Bhutan: Piloting the Design of e-Services Delivery Platform in Health Services

Sovereign Project | 47222-001

Summary

1. The Royal Government of Bhutan (the Government) has identified information and communications technology (ICT) based e-governance as a key area for improving efficiency and enabling wider reach of public service delivery. The focus of the Government is to enhance gross national happiness by building a knowledge society empowered by ICT. The Government is taking a dual approach to achieve this namely by (i) furthering efficiency building measures through ICT and (ii) developing ICT related sectors for exports and local consumption.

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Project Name Piloting the Design of e-Services Delivery Platform in Health Services
Project Number 47222-001
Country Bhutan
Project Status Closed
Project Type / Modality of Assistance Technical Assistance
Source of Funding / Amount
TA 8418-BHU: Piloting the Design of e-Services Delivery Platform in Health Services
Technical Assistance Special Fund US$ 225,000.00
Strategic Agendas Inclusive economic growth
Drivers of Change Governance and capacity development
Sector / Subsector Health - Health system development
Information and communication technology - ICT industries and ICT-enabled services
Gender Equity and Mainstreaming
Description

1. The Royal Government of Bhutan (the Government) has identified information and communications technology (ICT) based e-governance as a key area for improving efficiency and enabling wider reach of public service delivery. The focus of the Government is to enhance gross national happiness by building a knowledge society empowered by ICT. The Government is taking a dual approach to achieve this namely by (i) furthering efficiency building measures through ICT and (ii) developing ICT related sectors for exports and local consumption.

2. The Asian Development Bank (ADB) has undertaken discussions with the Government to explore opportunities for providing support to strengthen e-governance activities in the area of efficiency improvement by establishing an e-Services platform through a pilot initiative to deliver public services. The Government has recommended starting the pilot in the health sector by offering services such as telemedicine and basic medical laboratory testing facilities through e-Health centers. The proposed category B, small-scale capacity development technical assistance will finance the pilot establishment of an e-Services delivery platform in the area of e-Health in Bhutan in collaboration with private sector participants.

3. ADB, as part of its strategy to enhance sustainable development in its developing member countries, encourages private sector participation where possible in its developmental initiatives. Thus, for this initiative ADB is seeking to collaborate with and leverage resources through corporate social responsibility programs of private sector corporations, - Hewlett-Packard (HP) and Microsoft. ADB will liaise and facilitate with the two private entities in bringing together the needed hardware, software, implementation services, and subsequent knowledge transfer for maintenance of the pilot components to the Government agencies namely, the Ministry of Health (MoH) and the Ministry of Information and Communications (MoIC). The Government is expected to provide in-kind contributions, including civil infrastructure facilities, staff assistance, and utility services such as water and electricity.

Project Rationale and Linkage to Country/Regional Strategy

4. As a sparsely populated country in a mountainous region, Bhutan is still in the developing stages with regard to infrastructure. Poor roads, combined with the rugged topographical nature of the land, have made transportation difficult. With approximately 80% of Bhutanese people living more than an hour's walk from the nearest road, high costs are incurred when bringing patients and medical equipment to and from the remote locations. An ambulance may take over 20 hours going from east Bhutan to Thimphu, the nation's capital. Bhutan's underdeveloped transportation network has serious implications not only on the timely provision of efficient health care, but also on equal access to health services by rural and urban populations.

5. Bhutan's constitution mandates the provisions of free health care for its population. The Government of Bhutan together with development partners has implemented innovative approaches such as telemedicine and e-Health since 2000 to remote populations. The Government of Bhutan aims to expand the application of e-Health. According to the annual health bulletin 2011 report of MoH, there exists visible demand for quality health services and health care costs are rising. Therefore, using available information for decision making and designing cost-effective interventions is increasingly becoming the need of the day. The Government has introduced the health help center concept to provide medical advice on any medical presentation and ensure the right medical care is provided. Since the health help center is a new set-up, challenges are faced in various areas such as human resources, telecom solutions and budget. The interventions from ADB with support from HP, in the form of an e-Health center, will partially fill the gap in health services delivery and are in line with the Government's strategic plan. For delivering e-Health services at remote locations, availability of high capacity internet broadband access is a necessary precondition.

6. Enabling internet connectivity and ensuring its wider usage is a challenge faced in many developing member countries. There are various factors influencing its provisioning and usage. The cost of deploying conventional connectivity solutions such as terrestrial connections, satellite based connections, and the limited revenue generating prospects of such investments, are some of the major deterrents to provisioning of sustainable digital access at remote and rural areas. In the ICT industry, this is referred to as the last mile connectivity problem. With the advent of newer technologies, such as mobile technology, optical fiber technologies and television (TV) white spaces, solutions are used to tackle the last mile connectivity issue progressively. As internet is the backbone infrastructure for sustainable delivery of e-Services, it is essential to find innovative solutions to bridge the digital gap especially at remote and rural areas.

