November 2006

ICT for rural healthcare: The Tele-clinics way

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ICT has a lot to offer in bringing equity in service provision through innovative programmes which bring the poor closer to the health professionals and institutions. Tele-clinic of Christian Hospital, Chhatarpur (Bundelkhand, India) is one of the examples where ICT is explored as a means to ensure better access to both health professionals and the rural poor

ICT for rural healthcare: The Tele-clinics way Healthcare service is one of the important basic needs. Ill health could affect the living standards directly and indirectly. Healthcare service in the rural areas where more than 70 % of Indians live, is abhorrently inadequate. Bundelkhand region in Central India, which includes districts of Madhya Pradesh and Uttar Pradesh, is the most backward region in India with a lack of proper healthcare infrastructure. A majority of sickness in Bundelkhand villages is treated by untrained personnel.  This is a general phenomenon in many of the villages in rural Madhya Pradesh (M.P.) and Uttar Pradesh (U.P.). It is a dichotomy to see an overwhelming of highly technology based hospitals and dispensaries in urban areas while the rural villages do not even have basic minimum public health facilities. Even within cities the poor do not have access to high tech healthcare facilities because of various reasons, mainly financial limitations.

Many of the public healthcare services like Public Health Centres (PHCs) and sub-centres in rural areas are not equipped and staffed to provide quality healthcare to the rural poor. This suggests the yawning divide between rural and urban healthcare services, between the rural poor and the well off. The new developments in healthcare have not percolated to the rural areas and this is a matter of great concern. While  public healthcare system in India has the best professionals and one of the best systems (decentralized up to the sub centre level) there is a need to explore the ways and means to bring equity in access to health professionals and institutions. 

This article is an overview of the health-care services in the rural villages in Bundel-khand. The lacuna in the public healthcare delivery system in the poorest regions of M.P has been examined. It further suggests how the rural healthcare service delivery could be improved through the use of Information and Communication Technologies (ICT) with the example of the Tele-clinics of the Christian Hospital, Chhatarpur (a member of Emmanuel Hospital Association), where telephones are used to provide access to quality health (information and care). Tele-clinic is a pioneering healthcare service delivery project that addresses the health needs of the rural poor with the use of Information Technology.

Cost of ill health
Ill health is one of the major maladies that affect the livelihood and welfare of the poor. Hence policies that protect the health of the poor are critical in ensuring their well-being. Inadequate public health and safety measures could result in the inability of the poor citizens in investing their entitlement reserves for economic reproduction.

 Table-1 Health infrastructure availability per 1000 square kilometres (1993)

Source: South India Human Development Report 2003,  North India Human Development  Report 2003, NCAER

The use of entitlements to meet consumption needs could affect a family’s reserves negatively in the long run and could affect the ability of a family to face uncertainties. Though it is encouraging to note that some efforts are made to provide social protection to the poor through health insurance policies offered (public private partnerships) by some corporate insurance companies (even though a result of opera-tional compulsion by government) and some state governments, these schemes are yet to reach the majority living in the rural areas. Health status affects human development in many ways. According to the Noble Laureate Prof. Amaratya Sen, health is one of the important human capabilities, which determine access to wealth.

Rural healthcare in Bundelkhand – Current scenario

The public healthcare in Bundelkhand has the following challenges;

a) Healthcare Access
b) Healthcare Quality
c) Healthcare Cost
a) Healthcare access

When people become ill, low-income households in rural areas continue to use home remedies, consult traditional healers and local providers who are often outside the formal healthcare system.  Men have comparatively better access than women to healthcare options at all levels due to various socio-economic and cultural factors (including their easy mobility). The bicycle is the usual means of transport in rural villages and riding a bicycle by women is not a normal practice in rural commu-nities. It is also important to say that a sick man is better attended than a sick woman. Poor women are most vulnerable to diseases and ill health as they live in unhygienic conditions, carry heavy child bearing burden, place little emphasis on their own healthcare needs, and encounter severe constraints in seeking healthcare for themselves. Table 1 suggests the status of  health infrastructure in three states in India, which also include figures for M.P. It suggests that the state of M.P. is very poor in health infrastructure availability. For example the PHC available per thousand square kilometer is 0.27, which is far below the developed state of Kerala (average  2.28). The districts in Bundelkhand has the worst healthcare facilities. This  calls for an urgency in rural healthcare provision.

