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Why 2 Mbps is not sufficient for telemedicine in rural India?

The COVID-19 crisis has changed how people access medical care and has ushered in the new era of telemedicine. Almost overnight, patients stopped going to hospitals and are, instead, receiving medical care through various online platforms.

New Delhi-based Sitaram Bharti Hospital immediately started telehealth consultation service and emergency ambulance service as soon as the Government of India announced nationwide lockdown due to COVID-19 outbreak. Likewise, Aravind Eye Care Systems in Madhurai could set up a make-shift telehealth consultation option on their hospital website in just two days. On 22 March, a team of 18 doctors at Aravind Eye Care Systems was ready to take the patients’ calls from six different locations across South India. The high number of patients who wanted telehealth consultation service resulted in the hospital setting up parallel windows in each of their eight branches using Google Hangout. It was a right move in the anticipation of a bigger lockdown that was announced a couple of days later. Similarly, Nagarajan Ramakrishnan, a sleep medicine specialist, and director at Nithra Institute of Sleep Sciences, Chennai, is also treating his patients remotely.

At a time when physical distancing is among the major measures used to fight COVID-19 pandemic, face-to-face consultation poses a very serious risk to both patients and doctors. Under these circumstances, remote consultations over the phone or video calls is a new way to help patients get access to healthcare services. On 25 March, the Government of India issued a set of guidelines for telemedicine or remote delivery of medical services [1]. The guideline legitimises the practice of remote consultations.

This is the situation of the urban scenario where telehealth consultations are available and have enough internet bandwidth to extend their capacity for such consultations. But what about rural India that needs healthcare services the most? Are the health centres in rural India with limited healthcare resources providing telehealth facilities during COVID-19?

First, it is important to understand the structure of the rural public health system. It is a tiered structure. At the bottom of the pyramid are health sub-centres, catering to a population of 3,000 to 5,000 each, covering roughly five villages. These health sub-centres are usually manned by an Auxiliary Nurse Midwife (ANM) whose focus is on primitive and preventive healthcare services and to act as a referral to the primary health centres (PHCs) for curative services. PHCs are the first base for doctors, acting as referral units for six health sub-centres. PHCs act as a core and connected to community health centres (CHCs), followed by sub-district and district hospitals. There are over 1.5 health sub-centres, 25, 000 community health centres and 5000 public health centres in India. At the apex, there are medical colleges and advanced research institutes such as the All India Institute of Medical Sciences.

This tired structure looks impressive at first glance; however, the system is broken for large segments of the Indian population. According to Rural Health Statistics by the Ministry of Health & Welfare Services[2] only 11% sub-centres, 13% PHCs and 16% CHCs meet the Indian Public Health Standards. Moreover, a doctor-patient ratio is 1:2000 in India, according to the World Health Organisation (WHO). This means that six lakh villages where 70% of India’s population lives, the number of doctors is only a fourth of those in urban areas.

Thus, in times of COVID-19 crisis, adopting virtual healthcare approaches in rural health centres is essential. However, telemedicine is still a struggling concept in the countryside and even district-level healthcare centres are not able to do so.

Ostensibly, the National Teleconsultation Centre (CoNTeC)[3], an acronym for COVID-19 National Teleconsultation Centre launched by Union Minister of Health & Family Welfare Dr. Harsh Vardhan on 28 March 2020, is not meeting the requirements fully. CoNTeC has eight regional zones, establishing internet connection between medical colleges connected through the National Medical College Network (NMCN) with its National Resource Centre located at SGPGI, Lucknow. Presently, 50 medical colleges are registered under NMCN. It is reported that these medical colleges are connected through the National Knowledge Network (NKN) to provide telemedicine facilities.

However, these medical colleges are not connected with district hospitals and CHCs, which are located in the rural parts of the country. With 159 internet service providers in India, the broadband penetration in rural parts of the country is yet less than 16%, according to TRAI.

According to the Indian Public Health Standards (IPHS) for PHCs, CHCs, sub-district and district hospitals, the internet connectivity is provided for MIS (Management Information System)[4] and not telehealth services. The minimum internet speed allocated to district health centres is 2 Mbps to connect the doctor with the patient via video call. But this also is not available in most of the villages. As a result, the video quality turns out to be bad when district doctors try to connect with patients or health staff members. It thus becomes difficult to organise telehealth consultations. 2

Different sets of healthcare applications need different connection speeds. Table 1 below provides some applications that represent samples of activities typical of healthcare facilities of approximate download times to complete the transmission and download times at different network speeds. Individual healthcare facilities may use all, some, or none of these in addition to other network uses required for their operations (Hu, Wang, & Wu, 2006)[5].

