Executive India and Pakistan. The joint donor funded

Executive Summary

Bangladesh is one of the most densely populated
countries in the world. It is a unitary state and parliamentary democracy.
Health and education levels are relatively low, although they have improved
recently as poverty levels have decreased. Most Bangladeshis continue to live
by subsistence farming in rural villages. Bangladesh faces a number of major
challenges, including poverty, corruption, overpopulation and vulnerability to
climate change. However, it has been lauded by the international community for its
progress on the Human Development Index. Bangladesh has made more notable gains
in a number of indicators than some of its neighbours with higher per capita
income, such as India and Pakistan. The
joint donor funded Health, Population, and Nutrition Sector Development
Programme (HPNSDP) has contributed to significant improvement in a number of
health indicators including reduction in under-five mortality, immunization
coverage, maternal mortality and total fertility. The country has improved
women’s education, and economic conditions and life expectancy. Despite current
economic growth, poverty and income inequality remain persistent challenges in
Bangladesh.  Beginning in 1998, UPHCSDP is a government run initiative
that involves public private partnerships with national NGOs to improve the
health status of the poor in 11 city corporations and 4 municipalities by
providing an essential package of high-impact services. The project is now in
its third phase, which will run until June 16th 2017.

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Mobile technologies are increasingly growing in
developing countries like Bangladesh. There have been several new researches
and developments in this space. Nowadays mobile is becoming an important ICT
tool not only in City regions but also in remote and rural areas. The rapid
advancement in the technologies, ease of use and the falling costs of devices,
make the mobile an appropriate and adaptable tool to bridge the digital divide.
Mobile phone ownership in Bangladesh is growing rapidly, almost six million new
mobile subscriptions are added each month and one in five Indian’s will own a
phone by the end of 2014. By the end of 2015, three quarters of Bangladeshi
population will be covered by a mobile network. Many of these new “mobile
citizens” live in poorer and more rural areas with scarce infrastructure
and facilities, high illiteracy levels, low PC and internet penetration. The
availability of low-cost mobile phones and the already broad coverage of GSM
networks in India is a huge opportunity to provide services that would trigger
development and improve people’s lives. Present status of Mobile based
Health Care systems in different countries, shortfalls in Primary Health Care
Management in rural India, and the potential solution to fill it with the
enabling of Mobile Web technologies for Primary Health Care management.




Total number of mobile users worldwide as of late
2006 was about 2.7 billion and the number of Internet users was just above 1.1
billion. This means that at least there is 23.6% of world population (and at
least 22.2% of developing countries’ population) who already have mobile phones
but are not yet using the Internet. Mobile services are quickly emerging as the
new frontier in transforming government and making it even more accessible and
citizen-centric by extending the benefits of remote delivery of government
services and information to those who are unable or unwilling to access public
services through the Internet or who simply prefer to use mobile devices. In
theory, many government services can be now made available on a 24x7x365 basis
at any place in the world covered by mobile networks, which today means almost
everywhere. Approximately 50%–60% of government services including Primary
Health Management can be delivered via mobile channel. 2. Primary Health Care
Services using Mobile Devices ensures improved access to primary healthcare and
its gate-keeping function leads to less hospitalization, and less chance of
patients being subjected to inappropriate health interventions.


