1

TELE-OPHTHALMOLOGY IN TRIPURA

AUGUST 2011

Researched and Documented By:

OneWorld Foundation India

2

Contents

Executive Summary ............................................................................................................................................................... 3

Background .............................................................................................................................................................................. 4

Objective ................................................................................................................................................................................... 4

Working Design ....................................................................................................................................................................... 4

Methodology ............................................................................................................................................................................ 7

Key Stakeholders .................................................................................................................................................................... 7

Lessons Learned .................................................................................................................................................................... 7

APPENDIX A 11

3

EXECUTIVE SUMMARY

In order to overcome the challenges of inadequate resources for ophthalmologic1 care in the state the Department

of Health and Family Welfare, Government of Tripura, in 2007, initiated the Tripura Vision Centre - a tele-

ophthalmology project that utilises information and communication technologies (ICT) to facilitate quality eye care

to people residing in rural locations.2 This project is considered a success as it optimally employs the existing

resources and adopts advances in telemedicine programmes in order to address overall eye care needs of the

state’s population, at an affordable cost.

There are a total of 40 Vision Centres (VCs) in the state – one for each block. All the VCs of the state are

established in the premises of Community Information Centres (CICs) set up under National e-Governance Plan

(NeGP). The calculative move of establishing VCs adjacent to CICs served the purpose of leveraging existing

infrastructure and Tripura State Wide Area Network (TSWAN) connectivity along with attracting locals who visit

CICs for a host of citizen centric services provided.

The VCs are connected to the Indira Gandhi Memorial (IGM) Hospital in the state capital Agartala from where the

ophthalmologists tele-consult the patients. Ophthalmic assistants at the VC screen the patients and enter

information in the database. The assistants also capture the images of the eye which are uploaded to the

database along with the patient’s history. With the help of TSWAN, relevant information is transferred to the

referral centre, where the images are diagnosed and the modality of treatment is prescribed.

The decentralisation of healthcare enabled through VC has led to increase in the number of women screened to

10 percent during 2007-2011. Total number of glass prescribed from the vision centres 43,433 and total number

of refraction performed are 96,222. Total number of cataract patients identified till July 2011 are 5533 and total

number of cataract surgery performed till July 2011 are 3480 under the project. The successful implementation of

the tele-opthalmic project in Tripura is reflected in the number of patients being screened during the period April

2007- July 2011 - 1,28,200 out of which 56 percent are male and 44 percent are female.

Though the project had initially faced challenges such as lack of suitable site for vision centre layout, shortage of

modern infrastructure, unstable current supply and unavailability of ideal space for tower, it could mitigate those in

short time through expertise and mutual cooperation from all the stakeholders. Observing the success and

replicability of the Tripura tele-ophthalmologic project, the Planning Commission of India is contemplating to

replicate the model in the 12th Five Year Plan.

1 Ophthalmology is the branch of medicine which deals with the diseases and surgery of the visual pathways, including the

eye, brain, and areas surrounding the eye, such as the lacrimal system and eyelids.

2 Telemedicine, 2011-08-02, http://telemed.esanjeevani.in/Telemedicine/TeleOphthalmology.aspx

4

Structural Setup:-

-- We are having connectivity of

private lease line and VPN network

from Tulip.

-- Provision is there to use

T-Swan Connectivity.

-- Broad band Internet connectivity.

-- DATA CENTRE at IGM Hospital.

-- Un interrupted power supply to all

the Vision Centres by using online

UPS of back-up time 1½ hrs.

-- Additional Tele-medicine facilities

BACKGROUND Tripura has an acute shortage of modern ophthalmologic infrastructure and specialists. There is only one public

sector hospital, the Indira Gandhi Medical (IGM) Hospital, in the capital of the state that serves the need for all

secondary and tertiary care support. Seventy-five percent of the population that reside in the rural areas have to

spend considerably on transportation and

accommodation to avail the service. Apart from the IGM

hospital there are only three secondary care centres and

three primary care centres in the state. At present, a

total of 17 ophthalmologists and 26 ophthalmic

technicians are catering to the needs of 37 lakhs

residents. By 2014, the numbers are estimated to

reduce further as out of the 17 ophthalmologists, 10 will

retire from the service, implying that only 8 or 9

ophthalmologists will be providing eye care to a

projected population of 40 lakhs. This trend is bound to

increase pressure on ophthalmologic infrastructure and

expertise at the state healthcare mission. Moreover,

geographical location of Tripura presents an inherent

challenge of easily accessing services and expertise

from the mainland India as it is physically distant

because of Bangladesh.