Table 1. File size, transmission and download times at different connection speeds

 File type and size Network transmission speed
Type Size 4 Mbps 10 Mbps 20 Mbps 50 Mbps
High Definition Video

Conferencing

1.9 MBs 23.8

seconds

9.5

seconds

4.8

seconds

1.9

seconds

Tele-Pathology 3 MBs 2.3

seconds

0.9

seconds

0.5

seconds

0.2

seconds

Tele-Diabetic Retinopathy

Screening

5 MBs 6.2

seconds

2.5

seconds

1.2

seconds

0.5

seconds

Mammography 160 MBs 5 minutes 2 minutes 1 minute 24.4 seconds
MRI study 200 MBs 6.3 minutes 2.5 minutes 1.2 minutes 30.5 seconds

According to the Federal Communications Commission (FCC) recommendations, the following minimum bandwidth speeds are required to support electronic health record (EHR) system (Table 2) [6].

Table 2. Recommended bandwidth for healthcare providers

Healthcare service Bandwidth speed Services
Single Physician Practice 4 Mbps
  • Supports practice management functions, email, and web browsing
  • Allows simultaneous use of electronic health record (EHR) and high-quality video consultations
  • Enables non real-time image downloads
  • Enables remote monitoring
Small Physician Practice

(2-4 physicians)

10 Mbps
  • Supports practice management functions, email, and web browsing
  • Allows simultaneous use of EHR and high-quality video consultations
  • Enables non real-time image downloads
  • Enables remote monitoring
  • Makes possible use of HD video consultations
Rural Health Clinic 10 Mbps
  • Supports clinic management functions, email, and web browsing
  • Allows simultaneous use of EHR and high-quality video consultations
  • Enables non real-time image downloads
  • Enables remote monitoring
  • Makes possible use of HD video consultations

 

Tables 1 and 2 clearly indicate that a 2 Mbps connection is not sufficient enough to provide all sorts of telemedicine services such as tele-radiology, tele-surgery, tele-ophthalmology, tele-pathology and tele-ICU services. The absence of infrastructure, internet connectivity, and lack of sufficient technical staff members and medical personnel have impeded the progress of telemedicine in rural parts of the country.

Stimulation wireless network model for telemedicine facility in rural health centres

One way to deal with the bandwidth issue is to create a wireless mesh network that can connect three to five medical colleges with a district health centre. The topology of the network requires that every terminal be connected to every other terminal in the network. The topology incorporates a unique network design in which each hospital on the network connects to every other, creating a point-to-point connection between every device on the network. The purpose of the design is to provide a high level of redundancy. If one network cable fails, the data always has an alternative path to get to its destination and the district health centre and replicating it further to CHCs and PHCs.

Another approach could be to estimate the unused bandwidth available in the region which can further be used for connecting district health centres. Depending upon the availability of the network, different models can be adopted.

Other suggestions that the government can consider are to allocate high-speed wireless frequency band of unused spectrum (V band or 60 GHz, which is like short-range wireless optic fibre) and TV White space for the telemedicine facility and to be used for community services.

To sum up, the coronavirus crisis has made the need for high-speed, reliable internet clear. The current isolation period is a gentle reminder to authorities concerned about the necessity of an adequate internet connectivity and higher bandwidth in rural India that can potentially connect us and enable us to have a better healthcare facility all the time.

References

[1] Telemedicine Practice Guidelines; https://www.mohfw.gov.in/pdf/Telemedicine.pdf
[2] Rural Health Statistics; https://www.thehinducentre.com/resources/article31067514.ece/binary/Final%20RHS%202018-19_0-compressed.pdf
[3] National Telemedicine Portal; https://nmcn.in/about.php
[4] Indian Public Health Standards; https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=971&lid=154
[5] Hu et al. (2006). Mobile telemedicine sensor networks with low-energy data query and network lifetime considerations. Mobile Computing, IEEE Transactions on, 5(4), 404-417; 10.1109/TMC.2006.1599408
[6] HealthIT.Gov; https://www.healthit.gov/faq/what-recommended-bandwidth-different-types-health-care-providers

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Why India need low-cost and high-bandwidth connectivity models in a time of isolation?