Geography and

is bordered by the Bay of Bengal in the South, Myanmar in the south-east, and
India to the east, north and west. The majority of the territory is a low-lying
delta plain traversed by an extensive network of large and small rivers vital
to the socioeconomic life of the nation, with hilly areas scattered in the
north and east (Figure 1.1). Bangladesh is known as the worst victim of the
direct and indirect effects of global climate change (DGHS, 2012). Bangladesh
has a population of 151 million, occupying 147 570 square kilometres (World
Bank, 2013). The population density of 1161 people per square kilometre is one
of the highest in the world (Table 1.1) (World Bank, 2013). About 90% of the
population are Muslims, 9% are Hindus and 1% are Christians, Buddhists and
other faiths (DGHS, 2012). Bangladesh has experienced a remarkable demographic
transition, with a rapid decline in the fertility rate from 6.9 births per
woman in the early 1970s to 2.3 in 2010 (World Bank, 2013) and a population
growth rate of only 1.37% between the 1991 and 2011 censuses (Bangladesh Bureau
of Statistics (BBS) and Ministry of Planning Statistics and Informatics
Division (SID) , 2012). In addition, Bangladesh is experiencing rapid urban
growth, with an urbanization rate of 3.5% annually (Banks, Roy et al., 2011),
which has increased the proportion of the population living in cities and towns
from 3.6% in the 1970s to 14.4%in 2010 (Table 1.1) (UPPR, 2012; World Bank,
2013). 3 Administratively, the country is divided into seven divisions, 64
districts (zila) and 545 subdistricts (upazila) (NIPORT, Mitra and Associates
et al., 2013). The seven administrative divisions are, in order of population
size: Dhaka, Chittagong, Rajshahi, Rangpur, Khulna, Sylhet and Barisal. Each
rural area in the upazila is divided into union parishads, and mouzas within a
union parishad; an urban area in an upazila is divided into wards, and into
mohallas within a ward. These divisions allow the country as a whole to be
easily separated into rural and urban areas. There are no elected officials at
the divisional or district levels, and the administration is composed only of
government officials. Direct elections are held for each union (or ward),
electing a chairperson and a number of members.



The objective of this paper is to bring out status
of mobile devices based Health care management systems in the world
particularly in India and present the details of Mobile based Primary Health
Care Management System under development by CDAC, Electronics City for
deployment in the PHCs in rural India.

Program Goals

The Government of Bangladesh has made a substantial commitment to
provide comprehensive health care to its people. Notable success has been
achieved in the delivery of EPI, ORS, sanitation and family planning services
for which Bangladesh is internationally recognized. The national development
plans laid out the foundations for comprehensive delivery of a wide variety of
Health and Family Planning services in urban and rural areas. However, for a
period of time, there was proportionately less than optimum investment in
primary health care services for the urban poor and slum dwellers to meet those
priority needs.



The Project will improve the efficiency of urban health
services by:

Improving the spatial
distribution of health center – PHC centers, comprehensive reproductive health
care (CRHC) centers, and mini-clinics – in accordance with population density
and geographical factors.

Supporting cost-effective
interventions to reduce mortality and morbidity.

Enabling low-cost
private sector participation in the provision of preventive and promotive
health care services by partner NGOs.

Allowing appropriate
user fees.

Improving the
monitoring and supervision system.

Concentrating on the
provision of health services that will create the greatest public good in order
to use scarce government resources more efficiently.


Over 50% of the project’s target population is from four
main groups:

Slum dwellers living
legally in slums;

Squatters living
illegally on land owned by others;

Floating populations
with no fixed residence

Other urban poor
living throughout urban areas, mixed with the non-poor.

The Project
will target all four groups through mini- or satellite clinics, outreach
activities, and domiciliary services. Large slums will have mini-clinics, which
will be open in the evening to maximize their use by the poor.

The project
will continue to contract out primary health care (PHC) services to nongovernment
organizations through partnership agreements that were pioneered under the
first Urban Primary Health Care Project (UPHCP-I). The Project will ensure
pro-poor targeting by requiring that at least 30% of the preventive, promotive,
and curative services provided are for the poor. Overall, 38% of clinical
services are provided for free, including free medicine to the identified urban

As of 2014,
the project covers more than 10 million people amongst the urban populations of