The government of Tripura has initiated measures to address these concerns by increasing the number of

ophthalmologists to minimum one per 50,000 populations; however, it will require a considerable amount of time

to achieve this target. Therefore, to offer a pragmatic solution, the state government decided to adopt information

and communication technology (ICT) to extend the benefits of the advanced medical sciences to the entire

population, including the remote and inaccessible parts of the state, through Tripura Vision Centre programme.

OBJECTIVE The Tele-ophthalmology project implemented by the Ophthalmology Department, Department of Health and

Family Welfare, Government of Tripura aims to combine advances in medical sciences and ICT to offer primary

and preventive eye care services to the rural citizens of Tripura.

WORKING DESIGN Project Infrastructure

The tele-ophthalmology project required setting up of vision

centres in all the blocks of the state in order to decentralise eye

care to meet the requirements of the rural population of Tripura

The project was implemented in three phases to cover all 40

Blocks of rural Tripura. The first phase was commenced in the

month of April 2007 on a pilot basis in Melaghar. Based on the

progress made the project was upscaled in September 2008 to

include 10 additional blocks with a population of approximately

15 lakhs. The third phase, was completed in 2009 to cover the

rest of 29 blocks of the state.

FIGURE 1 VISION CENTRE

FIGURE 2 THE PROJECT INFRASTRUCTURE

5

Network Architecture of the Project

The Vision Centres (VC) are established adjacent to Community Information Centres in order to leverage the

existing Tripura State Wide Area Network (TSWAN) infrastructure at the CICs.

These VCs are connected to the IGM hospital located in state capital Agartala. Opthalmic assistants are incharge

of registering and screening the patient, and are also responsible for entering the patient’s history in the database.

Diagnosis in eye care is more focused on the images of the retina and the posterior of the eye. The VC captures

the images of the eye which is uploaded to the database along with the patient’s history. ICT is utilized to transfer

the images of the diseased eye to the referral centre where the pictures are diagnosed and prescribed the

modality of treatment.

Required Equipments

The equipment required for the technology-based treatment process is same as regular ophthalmology process.

The medical equipments used include a slit lamp, direct ophthalmoscope, streak retinoscope, trial set with frame,

+78D lens, digital camera, schiotz’s tonometer, starilizer etc. In addition, the technological hardware required for

the project is desktop computer with multimedia kit, including a web camera and a printer.

Network architecture

In order to facilitate video conferencing and data transfer between the VCs and the IGM hospital Mulitprotocol

Label Switching (MPLS) wireless VPN (peer to peer) connectivity and State Wide Area Network (SWAN)

connectivity are established. Wireless network is also deployed to operate with Near Line of sight (LoS) in most

areas and non Line of Sight in some areas.

For uninterrupted tele-consultation with patients from VCs across 40 locations a real time consultation facility is

established in the IGM hospital with required web based video conferencing software and VCMS module for

validation of doctors and sending out signed prescriptions.

FIGURE 3 NETWORK ARCHITECTURE

6

Database of patients’ history

The ophthalmologic assistant enters the patient’s history to the centre’s database along with the images of the

eye that can be easily shuffled between the secondary and tertiary care hospital as and when required. The VC

database server is located at the IGM Hospital in Agartala.

Human resources

Seventeen ophthalmologists from the IGM hospital are

diagnosing and treating patients through tele-ophthalmology in

40 blocks of the state.

Ophthalmic assistants are screening and examining the

patients, filling up the data in the online module along with

taking care of both clinical and non clinical infrastructure in the

VCs. They conduct regular tele-consultation with the

ophthalmologist at the base hospital.

There are also Multi Purpose Workers (MPWs) who register

the patients and counsel them in case they require attending

the base hospital for further treatment. Arvind Eye Care Hospital, Madurai, Tamil Nadu; and Netra Niramay

Niketan, Haldia, West Bengal give training of the ophthalmic assistants and MPWs on a regular basis.

