This article presents three studies dealing with information and communication needs in rural primary health care from Peru and Nicaragua. Results show that primary health-care systems in rural areas of developing countries are very inefficient. Among the main reasons we found factors related to communication infrastructure, information sharing, and continuous training of health professionals. We conclude that telemedicine systems can improve this situation, but the lack of infrastructures, low income levels, and other conditions, impose strong limits to the introduction of new technologies. The main conclusion is that differences in needs and conditions between developing countries and industrialized ones force to use different solutions and approaches. This article presents some proposals on technology requirements and how to deal with the use of telemedicine in rural areas of developing countries. These proposals can be useful to all kind of actors (national public administrations, multilateral institutions, industry, academy, civil society, etc.) in order to promote really relevant and sustainable proposals in telemedicine for rural regions of developing countries.

Voice and data communication facilities (email via VHF radio) were installed in 39 previously isolated health facilities in the province of Alto Amazonas in Peru. A baseline study was carried out in January 2001 and a follow-up evaluation in May 2002, after nine months of operation. We measured the reliability of the technology and the effect the system had on staff access to medical training and information. We also measured the indirect effects on the general population of access to better health-care. The experimental data were collected from 35 of the 39 sites in face-to-face questionnaire interviews. Before installation of the system, the mean consultation rate was 3 per month per facility (95% CI 1.5 to 4.5). At the end of the study, the mean consultation rate was 23 per month per facility (95% CI 14.7 to 31.5). There were 205 emergency transfers from the 39 health facilities. The system was employed in all these cases to alert the referral centre. The mean time required for evacuation was reduced from 8.6 h to 5.2 h. Health-care personnel reported that in 58 of the emergency cases (28%) the use of the system saved the life of the patient. The study shows that the use of communication technologies appropriate to local needs solves many problems in rural primary care, and that voice and email communication via VHF radio are feasible and useful for rural telemedicine.

GBT-UPM in Spanish) and the non-governmental organization Engineering Without Frontiers (ISF in Spanish) are leading the "Hispano-American Health Link" program (EHAS in Spanish), to develop low-cost telecommunication systems and information services specially designed for rural primary healthcare personnel from isolated areas in developing countries. The EHAS program has five lines of action: 1) research on the communication and information needs of rural health personnel in developing countries, 2) R&D on voice and data communication systems designed according to conditions of rural areas, 3) R&D on information services systems suited to the needs of health personnel, 4) deployment of those services and systems through pilot projects, and 5) evaluation of the impact of these telemedicine systems on health services. This article examines the results of each line of work, with emphasis on the pilot scheme deployed in 39 rural sites of the Alto Amazonas province, in the center of the Peruvian Amazon region.

Telemedicine systems providing voice communication and email by radio were installed at seven health centres (HCs) and 32 health posts (HPs) in the Alto Amazonas province of Peru during 2001. A cost analysis was performed to estimate the net effect on direct resource consumption from the perspective of society. Prior to the availability of the EHAS telemedicine system, there was a mean of 11.1 urgent patient referrals per year from the HPs and 14.0 referrals per year from the HCs. After the implementation of telemedicine, patient referrals fell to 2.5 per year from the HPs (P = 0.03) and to 8.4 per year from the HCs (P = 0.17). The net economic effect of the telemedicine programme over a four-year period was clearly positive, amounting to annual net savings of US$320,126 (using a 5% discounting rate). A one-way sensitivity analysis using a range of values for the discounting rate, and the number of urgent referrals, confirms that the programme was efficient (i.e. it made net financial savings) in all cases. From the restricted budgetary perspective of the health network, the results also demonstrate that the additional operational costs (telephone and maintenance) introduced by the telemedicine system were lower than the direct cost-savings produced for the health-care network.

The development of telemedicine programs for the public health network of the Department of Cauca, Colombia, (Department is the major political and territorial division of the country. The Department of Cauca is located on the Pacific coast in the southwest of the country.) would make it possible to satisfy many identified needs such as medical coordination, continuing education, epidemiologic surveillance, patient referral and counterreferral, and an end to the feeling of isolation among professionals who work in rural health centers. Nevertheless, geographic, economic, and social difficulties, and the lack of a telecommunication infrastructure in areas with these characteristics present a challenge of such magnitude that the majority of existing telemedicine projects in Colombia have been centered in urban or other areas which present fewer difficulties. In the municipality of Silvia, the University of Cauca has established a prototype network using the "Hispano-American Health Link" (EHAS in Spanish) program technologies, which uses very high frequency (VHF) and wireless fidelity, (WiFi, a set of standards for wireless local area networks) radio systems for the deployment of low-cost voice and data networks. Over this network information access and exchange services have been developed, in order to meet the needs identified above. The objectives were to obtain information about the development of the project's activities and their possible impact. Project telecommunication network and information services are described, and the results and conclusions of the first evaluation are presented.