Mobile technology for Health Care

Amongst the many ICT options available to govt. to
improve the efficiency& effectiveness of its delivery process of primary
health care, mobile & wireless technologies offer some exciting
opportunities for a low cost, high reach service. There is strong evidence that
mobile technologies could be instrumental in addressing slow response rates of
govt. to citizen requests, poor access to services, particularly for low-income
and marginalized populations in underserviced rural areas. In addition, mobile
technologies offer significant opportunities for improving the back-office
operations of govt. In addition, many primary healthcare clinics located in the
rural areas do not have any electronic systems at all & continue to operate
paper- based systems, resulting in patient records being kept by patients
themselves. The impact of the use of multiple systems is that it is
difficult& costly to develop a national overview of patient statistics. On
a more basic level, it is extremely difficult for individual institutions
within the healthcare sector to share information between each other. One of
the clearest examples of this is to be found in the sharing of patient
laboratory results. Currently in most instances, this only takes place through
manual exchange. Many vendors of Cellular phones started to embed a variety of
e-health services in Mobiles.



Telemedicine System in Indonesia.

 The project began by conducting several field
surveys in the implementation area of Sukabumi, West Java. The target area
covers about 4,248 square kilometres and has a population of about 2.3 million
people. The altitude varies within the range of from sea level to nearly 3,000
metres. The topography consists of highlands, hills and coasts. Three hospitals
and 71 community health centres serve the local population. The project has also
completed field surveys on the quality of the existing communication signals in
about 35 locations in Sukabumi area. To date the results of the project
research activities have been presented in two national seminars, the National
Biomedical Engineering Seminar, Yogyakarta, 25 February 2006 and the Symposium
on Development of Emergency and Disaster Communication & Information
System, Jakarta, 7 March 2006.

Systems in

A number of Organisations have been working on
various projects for enhancing the role of ICT in Health care. UK-based
Loughborough University’s engineers have entered upon a partnership with
experts of India to develop a unique mobile phone health monitoring system. The
system, which was first unveiled in 2005, uses a mobile phone to transmit a
person’s vital signs, including the complex electrocardiogram (ECG) heart
signal, to a hospital or clinic anywhere in the world. Professor Bryan Woodward
and Dr Fadlee Rasid from the Department of Electronic and Electrical
Engineering at the Loughborough University have developed this mobile phone
monitoring system. Presently the system can transfer the signals pertaining to
the ECG, blood pressure, oxygen saturation and blood glucose level. Now the
UK-India Education and Research Initiative (UKIERI) has awarded Professor
Woodward a grant to further develop this mobile phone monitoring system. They
have tied up with the Indian Institute of Technology Delhi (IIT Delhi), the All
India Institute of Medical Sciences and Aligarh Muslim University and London’s
Kingston University, to further develop the system.

Team work

The research team is aiming to miniaturise the
system, through designing sensors and mini-processors that are small enough to
be carried by patients, and at the same time procure biomedical data. The
network of sensors would be linked through a modem to mobile networks and the
Internet, and to a hospital computer. Then, doctors can use this device to
remotely monitor patients suffering from chronic diseases, like heart disease
and diabetes, which plagues millions across the world. The UK government will
promote the device to improvethe efficiency of healthcare delivery. In India,
the project will link clinics and regional hospitals in remote areas to centres
of excellence. The clinical trials of the system will take place in the UK and
India in the next three years.

Health Care

The Vancouver Island Health Authority defines
Primary Health Care as the range of services individuals and communities
receive on a regular, ongoing basis in order to stay healthy, get better,
manage ongoing illness or disease, and cope with end of life. In India, Primary
Health Centers (PHCs) are the cornerstone of rural healthcare; a first port of
call for the sick and an effective referral system; in addition to being the
main focus of social and economic development of the community. It forms the
first level of contact and a link between individuals and the national health
system; bringing healthcare delivery as close as possible to where people live
and work.

Primary healthcare services substantially affects
the general health of a population, however many factors undermine the quality
and efficiency of primary healthcare services in developing countries. The
World Health Organisation (WHO) specifically points out that to some extent,
the deterioration in health status in developing countries is attributed to
inadequacies in PHC implementation, neglecting the wider factors that have been
responsible for this deterioration such as lack of commitment, inadequate
allocation of financial resources to PHCs and community participation

Health care in India.