7. The geography of Bhutan consists of Himalayan Mountains, river valleys, and sub-tropical forests. Topographical extremes are a defining feature of its geography. In such conditions providing telecommunications infrastructure throughout the country is a challenge. Providing terrestrial broadband connectivity in remote areas is thus not feasible. To a large extent, these areas can be served by wireless functionalities. However, conventional wireless methods suffer from attenuation issues in high mountainous habitations. TV white spaces technology is emerging as a new technology in extending solutions to the last mile connectivity problem. Bhutan's internet service provider (ISP) market is a dominated by two major operators namely Bhutan Telecom Limited and Tashi infoComm Limited. The leased lines for internet services for higher bandwidth requirements will have to be sourced from them. These lease lines offer data security, high access speed, resilience and stable connectivity. However, leased lines are expensive, take long lead times to install and need contract management function to monitor and enforce service level agreement.

8. The Government of Bhutan, in its effort to promote ICT, has started initiatives such as (i) demand creation for Information Technology (IT) and/or Information Technology Enabled Services industry; (ii) talent development; (iii) infrastructure building; and (iv) establishing conducive legal, policy, and regulatory frameworks. The proposed pilot approach will establish the requirements for the larger e-Services initiatives in line with the government's effort. It will provide needed insights to demand generation, infrastructure upgrade, capacity development, and policy requirements.

9. Therefore, it is anticipated that this pilot will help in identifying operational issues and approaches to scale up on a countrywide basis. Discussions with other development agencies will be undertaken to draw lessons, assess risks, and design risk mitigation measures. The concept will provide insights to strengthen the Government's service delivery requirement and establish a sustainable engagement mechanism to plan, maintain, and extend the pilot country wide.

10. The TA will (i) establish dedicated lease line and associated link infrastructure for the project; (ii) pilot implementation of TV white spaces technology in the remote location; and (iii) establish pilot e-Health center. The details on the project components are provided as supplementary appendix 1.

Impact Improved health service delivery system in Bhutan
Project Outcome
Description of Outcome Establishment of e-Services delivery platform capabilities in health services in Bhutan.
Progress Toward Outcome
Implementation Progress
Description of Project Outputs

Telecommunications backbone infrastructure leveraging optical fiber network is implemented at the identified pilot location.

Last mile connectivity at the remote location using TV white spaces technology is deployed.

Establishment of e-Health center.

Status of Implementation Progress (Outputs, Activities, and Issues)
Geographical Location
Summary of Environmental and Social Aspects
Environmental Aspects
Involuntary Resettlement
Indigenous Peoples
Stakeholder Communication, Participation, and Consultation
During Project Design

A. Impact and outcome

1. The impact of the project will be improved health service delivery system in Bhutan. The outcome of the project is establishment of e-Services delivery platform capabilities in health services in Bhutan.

B. Outputs and Key Activities

2. Output 1: High performance telecommunications backbone infrastructure is established at the block level. This is established by (i) leasing bandwidth services from internet service providers; (ii) testing the internet capacity and stability provided by internet service providers; and (iii) if required, adding additional equipment to enhance capacity of broadband performance.

3. Output 2: Last mile connectivity at the remote location using TV white spaces technology is deployed. The approach involves (i) securing regulatory clearances from the MoIC for allocation of telecommunications spectrum; (ii) assessing the feasibility of providing wireless services at the remote location using TV white spaces; (iii) preparing detailed implementation plan; (iv) procuring and configuring the equipment; and (v) training and knowledge transfer to the maintenance team of MoIC for troubleshooting issues relating to TV white spaces. This output will be delivered in collaboration with TV white spaces vendors through Microsoft.

4. Output 3: Establishment of e-Health center. This component will establish an e-Health center to provide basic primary health services in the areas of gynecology, cardiology, and dermatology. This output will be delivered in collaboration with HP. The approach includes (i) assessing health service needs in the remote location; (ii) developing an implementation plan; (iii) configuring the HP e-Health unit; (iv) identifying maintenance team with support from MoH; and (v) training and knowledge transfer on operations of e-Health center to the maintenance team.

C. Cost and Financing

5. The technical assistance (TA) is estimated to cost $225,000, which will be financed on a grant basis by ADB's Technical Assistance Special Fund (TASF-V); The government will provide counterpart support including office space, office supplies, venues for conferences and seminars, and other in-kind contributions. The cost estimates and financing plan are in Appendix 2. Disbursements under the TA will follow ADB's Technical Assistance Disbursement Handbook (2010, as amended from time to time).

During Project Implementation

1. The Ministry of Finance (MoF), will be the executing agency for the TA. MoF will oversee the project implementation, monitoring, and reporting; and will chair a committee comprising of the Government line agency representatives, ADB, HP, and Microsoft. As executing agency, MoF will facilitate smooth resolution of issues during the project implementation. At the end of the pilot, the ownership of equipment and other associated materials will be transferred to the respective line agencies at no cost. Necessary knowledge transfer and training for assumption of ownership for maintaining the equipment and facilities will be provided to the Government by equipment providers at no cost to the Government identified personnel.