Monitoring

Regular supervision and cross examination of the service delivery with assistance from the Management

Information System (MIS) generated data along with hospital reports enable accurate measurement of the quality

and effectiveness of the service offered.

Diseases diagnosed

Catract Pterygium Lid disease Blunt Trauma Corneal ulcer

FB PCO Corneal Opacity Fungal Keratitis Viral Kertitis

Anterior

Uvetis

Retinal problem Chalazion Hazy cornea Entropion

BRVO ARMD Squint Ptosis High IOP

Optic Atrophy Def. Vision Glaucoma Dacryocystitis Asthenopia

Corneal Scar High Myopia High

Hepermetropia

High Astigmetism Physician Check

Up

FIGURE 4 PATIENT SCREENING

7

METHODOLOGY The Governance Knowledge Centre (GKC) research team identified the tele-ophthalmology project of Tripura as

a best practice because this is a comprehensive model for providing primary and preventive eye care in a

decentralised manner using the benefits of Information and communication technologies (ICT) integrated with the

medical eye care solutions. The team used both primary and secondary research methods for the preparation of

this best practice document.

Conducting desk based secondary research, available through online material the team gathered important

information on the background, operations and achievements of Tripura Vision centre. In order to validate the

secondary research findings, the team adopted the interview method to carry out primary research. Responses

were obtained from Dr Sukumar Deb, Deputy Superintendent- IGM Hospital, Department of Health and Family

Welfare, Government of Tripura through telephonic interview on many important aspects of implementation of the

programme. The insights obtained were utilised with the desk research to prepare this document.

KEY STAKEHOLDERS The Department of Health and Family Welfare, Government of Tripura conceived the tele-ophthalmology project.

It is responsible for allocation of doctors as well as its budget for successful operation of the project. The

Department of Information Technology, Government of Tripura helps in promoting the project across the state.

National Rural Health Mission shares the financial liability with the state government.

IL & FS Education and Technology Services Ltd and Arvind Eye eCare System designed the project for the

government of Tripura. They bring in required technology and clinical partners for the project. IL & FS also creates

an administrative framework for VC management along with ensuring meeting of project deliverables. IL & FS and

Arvind Eye eCare also build capacity for managing the project within the health system of the government.

LESSONS LEARNED Leveraging ICT to offer advanced medical care

Tele-medicine as a promising branch of advanced medical care was not much popular in Tripura prior to the

conception of the Tripura Vision Centres. The project is an innovative attempt to deliver eye care services using

sophisticated yet easily replicable technology to even the most marginalised person of the remotest part of the

state. Articulate distribution of VCs around the state and each of its uninterrupted connectivity with the base

hospital are enabling patients to obtain eye care service on a daily basis from 9 am to 4 pm. Appropriate

utilisation of technology is mitigating the acute shortage of man power and infrastructure in the state.

Convergence with CICs

The CIC project of the government of India was implemented with the aim of bringing the

multifarious benefits of ICT to the grassroots in the relatively remote and less developed regions of India.3 Apart

from providing basic services such as IT education, training, internet access and e-mail, CICs established under

National e-Governance Plan also provide citizen-centric services. The government of Tripura in an innovative

approach decided to establish all the VCs adjacent to all the CICs. It helped VCs to use dual connectivity, one

from CIC i.e. TSWAN and another is from private MPLS-VPN network provided by Tulip. This move of the

33

Chaudhri nadita and Shefali S Dash, Community Information Centres, 2011-08-03, http://www.csi-

sigegov.org/casestudies/13_cics.pdf

8

government of Tripura helped in reducing the

cost of civil infrastructure by the health

department on connectivity. The location of the

VCs adjacent to CICs has helped in outreaching

the rural population as they often visit the CICs

for other government-to-citizen (G2C) services.

