Some of the critical factors for success are proper project management and a coordinated approach following the clear vision, the building up and maintenance of adequate technological infrastructure, the commitment of trained end-users and ICT literate citizens, and the political will to achieve challenging but realistic e-health goals.
Currently, Kyrgyzstan does not have a specific national strategy on e-health, which would require the initiative of the Ministry of Health together with other relevant Government agencies and CSOs. With the support of UNDP in Kyrgyzstan, the project on e-health in one of the remote areas (Batken) was implemented. UNDP is further looking at nation-wide project which would provide policy support and technical assistance toThe Ministry of Health of the Kyrgyz Republic, envisaging the following components:
Component 1: Draft National e-Health (including m-Health) Strategy & Action Plan developed and submitted for approval to the Kyrgyz Government.
Country’s e-Health strategy will be based on national health priorities, the available and potential resources, and the current e-health environment. The enabling environment for e-Health is fundamental to scaling up and sustaining ICT adoption in the health sector. It includes aspects such as governance, policy, legislation, standards and human resources. Within the Kyrgyz Republic’s national context, where the first pilot e-health project was implemented in 2009-2010 (joint initiative of UNDP, MTC and MH). This project featured a small initiative, within limited time-line, where advantages of using ICTs were demonstrated, including innovative ICT applications (with elements of m-health). The project was not sustainable due to the lack of ownership, commitment and e-health skills. In addition, it had a narrowfocus on certain aspects of e-health, while the changes and overall approach in the health care system were required. A national plan for a country in this context will be focused on making the case for e-health, creating awareness and establishing a foundation for investment, workforce education and adoption of e-health in priority systems and services. Without a parallel focus on creating the enabling environment, innovations in ICT will stay isolated and have only a limited impact on health.
Mobile communications have arguably had a bigger impact on humankind in a shorter period of time than any other invention in human history. Mobiles are also contributing to social, economic and political transformation. According to new WB Report (2012) to human and economic development opportunities, around three-quarters of the world’s inhabitants now have access to a mobile phone and the mobile communications. The number of mobile subscriptions in use worldwide has grown from 1 billion in 2000 to over 6 billion in 2012, of which nearly 5 billion in developing countries. In developing countries citizens are increasingly using mobile phones to create new livelihoods and enhance their lifestyles, while governments are using them to improve service delivery and citizen feedback mechanisms. Mobile communications can help provide health care services more quickly and cheaper in many cases, mainly by focusing on primary, preventive and self-empowered approaches to health care. M-Health encompasses any use of mobile technology to address care challenges such as access, quality, affordability, matching of resources and behavioral norms through the exchange of information. It is a dynamic field for innovative new services that move health care away from pure public service delivery toward seeing the patient as a consumer. The recent studies estimated that m-health reduces data collection costs by approximately 24 percent, costs of elderly care by 25 percent and maternal and perinatal mortality by 30 percent (Telenor Group 2012). The same study finds that m-health can improve compliance with tuberculosis treatment by 30-70 percent. Taking into account above, finally, M-health should be integrated with larger e-Health Strategy and Action plan.
Component 2: National Process for e-Health Standardizationinitiated, key technical standards developed/adopted and submitted for approval to the Kyrgyz Government.
Considering the rapid introduction of e-health worldwide and potential growth in Kyrgyz Republic it is necessary to initiate the development of generally acceptable the national standards and guidelines to facilitate growth of e-health application in Kyrgyzstan. Enormous international efforts are being put in this direction to regulate/guide the growth of healthcare IT ecosystem. These efforts are the result of compelling need for the standardization of processes in which healthcare information is represented and transmitted from system to system. For any developing country to embark on proposing standards for
e-health and Hospital Management Information Systems (HMIS) it is imperative to study the existing international standards. Many Standard Development Organizations (SDOs) and Special Interest Groups (Sigs) are active in standardization process for addressing the issues of sharing of health data, data structure, access management, standardizing clinical and business process in healthcare and security and privacy. Some of the key relevant standards such as ISO/TS 18308, CEN/TC 251 EN 13606, DICOM, HL7, CCR-ASTM, CEN/TC 251 EN 13940, ICD-10-PCS, SNOMED-CT, CPT, UNLS, ITU-T H.32x. For any developing country embarking on introducing standardization will benefit by going through the exercise of reviewing these available standards to see their suitability for adoption.
Component 3: National e-Health network (with national e-Health center/node) and mechanisms for rapid deployment of ICT-enabled public e-health services created and some public e-health services (on cardiovascular, maternal and prenatal healthcare) provided to the citizens of Naryn and Osh provinces of the Kyrgyz Republic.