The World Health Organisation (WHO) declared COVID-19 as a global pandemic on March 11, 2020, with growing cases getting detected in over 100 countries globally. Subsequently, WHO pushed to take ‘aggressive’ on 17th March 2020 action fearing that some countries may be moving towards community transmission.

To date, 30th March 2020, there are more than 700,00 COVID-19 cases and more than 35000 deaths are reported[1]. The director-general of WHO, Tedros Adhanom Ghebreyesus in conference stressed the vulnerabilities to be faced by ill-prepared ‘weak’ countries that have poor public health systems. South Asia has seen a total of 2000 cases as of 30th March 2020 and over 1100 cases are registered in India.

The steady rise of COVID-19 cases is a huge concern for South Asian countries due to a lack of public health infrastructure and the limited availability of professionals. It can strike a crisis of very high magnitude. In response, governments, corporates, and academic institutions have not only cancelled the public events and gatherings but also closed public spaces including museums, restaurants to avoid the highly contagious pneumonia-like disease to spread from one person to another.

On March 25, the government of India announced nationwide 21 days lockdown till 14 April 2020 closing schools, offices and public transportation. In the scenario of isolation, internet connectivity has never been so important. It is critical to receive up-to-date health information and students must continue their education and working professionals to continue work from their home.

Following the footsteps of Harvard and MIT, Indian academic institutions, including IITs and IIITs also started holding virtual classrooms due to suspension of face-to-face classes. However, slow-speed and irregular connectivity are emerging issues for educational institutes before they even start online classes. For instance, Delhi University professors who are trying to conduct online classes faced the issue of connecting their students[2]. V. Sridhar, Professor at the Centre for IT and Public Policy at the International Institute of Information Technology Bangalore (IIITB), India states even though he has two fixed-line broadband services and 4G enabled mobile connectivity, yet he feels annoyed due to miserable internet connectivity available in the country. The poor status of network infrastructure in the country is amplified due to the exponential demand for connectivity at the household level. This is a scenario of metro cities like Delhi and Bangalore, where institutions like IITs and IIITs are facing the connectivity issue.

India stands at 128 out of 140 listed countries in mobile broadband, according to Ookla Speed Test report[3]. It is even behind some of the South Asian countries, including Pakistan and Sri Lanka and African countries such as Ethiopia and Senegal. Whereas in fixed broadband, the country stands at 69 out of 176 listed countries giving average speed 39.65. India has 19 million fixed-line broadband users which include enterprises and offices and 17 million home fixed-line broadband users.

If we take a closer look at the public infrastructure that is required to be connected with internet connectivity in India. There are 15 lakh schools in the country, out of which over 8.5 lakh schools are located in rural regions. There are over 1.5 health sub-centers, 25000 community health centres and 5000 public health centres in India. Around 20% of rural regions of the country are connected through the internet and most of them are connected through mobile connectivity.

In the time of isolation when we are avoiding cash-payment systems, the lack of proper digital infrastructure including mobile connectivity and broadband communications to a large proportion of the populace makes it more difficult to address authentication challenges, card security infrastructure and last-mile connectivity of Point of Sale (POS) terminals.

Moreover, in this pandemic when thousands of migrant workers are going back home in rural regions of the country, the questions arise whether they will be able to educate their children if schools are closed and not connected through the Internet and able to get basic health facilities or medicines.

The telecom networks that support voice, telephony and broadband data services are critical infrastructures for the country like India much like electricity, water, sewage and road networks. Most of this critical telecom infrastructure is built by private firms using their capital. Though, telecom providers such as Vodafone, Airtel, BSNL, Reliance Jio to activate intra-circle roaming (ICR) and also offering increased bandwidth or data plans to maintain seamless connectivity. It is not only the major telecom providers who are seeing the data traffic spikes in their network but small operators including cable operators’ network are seeing a significant spike in data traffic and demand in new connections. However, as the data traffic will increase it will not be sufficient to cater to the demand.