Decentralisation of eye care

Prior to the establishment of vision centres the

patients had to travel to the capital of the state

Agartala for ophthalmic care. 75 percent of the

population of the state who reside in rural areas

had to spend a lot of money on travelling and accommodation. With the establishment of four vision centres in

semi urban locations and 36 in rural areas of the state ophthalmic care became decentralised. The massive

increase in the number of patients screened due to the decentralised service delivery is shown in the diagram:

Integration of primary, secondary and tertiary care

Majority of the patients visit VCs for treatments related to

refractive errors.4 The numbers of patients with cataract

surgical requirements are lesser and are referred to secondary

eye care service hospital only after video consultation from the

VCs. Tele-ophthalmology helps in reducing the unnecessary

patient transfer to secondary care facilities. Thus, the project

enhances the capacity of the existing ophthalmological services

in Tripura by structurally integrating the primary, secondary and

tertiary care.

4 The inability of the eye to accurately focus the rays of light coming from distance on the retina is called refractive error. Glass

and contact lens often correct refractive error.

Total Refraction Performed

96222

Eye Glass Prescribed

43433

Year April'07 - March'09

Year 2009-10

Year 2010-11

Year April'11-July'11

14709

34361

58475

20675

8101

19957

32959

11241

6608

14404

25516

9434

Female Male Total

FIGURE 5: TOTAL PATIENTS SCREENED

FIGURE 6: EYE GLASS PRESCRIBED AT THE VISION CENTRE

9

Increase in women’s participation

In the initial stage of the project it was

observed that percentage of women

being screened in the government

hospital was considerably low. With

establishment of vision centres, eye

care service was taken to the door step

of the rural people leading to an

increase in the number of women being

screened in the centre. Prior to the

implementation of the project 34 percent

women and 66 percent men were

screened in the government hospital.

Now, with the improvement in

accessibility, more women are

encouraged to come out of homes for diagnosis and treatment, resulting in 10 percent increase in women’s

participation.

Creation of trained manpower

In order to ensure quality human resources, the government provided training to qualified medical technicians to

familiarize them with necessary skills required in the field of ICT and advanced medical sciences to operate

clinical and non clinical infrastructure in VCs. These capacity building exercises for the project were in

collaboration with Arvind eye care hospital in Madurai, Tamil Nadu and Netra Niramay Niketan, Haldia, West

Bengal.

Male56%

Female44%

Total Patientss Screened w.e.f April'07 to July'11

Total - 128220,Male Patients Screened - 72258,

Female Patients Screened - 55962

Male66%

Female34%

Percentage of Men & Women Screened in Govt. Hospitals & Screening Camps b/w

2005 and 2009

Number of refral patients till

July2011, 8340

Number of refral patients treated & cured till July

2011, 5478

FIGURE 7: NUMBER OF REFERAL PATIENTS TREATED AND CURED AS OF JULY 2011

Source: IGM Hospital

10

Leveraging existing resources

The project uses the already existing infrastructure of the state by establishing the VCs in CIC premises. The

government did not have to procure any special equipment apart from the mandatory medical and IT equipments

such as slit lamp, direct ophthalmoscope, streak retinoscope, digital camera, sterilizer, desktop computer,

multimedia kit, web camera etc. The establishment cost of 40 centres including site preparation, equipment and

manpower charger was Rs 3,24,25,686. Running and maintenance cost of the project per year is Rs 1,60,07,857

with an enhancement of 10 percent per year. Entire financial liability is borne by the NRHM and government of

Tripura. In case of Tripura this is the best financially viable ophthalmic care service that helps the state

government in reducing the acute pressure that was build up due to extreme shortage of ophthalmic care in the

state. The project at present is offered to the poor patients of the state free of cost.

Challenges and the way ahead

The project had initially faced challenges such as lack of suitable site for vision centre layout, lack of modern

infrastructure, unstable current supply and unavailability of ideal space for tower. However with diligent planning,

efficient management and continuous dialogue among all the stakeholders the challenges were mitigated. The

task of humanising and localising information communication technology as well as medical advancements to

serve at the grassroots was one of the major challenges of the Tripura government. The success in dealing with

this particular challenge makes the tele-ophthalmology project of Tripura Vision Centre a unique one.

The scalability and replicability of this ongoing project has inspired the Planning Commission of India to replicate

the model in the 12th Five Year Plan of the country.

Research was carried out by the OneWorld Foundation, Governance Knowledge Centre (GKC) team.