Table – 2 Availability of doctors and nurses per 100,000 population (1993)

Source: South India Human Development Report 2003, North India Human Development Report 2003, NCAER

b) Healthcare quality
Numerous studies have indicated that the healthcare facilities at Primary Health Centre (PHC)and Sub Centre levels are mostly understaffed and short of drugs and essential supplies and that they sometimes suffer from low staff morale and motivation. The quality of healthcare in the rural and urban areas also differ. While the urban localities have healthcare options from five star medical colleges to small private dispensaries run by trained doctors, the rural areas often are left with the only option of untrained private practitioners. Table 2 suggests the availability of health care personnel in M.P., U.P. and points to the fact that the number of medical professionals available in M.P. is far inadequate as compared to Kerala.  It also shows that a significant number of the deliveries in these states are conducted by untrained (traditional) practitioners. This to a large extent affects the quality of maternity care and impacts maternal mortality rates.

c) Healthcare cost
Providing healthcare services to the poor at a reasonable cost requires a significant amount of subsidy, either through govern-ment or non-government source. The study of many of the health insurance schemes implemented in Africa, Asia and Latin America points to this conclusion (Community Health Fund Tanzania and Nkoranza Community Financing Health Insurance Scheme, Ghana are some of the examples). Moreover, access needs to
look into other viable and cost effective alternatives.  
Thus, an assessment of healthcare facilities available for the rural poor in Bundelkhand suggests the following:

• The health status in Bundelkhand villages in general is inadequate and does not comply even with the minimum public health requirements. 
• The main healthcare providers for more than 80% population living in rural Bundelkhand are untrained private ‘practitioners’.
• The government PHCs are not regular and are not efficient in accomplishing its mission of facilitating quality medical outreach to the poor in the rural loca-lities, both due to poor infrastructure, equipments and inadequate personnel.
• Emergency healthcare services are almost nil in rural areas. Accessing health services at odd times is a Herculean task for the people in  rural areas.

ICT kiosks and public health 
Information and communication technology has a very important role to play in facilitating quality healthcare to the rural poor in a cost effective manner. In an age of high-tech medical care, those excluded from the mainstream healthcare service could be provided with the benefits of medical professionals through the use of an appropriate ICT kiosk. This needs a joint commitment from both private and public sector.

Telemedicine is used as a means to provide health access to people world wide through the use of various kiosks. However, this has not become popular among the rural poor because of inadequate know-how on the use of various kiosks. The countries in Asia have less than 10 % Internet users and less than 20 % telephone users in their rural localities, while in India the use of Internet in rural areas is less than 1%. In a situation where large-scale tech-nology illiteracy exists, it is important to promote appropriate technology kiosks
that would be easy for the poor to use.

Use of telephones could be a starting point for rural areas. Even operation of a telephone is complicated for many living in rural areas.

Tele-clinic Project of Christian Hospital is an example where a telephone is used to give access to quality medical care.  Health workers are trained to make the communi-cation more qualitative to enable the doctor to better diagnose and advise treatment.

Tele-clinics – Combination of ICT and social protection
Tele-clinic initiated by Christian Hospital in Bundelkhand is one of the innovative mixtures of technology and health protection supplement. It is an attempt to introduce ICT in healthcare to improve the access to specialty care to those living in remote rural areas. The communication between a doctor and a patient is enabled through the use of a telephone.

Tele-clinic is a telephone enabled closed network of rural people, trained health workers and medical professionals of Christian Hospital. This network enables communication between doctor and a patient in a remote rural village with the help of a telephone. A trained health worker facilitates the communication between a doctor and a patient through a WLL phone provided by the BSNL (government owned telecommunication agency).

A trained health worker is recruited in all the call centres. These call centres provide services like primary healthcare, ambulance service, telephone consulta-tion, emergency drugs and so on. One call centre covers three to five surrounding villages.

Tele-clinic – Aims and objectives
The above mentioned project is innovative and is a first with this unique combination in the whole world, especially in India. It is a combination of financial protection and healthcare access. The main goals and objectives of Tele-clinic are as follows.

Aim: Develop healthy and economi-cally productive rural citizenship through facilitating affordable, reliable and high quality health information to the rural poor using ICT.

Objectives:

• To provide emergency healthcare to the rural poor
• To ensure safe delivery and motherhood in rural areas
• To provide access to health information and making healthcare accessible to the poor.                  
• To facilitate quality medical care to the poor in remote rural villages.
• To provide public health safety net to the rural poor.

Tele-clinic components

1. Village Call Centres: Call centres are a very important component of the Tele-clinic. These centres are established in the villages where Tele-clinic project is initiated. The centre is currently running in a rented room in the village. A trained health worker mans the call centres. The health worker is called Tele-health Worker (THW), who is provided with a telephone, basic diagnostic equipments and emergency drugs. All the health workers are trained by St. Johns Ambulance Service and Compre-hensive Rural Health Project Jamkhed (Maharashtra). Call centres provide the following main services:

a) Telephone consultation with a doctor at Christian Hospital
b) Emergency drugs
c) Clinical support through nurse-run-clinics
d) Health awareness through periodical campaigns

2. Ambulance Service: A round the clock ambulance service has been started by the Tele-clinic Project to provide access to the hospitals. A separate phone number is given to access the ambu-lance and this service is available any time of the day or night.  Further, this service could be used to visit any hospital in the town at times of emergency. The following figure shows the same.