In India, although there are many reasons for poor
PHC performance, accessibility is one of the major obstacles. The public health
system is managed and overseen by District Health Officers. Although thre are
qualified doctors, PHCs have barely able to utilize due to non-usage of IT and
Mobile access. The rural primary public health Infrastructure has recorded an impressive
development during the last 50 years of independence. The network consists of
1,45,000 sub-centres, 23,109 primary health centres and 3222 community health
centres, catering to a population of 5000, 30,000 and 1,00,000 respectively
(and 3000, 20,000 and 80,000 population in tribal and desert areas)3. Each
PHC is targeted to cover a population of approximately 25,000 and is charged
with providing promotive, preventive, curative and rehabilitative care. This
implies offering a wide range of services such as health education, promotion
of nutrition, basic sanitation, the provision of mother and child family
welfare services, immunisation, disease control and appropriate treatment for
illness and injury. The PHCs are hubs for 5-6 sub-centres that cover 3-4
villages and are operated by an Auxiliary Nurse Midwife (ANM). These facilities
are a part of the three tier healthcare system; the PHCs act as referral
centers for the Community Health Centers (CHCs), 30-bed hospitals and higher
order public hospitals at the taluka and district levels.

based Primary Health Care Management System

CDAC, Electronics City, Bangalore has initiated the
development of “Mobile based Primary Health Care Management System” for
deployment in the PHCs for betterment of management of Primary Health Care
specifically in the rural and urban slums of India. The system will capture of
complete information related to an individual patient treated by a PHC. The
Software components under development are Patient Database management,
Interaction between doctor and a patient, capture of Medical data acquisition-
such as ECG, images of heart & lung, eye etc and Scheduling management. The
project involves development of the following:

(a) A Web based
Information system for Management of Primary health care.

(b) SMS
interface for integrating SMS messages from the patients using 2 nd Generation
mobile systems (GSM/CDMA) with the Information system.

(c) WAP Gateway
for Web access Applications using WML for integrating GPRS/3G/4GMobile devices
of Doctors and Nurses with the Web server.

 (d) Development of Localization Support to
National and other Indian languages in mobiles by providing interface for


System Overview

A Central repository of Primary Health Center
management System with a Web interface is proposed to be developed in an Open
source database. An SMS based interface to the Web is planned to be added for
integrating with 2G (GSM/CDMA) telephones, since Mobiles have penetrated
overwhelmingly in rural India. A WAP web Gate way will be developed for
integrating with a GPRS/3G mobile devices, which are expected to be used by
Doctors and Health Assistants. In case of GPRS/3G systems, the Web request from
the phone is first served by the WAP Gateway Server. The gateway server
translates mobile phone requests (WAP) into HTTP requests and sends them to Web
server. The Web server processes the request, and sends WML to gateway server,
which in turn sends the WML to phone in the binary compressed WML format.


The pictorial
representation is depicted below-




The Primary
Health Care Server, having the information System can be

Accessed through
Mobiles with GPRS connectivity-





Sub Systems

The sub-systems under development are

(a) A Central Information Repository with database
of the Patient information and other resources/services

(b) Web server

© SMS interface for receiving/sending SMS to 2G
Mobile systems, which receives the SMS, converts the SMS into a query and
executes the query. The results are then sent as an SMS reply.

(d) WAP Gateway for linkage with a GPRS/3G mobile.
The gateway server translates mobile phone requests (WAP) into HTTP requests
and sends them to Web server. The Web server processes the request, and sends
WML to gateway server, which in turn sends the WML to phone in the binary
compressed WML format

Localization Module for providing interface for translation. Highlights 18.
Health Information system in which each family has an up-to-date family folder
is a valuable tool for maintaining, analyzing and interpreting the enormous
data. The Mobile based Primary health Care Management System will seek to

Increased quality of primary healthcare (PHC) services.

Increased efficiency of service care with an adequate referral and remote
consultation system.

 (c) Improved epidemiological surveillance and

 (d) Better pregnancy case registration and

 (e) Reduction of maternal and perinatal
mortality and morbidity.