2. Consulting services for implementation of the pilot are expected to commence in September 2013 and be completed within four months. The consulting services for the maintenance of the e-Health center will run till September 2014. The total duration of the project is from September 2013 till September 2014. The outline of the terms of reference for consultants is in Appendix 3. Individual Consultants or firms will be selected in accordance with the ADB's Guidelines on the Use of Consultants (2013, as amended from time to time). Procurement of equipment will be carried out in accordance with ADB procurement guidelines.

3. MoH is responsible for identifying the pilot location and provisioning of civil infrastructure facilities including electricity, water, land, generator fuel, IT consumables, human resources, insurance, and other needed requirements. The facility incurs recurring monthly operational expenses for continuing the service delivery. The monthly operational expenses for running the facility for the first year will be financed from ADB's TA, and from the second year onwards, will be funded by MoH, through its budgetary allocation procedures.

4. . The MoIC will also facilitate the needed policy and regulatory requirements associated with allocation of the telecommunications spectrum. The MoIC will also assume the responsibility to maintain the TV white spaces infrastructure after hand over and knowledge transfer by Microsoft. The MoIC will procure and manage the internet service providers. The annual subscription fees for leased line will be financed from ADB's TA and second year onwards, will be funded by MoIC, through its budgetary resources.

5. HP will bear the initial capital expenditure for the e-Health center estimated at $86,000 and annual hosting charge of $10,000 for the first years for the medical data processing service of the pilot implementation. The major capital expenditure expenses to be borne by HP include (i) container infrastructure, (ii) registration, (iii) telemedicine studio, (iv) initial pharmacy, (v) initial lab basics, (vi) transportation to port from base, and (vii) implementation services.

6. Microsoft through its TV white spaces vendor will be responsible for providing implementation support and services for the TV white spaces component. ADB will finance the equipment, annual equipment maintenance cost for the first year, and travel cost of a training resource for technical knowledge transfer of TV white spaces technology to MoIC staff. The annual maintenance cost from second year will be the responsibility of MoIC, to be funded through its budgetary allocation procedures.

Business Opportunities
Consulting Services Consulting services for implementation of the pilot are expected to commence in September 2013 and be completed within four months. The consulting services for the maintenance of the e-Health center will run till September 2014. The total duration of the project is from September 2013 till September 2014.
Procurement

MoH is responsible for identifying the pilot location and provisioning of civil infrastructure facilities including electricity, water, land, generator fuel, IT consumables, human resources, insurance, and other needed requirements. The facility incurs recurring monthly operational expenses for continuing the service delivery. The monthly operational expenses for running the facility for the first year will be financed from ADB's TA, and from the second year onwards, will be funded by MoH, through its budgetary allocation procedures.

The Ministry of Economic Affairs and the MoIC will provide in-kind support to facilitate broadband service generation to allow the use of spare capacity of optical fiber based infrastructure owned by the ministries for the pilot project. The MoIC will also facilitate the needed policy and regulatory requirements associated with allocation of the telecommunications spectrum. The MoIC will also assume the responsibility to maintain the TV white spaces infrastructure after hand over and knowledge transfer by Microsoft.

HP will bear the initial capital expenditure for the e-Health center estimated at $86,000 and annual hosting charge of $10,000 for the first years for the medical data processing service of the pilot implementation. The major capital expenditure expenses to be borne by HP include (i) container infrastructure, (ii) registration, (iii) telemedicine studio, (iv) initial pharmacy, (v) initial lab basics, (vi) transportation to port from base, and (vii) implementation services.

Microsoft through its TV white spaces vendor will be responsible for providing implementation support and services for the TV white spaces component.

ADB will finance the equipment, annual equipment maintenance cost for the first year, and travel cost of a training resource for technical knowledge transfer of TV white spaces technology to MoIC staff. The annual maintenance cost from second year will be the responsibility of MoIC, to be funded through its budgetary allocation procedures.

Responsible ADB Officer Arun Ramamurthy
Responsible ADB Department SDCC
Responsible ADB Division SDGG
Executing Agencies
Ministry of FinanceRoyal Government of Bhutan
Thimphu, Bhutan
Attention: Director
Timetable
Concept Clearance 12 Sep 2013
Fact Finding 13 Sep 2013 to 30 Sep 2013
MRM -
Approval 02 Aug 2013
Last Review Mission -
Last PDS Update 19 Aug 2013

TA 8418-BHU

Milestones
Approval Signing Date Effectivity Date Closing
Original Revised Actual
02 Aug 2013 - 02 Aug 2013 30 Sep 2014 - -
Financing Plan/TA Utilization Cumulative Disbursements
ADB Cofinancing Counterpart Total Date Amount
Gov Beneficiaries Project Sponsor Others
225,000.00 0.00 0.00 0.00 0.00 0.00 225,000.00 02 Aug 2013 88,115.42

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Evaluation Documents

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