The situation, however, again highlighted not only the need for deep fiberisation across the country to connect towers but also the need for small community-based network solutions to connect the communities living in far-flung areas of the country. It is the requirement of time when we need an integrated model of centralised and decentralised community-led networks, which operates in both intranet and internet methods.

There are very few community-led social enterprises working for designing or deploying wireless networks catering to rural parts of the country. AirJaldi in Dharamshala, Digital Empowerment Foundation (DEF), GeoMesh Informatics in Tamil Nadu, MojoLab in Dehradun, Uttarakhand, Janastu in Tumkur, Karnataka and GramMarg in Pathardi, Maharashtra are organisations which are providing low-cost internet connectivity, enabling access to information for citizens, particularly living in rural and remote areas. These community-led network solutions are using low-cost wireless devices and unlicensed spectrum bands 2.4 GHz and 5.8 GHz to create community-owned and community-operated wireless networks.

These network providers are using different bottom-up approaches such as generating locally-created content, innovative pricing and marketing approaches to content are gaining traction, providing digital services to information services to sustain these networks. These networks are trying to provide affordable, ubiquitous and democratically controlled internet access in rural regions of the country.

For instance, GeoMio Mesh wireless node that connects the unconnected in the rural villages and power healthcare, education and security with modular software and services. Using two 5GHz radios and sector antennas, GeoMesh is an indoor/outdoor weatherproof 3-radios wireless mesh router that automatically forms a mesh network with another Geo Mesh router within range. GeoMio Mesh creates both intranet and internet networks. It automatically creates hot-spot using the 2.4 GHz radio and creates the local (intranet) network. Thereafter users can easily connect to the local network and if any router on the local network connects to other networks such as the Internet, then users on that local network automatically get access to the Internet through the mesh. Each mesh can relate with the others easily, including peering, allowing users of each network to reach the other network and can transit to get to other networks through one of your neighbours.

Whereas DEF’s Wireless for Communities (W4C) uses 2.4 GHz and 5.8 GHz unlicensed spectrum bands and low-cost wireless devices in the hub and spoke model. In the last nine years, the programme has adopted various models of engagement, ranging from the Hub-and-Spoke and Wireless on Wheels to and Internet-in-a-Box set up. These models have established 178 access nodes in 35 districts across 18 Indian states, engaging men and women equally for its installation and management. Thus, ensuring the social sustainability of the wireless community networks.

Similarly, AirJaldi started as a social, non-profit enterprise established in Dharamshala, Himachal Pradesh, to provide affordable and reliable Internet connectivity using unlicensed spectrum and wireless networks in rural communities. Gram Marg, an incubation of the Indian Institute of Technology (IIT) Mumbai, uses TV white space and now Wi-Fi to provide Internet connectivity in 13 villages of Maharashtra. DEF uses low-cost wireless technology, unlicensed spectrum bands—2.4GHz and 5.8 GHz—and line of sight to support the provision of affordable, low-cost and reliable Internet services in 38 districts of the country.

Connectivity, when combined with the Wi-Fi information hub and spoke model, can help to empower communities and bring holistic development. If people have access to broadband and adequate bandwidth, they could pursue distance education through video conferencing, able to share their local indigenous content with a larger audience. By delaying access to the Internet and not enabling communities with high-speed internet connectivity, we are constantly underutilizing our potentials and, consequently, delaying economic prosperity.

It is high time for the government to take a broader decision on the health of the telecom industry, thereby need to have a new policy for rural ISPs, which can focus on serving underserved communities. Rural ISPs that can become sustainable and commercially viable entities that offer internet connectivity, digital literacy, and other digital services at prices that the bottom of pyramid consumers can afford. The situation of isolation is a polite reminder to have adequate internet connectivity and higher bandwidth that can potentially connect us and also provide economic and business continuity to some extent.

Author: Ms. Ritu Srivastava, representing Jadeite Solutions, has over 14 years of experience in the development sector specifically focusing on the ICT domain, using digital technology towards sustainable development of underprivileged communities / marginalised sections of society and over 8 years of experience in working with community networks.