Under this new project it is planned to create national e-health center (s)/node(s) equipped by different modern digital medical and telecommunication equipment, real-time management of medical records, broadband connection and adapted e-health software systems in national e-health center. Thesecondary and primary health centers in Naryn and Osh provinces of the Kyrgyz Republic to enable continuous medical education and tele-consultation will be also established. Webcasting of the interactive courses by leading medical professionals to university students and young professionals in remote areas will be provided as well. Tele-consultations using an integrated system capable of managing patients, storing and forwarding medical records and images and providing second opinion to remote patients will be held. The system will comply with international standards adopted and approved by Kyrgyz Government. Some
e-health services in cardiovascular, maternal and prenatal areas will be operational for Naryn and Osh province’s patients.
1.9.4 Activities Implemented
UNDP Kyrgyzstan jointly with the Ministry of Health and Ministry of Transport and Communications of KR has successfully piloted in 2009-2010 the first e-health project in the Kyrgyz Republic in the remotest region of the country - Batken province, which lacked medical personnel, health services and special medical equipment. Two leading national medical institutions participated in this first e-health project. Medical receiving stations installed in these institutions and remote equipment for transferring the medical data wereprovided to the regional hospital. 24/7/365 help was arranged at the national centers with high professional medical staff in order to provide ON-OFF medical support with diagnostics and prescriptions. Different types of telecommunication and special medical equipment installed to ensure high quality communication of all necessary medical information to the both ends. Local population had access to health services at their place of residence.
The main objective of the project was to create and implement the first interactive E-Health services in the Kyrgyz Republic in order to decrease the mortality rate, especially on cardiovascular and maternity & child healthcare andto promote effective use of ICT as a powerful instrument for governance, economic and social development, citizen’s access to public information and government services. E-Health services are considered as a component of the E-Government implementation in the social sector, which is an effective tool for improvement of health care service delivery through use of modern ICT technologies, especially in remote rural areas with focus on women and children and contributes to MDG 4 and
1.9.5 Changes and Results Achieved
The project produced the following outputs:
Access to public medical services was improved for populations in remote rural areas.
Distance medical services for remotest region (tele-cardiology as well as maternity and child health care) were established.
ICT possibilities in the healthcare area on provision of different medical services were demonstrated.
Qualification of local medical personnel was improved through professional and IT-trainings.
The project’s idea and results were presented on round table with participating of the Vice-prime Minister of the Kyrgyz Republic and all interested stakeholders- Government entities, NGO’s, mass media, universities and others. Very positive feedback received from all parties. Based on a result of this pilot project, the Ministry of Health of KR developed and submitted the document requesting budget from Government of sharing the best practice in order to implement the project’s idea in all other regions of KR.
The project was also presented at the SWAP meeting – regular biannual meetings of international donors, investing in healthcare sector of KR. It was the request from the Ministry of Healthof KR (from stats-secretary of the ministry) to mobilize additional resources for extension of the project to other regions of KR.
The information about project was placed in DG TTF 2009 Annual report as best practice example (Democratic Governance Thematic Trust fund Stories from the field).
1.9.6 Lessons Learned
The project’s idea and suggested technological solutions are practical and can be easily replicated in other regions of the country and even more – in other countries with similar geographic and socio-economic conditions.
State ownership: there was a high degree of commitment of key stakeholders during the project implementation. The Ministry of Health, despite the frequent changes of the departmental heads, remained interested in the project and expressed the intention to sustain project results. Middle managers were included as facilitators in the technical working group, have consistently advocated to the senior management the expansion ofthe interactive electronic medical services through the inclusion of this thematic area in the SWAP strategic objectives.
Not all modern digital medical diagnostic equipment could transfer its data outside of the device using Bluetooth or USB ports and allow to connect to third party (not own) software.
Lack of practical experience and knowledge on e-health not only in Kyrgyzstan and the Central Asia region.
The lower level of preparedness and competences of the local medical personnel to use the computer and modern medical diagnostic equipment.
Latent resistance (or skepticism) from doctors (rural and central) to accept new way of providing medical services.
Lack of involvement of NGOs in the project activities. The project document envisaged NGO stakeholders in the steering committee, which however were not able to provide necessary contribution.
Prior to the project commencement, there was no proper stakeholder and institutional analysis made. This impacted project implementation results.
Strategies for engagement and cooperation of donors in this area need to be developed and the Government should play a central role in coordination and facilitation of this process.