Documentation was created by Research Associate, Ajupi Baruah

For further information, please contact Mr. Naimur Rahman, Director, OWFI.

REFERENCES

Chaudhri Nadita and Shefali S Dash, Community Information Centres, 2011-08-02, http://www.csi-

sigegov.org/casestudies/13_cics.pdf

eHealth India 2009 Award for Government/Policy Initiative of the Year, 2011-08-02,

http://www.eindia.net.in/2009/awards/pdf/tvc.pdf

Tripura Vision Centre Project, 2011-08-02,

http://www.eindia.net.in/2010/awards/details/ehealth_GvtPolicyInitiative-Details.asp?PNo=5

Telemedicine, 2011-08-02, http://telemed.esanjeevani.in/Telemedicine/TeleOphthalmology.aspx

11

APPENDIX A

Interview Questionnaire

Background:

1. When was the Tripura Vision Centre project implemented? What was the motivation behind

implementing the project?

a. Can you describe the status of eye care services in Tripura prior to the implementation of the

project?

2. What is the current geographic scope of the project? How many centres are there in every district?

a. Vision Centres (VC) are established in Community Information Centres. Are there VCs in all CICs

in the state? If no, what is the basis for selecting project location?

3. Are these centres in both urban and rural areas? Please provide statistics on existing VC in both urban

and rural area

4. Why did the government choose to integrate VCs with CIC?

a. Are these CICs established under National e-Governance Plan (NeGP)? If no, please elaborate

on the structure of CICs in Tripura.

Stakeholder:

5. Government of Tripura’s Department of Health and Department of Information Technology, together

with IL & FS are key stakeholders of the project. Are there any other stakeholders? If yes, please list

the stakeholders and explain their roles and responsibilities.

Working design:

6. We understand that the Tripura Vision Centre model was designed in three phases. Can you explain

these phases in detail?

7. How does the teleopthamology work? What kind of Information and Communication Technologies are

utilised to treat/diagnose patient?

a. What are the infrastructural requirements for setting up VC?

b. Does teleopthamology require government to procure special equipment? If yes, what are they?

8. What kind of technological connectivity is used for exchanging data between VC and base hospitals?

a. If real-time data exchange is not used, then what kind of data storage facilities is used at TVC?

b. Are there any challenges in data transferring?

9. As per our research, the VCs are connected to IGM hospital based in Agartala. Are there any more

base hospitals that are connected to VCs?

12

10. Can you explain the roles and responsibilities of Multipurpose Workers (MPWs) and Opthalmic

Assistants (OA)?

11. What kind of training and capacity building measures are provided to VC staff to handle medical

practices as well as to maintain clinical and non clinical infrastructure in VCs?

12. Our research indicates that the project enhances the capacity of prevalent eye care system of the state

of Tripura by structurally integrating the primary, secondary and tertiary care. How does this project

carry out the integration of primary, secondary and tertiary care?

13. We understand that the application of ICT tools utilised in the project not only takes eye care services to

the rural areas but also enables measuring the quality and effectiveness of the service really offered.

How is this process of measuring quality and effectiveness of service delivery carried out?

Financial Aspect:

14. Would you consider this model to be cost effective, if yes, why?

15. Can you describe the financial model of the project? Is there a revenue generating mechanism? If yes,

how does it work?

16. Can you provide us a breakdown of initial costs for: Site preparation, equipment, technology, manpower

etc?

Challenges:

17. Were there challenges in designing and implementing the project? If yes, what were they and how were

those overcome?

Impact and Achievements:

18. The project states that there has been an increase in the percentage of women patients over the years

due to the initiatives taken by the project administration. What kinds of measures were taken to

popularise the programme among the masses?

a) What are the indicators to prove increase in women’s participation? Provide data.

b) Provide data on total number of patients screened so far, percentage of women,

percentage of men.

19. Can you provide quantitative data indicating the achievements of the project? (For example, provide

data supporting the project’s contribution towards avoiding needless blindness).

Scalability and replicability

20. Is there any plan to replicate the tele-medicine model to provide treatment for other diseases in

Tripura? If yes, please provide details.

21. Has the project been replicated in any other state of India?