 

[1] https://www.worldometers.info/coronavirus/#countries

[2] https://www.outlookindia.com/newsscroll/covid19-internet-speed-connectivity-emerging-as-challenges-in-holding-online-classes-du-professors/1785213

[3] https://www.speedtest.net/global-index

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Regional languages and changing trends of internet users

REGIONAL LANGUAGES AND CHANGING TRENDS OF INTERNET USERS

India is the home of 1.21 billion people (Census 2011), speaking 30 languages with 1600 dialects. It is the third largest country in-term of internet users in the world after USA and China. Internet users are growing with every passing second, extensive reach of Internet made it possible for India. As per KPMG in India’s analysis, April 2017, 78 per cent internet users accessing internet through their mobile phones. Despite these statistics, India still has the potential to perform exceptionally in the number of Internet users in the world. Standard language (English) to use internet holding the number of Internet users.

Language barrier 

Language is one of the prominent barriers that is restricting the number of internet users mainly from rural India. As per W3Techs estimation until September 2018, more than 53 per cent of the website’s homepages found in English and language ranked first. Whereas, the website available with Hindi homepage found a position at 39th place with 0.1 per cent.

Source: W3Techs.com

Language preference

As per KPMG in India’s analysis, April 2017, out of 521 million Hindi speakers 254 million users prefer the Hindi language over English to read, write and converse with each other. Other insight details of different languages illustrated in the figure given below.

Source: KPMG in India’s analysis, April 2017
*These 8 languages have been considered as Indian languages for the purpose of this report
** Indian languages users are Indian language literates who prefer their primary language over English to read, write and converse with each other

There were 110 million internet users in 2011 in India. Majority of internet users (62%) were using internet in the English language, there were only 38 per cent internet users using internet in different Indian languages. In the year 2016, the picture had changed, a number of internet users have grown to 409 million from 110 million in 2011. Internet users using internet in Indian languages subsequently grown to 57 per cent (234 million).

Source: KPMG in India’s analysis, April 2017

As per the report, Internet penetration in India expected to grow 52 per cent by 2021 and the number of internet users would be around 735 million. Out of total internet users in 2021, 73 per cent would be using it in Indian languages.

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Cyber-crime cases registered in India from 2013 to 2015

Cyber-Crime cases registered in India from 2013 to 2015

Cyber-crime achieving new heights every year in India. India has the third highest number of internet users in the world after USA and China. Register number of cyber-crime cases have increased more than 100 % from the year 2013 to 2015. Collectively, 11592 cyber-crime cases registered in the year 2015. However, a sizable number of cyber-crimes are not be registered in the absence of knowledge.

Source: Ministry of Electronics and Information Technology

The figure below shows the percentage of cyber-crime cases registered in India. Altogether, 11592 cyber-crime cases registered during the year 2015. Majority of cyber-crime cases registered in Uttar Pradesh (19%) and Maharashtra (19%). Maharashtra has the highest number of internet subscribers in the country, as per the government of India at end of March 2016.

Source: Ministry of Electronics and Information Technology

Karnataka and Rajasthan registered 12 and 8 per cent of cyber-crime cases respectively. In West Bengal, Odisha and Kerala there were three per cent cases registered in each state. Puducherry, Lakshadweep, D&N Haveli, Nagaland, Sikkim, Manipur, Arunachal Pradesh and Goa were the state where no or a negligible number of cyber-crime cases registered in India during the year 2015.

 

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Facebook: A giant of social networking sites

We are more connected and updated over the social networking with our family and friend. The virtual world is full of social networking sites and we are feeding these websites every day with our daily information. Facebook is one of the top social networking site in the world with 2234 million active users until the second quarter of 2018.

Sources: Sources: We Are Social; Kepios; SimilarWeb; TechCrunch; Apptopia; Fortune

Facebook launched in the year 2004, now it is a 14 years old social networking platform. In all these years, it has gained 2234 million users. In the recent decade (2010 to July 2018), Facebook has added 1626 million fresh users. A large number of users made it the top website among the all social networking sites.

 

Source: Facebook

 

Facebook has the responsibility to protect the personalized information of users and keeping the credibility of the platform. A large number of available information on this website attract hackers to breach the information.
At the end of September 2018, Facebook engineers discovered a breach in the website. Around 50 million Facebook user’s account compromised by the attack that gave accesses to hackers to take over user’s account.

 

Source: Facebook

Annual growth of Facebook users depicted in the above figure, it shows that on an average Facebook adding more than 200 million users every year.  In the years 2013-14, Facebook was the low performer in term of adding new users. However, in the last two years (2016-17) it performed quite well in adding new users.