3. Medical Assistance Plan (MAP): Medical assistance plan is similar to a health insurance and is an important component of Tele-clinic Project. Those who are in MAP pay an advance membership fee to avail medical (In-patient and Out-patient) facilities at the Christian Hospital, at a prefixed rate. MAP has membership fee ranging from USD 1.33 to USD 12.79 with coverage of USD 22.25 to USD 222.45.

Currently there are around 50 villages covered through 15 different call centres. One call centre serves 4 to 6 villages. The population per call centre ranges from 3000 – 10000. The current MAP membership varies from 100 to 250 per call centre. There are a total of more than 1500 members enrolled in this scheme. The project currently serves a total population of 30,000. All the target villages are at very remote locations and are away from the main road. While selecting a village access is one of the important criteria. Those villages with minimum access are selected because it would help in effective imple-mentation of the project. Figure titled call centre structure shows the network of call centres, villages and the hospitals.

Tele-clinic – Levels of treatment

Tele-clinic uses a three tier healthcare service through use of Information and Communication Technology (at present telephone is being used)

a) Call Centre level – primary care – manned by a health worker:
b) Weekly referral clinics at Call Centre Level – Manned by nurse & laboratory technician
c) Hospital level – secondary care

At all these levels the consultation of a qualified practitioner / a specialist is important. All treatments are provided after specialist consultation over phone, except in case of causalities where health worker administer emergency drugs / refer the patient to the hospital. 

Tele-clinic – Value addition in rural healthcare

• Promotion of good practices in healthcare in rural areas: There is a remarkable change in the practices related to healthcare in the villages after the introduction of Tele-clinics. Many of the members enrolled in MAP have never been to a qualified practitioner / a hospital. The poor people buying this new idea is an indication of their change in attitude towards healthcare. 
• Improved access to specialists through a telecommunication network: Tele-clinic wherever established has been successful in presenting a reliable healt-hcare alternative to the rural poor (in spite of problems with connectivity and electricity some times). People though consult the local practitioners for minor ailments; at times of medical emerge-ncy they use the MAP membership and consult the doctors at Christian Hospital.
• Improved access to hospitals through a round the clock ambulance service:  Ambulance service significantly impa-cted the health seeking behaviour of people in the villages where call centres are established. This service is the only transport facility available at a phone call to the people in the target villages.


Tele-clinic in a district public health


Replicating Tele-clinic in district healthcare system – A model rural health service plan
The Tele-clinic project could be replicated in the District Public Health System (DPHS) to improve the overall public health delivery system. Various public health hierarchies could be networked through the use of a telephone (or by joint venture with ISRO – Indian Space Resea-rch Organisation and DPHS). This would in a way improve the efficiency of various hierarchies and also would make them more accountable to both the public and to the DPHS.  Moreover, such a network could make public health monitoring cost effective and efficient. The following needs to be done before actually replica-ting the system.

• Clustering different levels of healthcare centres – Lead centre at different levels.
• Identifying interested practitioners – Enlisted practitioners /specialists
• Partnering with Telecommunications Department / Private Telecommuni-cation Companies – Establishing communication network
• Establishing Tele-clinic information control units at all the district offices

A model plan is depicted in the figure titled telemedicine in a district public health system.


Conclusions

ICT – Not the complete answer – Need for location specific supplements
ICT is not sufficient to ensure improve-ment in the well-being. Application of ICT should be supplemented with appropriate social protection policies which would enable the poor to actually benefit from information/knowledge. Practicing information is not just a function of availability of options but depends on the supplementary policies that enable practicing in real life situations.

Social orientation of private sector
Not only the government, the private sector should also be socially responsible. The IT companies and educational institutions should respond to the social cause through developing rural friendly communication kiosks and rendering technology education in rural areas.

Civil society – Capacity building of traditional actors
Civil society institutions should take up the job of building the capacities of the traditional actors such as untrained health workers, private practitioners, traditional birth attendants and other health workers with in the community apart from their role of building partnerships. The Public Health Network through technology should include these actors who are working at the very local level. Linking them with qualified medical practitioners could bring change in overall health condition of the poor in rural areas. ICT could be also used in facilitating a continuing medical education to the practitioners in the rural localities. They are an important part of the ‘rural healthcare system’. However, the practices needs to be standardised through adequate trainings and regulation.

Call centres – Beyond healthcare   
The call centres could also perform as ‘knowledge banks’. This would be a two-way knowledge bank that gathers tacit knowledge from rural communities and promotes current information on various issues related to rural livelihood. The information on product markets, labour markets, commerce, etc. also could be made available through call centres, which could affect the livelihood of the poor living in the rural areas. The centre could be transformed as ‘knowledge centres’, which would have information on a range of human development aspects from health, education to livelihood.

The Mission 2007 of the government of India should be integrated into the Tele-clinic project and should focus on provision of information and knowledge beyond public health. There is no doubt that a careful promotion of information technology in rural healthcare could bring about drastic changes in the public healthcare system of India and this would benefit the poor who are excluded from the mainstream healthcare system. 

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