August 2007

Healthcare in India:Problems and Prospects

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By the application of e-Health, knowledge or information pertaining to a quality and sophisticated healthcare system can be made accessible to  remote corners of India, where only rudimentary health infrastructure is available. For example, a team of medical experts sitting in London or the USA can impart their diagnostic skills or prescribe appropriate medication to a critically ill patient in rural Bihar, through the help of effective information technology networks. Telemedicine can also help in training of medical personnel across the country, and thereby India can improve its human resource in health sector, by making them abreast of the current developments in the field of medicine.

Despite all the recent hypes about India's perceived emergence as a knowledge superpower, which are bandied by the popular media with tacit support from the establishment, with uncommon enthusiasm, there is no denying the fact that India as a country, even after six  decades of its political independence,  is still failing miserably to address the basic needs of its multitude of teeming millions. And it is common economic wisdom  that without sustained development measures, knowledge can't flourish in a society. At best it can remain confined to the elite echelons of the society, who have their eyes set on the Silicon Valley.

Perhaps one of the most basic of these basic development parameters is the need for basic healthcare to its population. Health is a very neglected sector in India. In the past decade, the average expenditure of the Union  Government on health and related areas has been around 0.35 per cent of GDP, and in the 2007-08 budget, the budgetary allocation for health was only a dismal 0.2 percent of India's GDP. This is abysmally low by global standards.

A Lopsided Story

The WHO recommendation for spending in health is 5 percent of the state's GDP; a target which needs enormous political will for India to reach in the near future. However, this meagre spending on health is also not evenly distributed; a major chunk of the public healthcare spending is concentrated in the metros. Ironically 80 percent of health allocation in India is in urban areas, though 74 percent of India's population lives in rural areas. It doesn't take a statistician  to gauge that rural India of 2007 has very limited access to quality healthcare. The unequal true story doesn't end here. About  85 percent of healthcare in India is channeled through private enterprises, and private healthcare is beyond the reach of majority of Indian populace. Though India boasts of a few super-specialty hospital chains like Apollo, Fortis and Max, etc. and they do offer  medical services at par with global standards, but their prohibitive costs are beyond the reach of the vast majority of Indian populace. The fact that majority in India is outside the safety net of medical insurance, further compounds the problem. Thus there is a yawning gap between the privileged, and the not so privileged, and the underprivileged class in India, in terms of  access to quality healthcare, both in terms of medical and human resources. While India has 30,000 MBBS graduates coming out of its colleges every year, the entire rural health system of more than 750 million people never has more than 26,000 doctors. Moreover, the better skilled and educated among them always naturally opt for greener pastures in metros and foreign countries, leaving rural India reeling under an acute paucity of  high level medical specialists.     
 
Amidst the backdrop of such a sordid scenario, it comes as no wonder that in India, annually, on an average, 22 lakh infants and children die from preventable illnesses and about one lakh mothers succumb to death during child birth. India  has an unhealthy infant mortality ratio of  57 per 1000 live births, which is even higher than that of the less developed nations like Bangladesh and Namibia, and the maternal mortality ratio of the country; even as late as 2006, stood at a shameless 540 for every 100,000 live births. In rural areas this figure was 619. What's more, according to UNICEF, India also has the dubious distinction of accounting for 20 percent of the world's maternal mortality cases. It is alarming that there are 2.5 million HIV/AIDS victims in India, but what is more alarming is that lakhs of people die in this country through tuberculosis every year, which is easily curable by today's medicine.

At the very outset, we have to acknowledge that the main problem in India's health sector  is not the unavailability of medicine and human resources, but their proper accessibility and distribution. Like in everything else, the health sector in India is plagued more by the distribution lacunae than the production bottlenecks.

Unless we take care to make a decent health system accessible to the multitude  of our population(accessible in terms of cost, demographics and geography), many such tragic incidents like that of Sarita's would continue to hog newspaper headlines and stream through audiovisual bytes. Sarita is a seven-year-old girl suffering from complete renal failure, a daughter of a vegetable vendor, who was recently thrown into the river by her hapless father, who couldn't carry her medical expenses. She was luckily rescued by some fishermen, but her future, and the future of Indian healthcare,
remains a big question mark.  I have a nagging suspicion that for every Sarita gaining media attention, there are hundreds of such 'Saritas' suffering in oblivion.

Silver Linings

By rattling off the above statistics, I am here not implying that nothing has been done to improve India's healthcare. There have been developments in the recent years, but much more needs to be done to address this mammoth problem. The fact that the Union Government has proposed to increase the allocation of the National Rural Health Mission(NRHM) from Rs.8207 crore in the 2006-07 budget to Rs.9947 crore in the 2007-08 budget reflects the present government's concern about the country's appalling healthcare. Overall, the Finance Minister has enhanced the expenditure on health and family welfare by 21.9 percent in the current fiscal, as compared to that of the previous fiscal year. The Finance Minister has also expressed the present government's determination and resolve to achieve zero level growth of HIV/AIDS in his recent budget. The provision for the AIDS Control Programme has also been proposed to be stepped up in the current budget to Rs.969 crore. But all said and done, these are small steps…we need some revolution of sorts to make any significant difference to our healthcare system.   

IT can be a Healthy Solution

In this depressing scenario, e-Health or electronically enabled healthcare can provide the much-needed silver lining and bridge the gaps in healthcare access that is prevalent in the Indian society. In fact, India and many other developing countries need e-Health more than the developed world, because conventional healthcare has failed to reach the former group's large sections of underserved population.

By application of e-Health, knowledge or information pertaining to a quality and sophisticated healthcare system can be made accessible to  remote corners of India, where only rudimentary health infrastructure is available. For example, a team of medical experts sitting in London or the USA can impart their diagnostic skills or prescribe appropriate medication to a critically ill patient in rural Bihar, through the help of effective information technology networks. Telemedicine can also help in training of medical personnel across the country, and thereby India can improve its human resource in health sector, by making them abreast of the current developments in the field of medicine. However, before all things, the government and the private players have to collectively ensure that the cost to incur the benefits of e-Health are within the reach of the majority of India; otherwise the entire exercise will be a futile one from a development perspective, though reflecting mercenary dividends.

Besides ensuring a more equitable access to healthcare delivery, e-Health in India, among myriad other welfare-oriented aspects, can also ensure knowledge management in healthcare industry and facilitate a more optimal utilization of limited medical resources.The example of the former is an electronic data base of patients' history and other basic health performance indicators such as sterilisation, birth attendance, and immunisation rates in a given district. Electronic health records can ensure easy access to patient's information across the globe, minus the clinical errors. Another example of optimal allocation of limited healthcare resources can be the proper allocation of healthcare centers across the geographic ambit of a given district, achieved through geographic mapping systems.

Inches Achieved, Miles to go

There are some significant initiatives by the public as well as the private sector to increase e-Health's incidence in the health sector. The Integrated Disease Surveillance Project of the Ministry of Health and Family Welfare, and the Department of Information Technology's initiatives of networking the district hospitals in Mizoram and Sikkim with Apollo Hospital, Delhi, and its development of Teleoncology network in Kerala and Tamil Nadu,  are noteworthy e-Healthy achievements in the public sector. 

ISRO's telemedicine programme aims at connecting the rural and district hospitals in the country with the super-specialty hospitals in the cities through INSAT. Under this satellite network, while ISRO provides the software, hardware and communication equipments as well as satellite bandwidth, the specialty hospitals provide the infrastructure and human resource, and also maintain the system. Presently ISRO's telemedicine network covers 165 hospitals, which include 132 district/rural hospitals and 33 super-specialty hospitals. What's more, the Indian Space Research Organisation (ISRO) is envisaging to bring more government hospitals across the country, under the ambit of its telemedicine programme. Other important players and institutions furthering the cause of e-Health  in the country include the names of AIIMS, C-DAC and Sanjay Gandhi Postgraduate Institute of Medical Sciences(SGPGIMS) in Lucknow. In the private sphere, Apollo Telemedicine Networking Foundation(ATNF) is doing a yeomen service to facilitate the progress of telemedicine across India, and has even established overseas telemedicine units in Colombo, Dhaka, Maldives and Lagos among others. With over 17,000 teleconsultations, ATNF has emerged as possibly the largest multi-specialty telemedicine network in South Asia. However, though Apollo may be the first player to enter the field of telemedicine, when it started its telemedicine network in the Aragonda village of Andhra Pradesh way back in 1999, but lately there have been many other private players making noteworthy inroads in the e-Health domain. The names of  Narayana Hrudayalaya, Bangalore and Aravind Eye Hospital based in Madurai, must deserve special mentions in this regard.

Handle With Care

However, all said and done, we have taken only a few fumbling forays towards realising the seemingly enormous potential of e-Health in our healthcare scenario, and there are miles to go. For this, only talks and seminars  wouldn't do. We need proactive action to translate the idea of e-Health into a welcome reality. We need to pull up our socks as far as adoption of ICT in medicine in India is concerned. At present the penetration of e-Health in the Indian context leaves much to be desired. An average  mid-sized hospital in India(which are mostly concentrated in cities) spends less than 1.5 percent of its turnover on IT (new investments plus the annual maintenance) while a large hospital spends only around two percent of its turnover on IT, which by any standards is not a noteworthy achievement. 

At the same time, we should not throw caution to winds and celebrate the adoption of this amalgamation of ICT and medicine without circumspection. e-Health's usage must be very prudent, and care should be taken to see that the benefits of ICT revolution helps to transmit the benefits of medical knowledge effectively to the underserved sections of the population of India, without compromising on their privacy, which may be revealed through insensitive dissemination of sensitive electronic health records among other things.   

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