The article briefly describes the status of health and health infrastructure in India and also tries to discuss governance issues involved in delivery of public health care. Further, it examines the governance structure for public health in India and finally proposes a Spatial Health Management Information System (SHMIS) and its effective operationalisation.
Public health management needs information on various aspects like spatial pattern of the prevalence of diseases and health infrastructure available in order to take decisions on either creating additional infrastructure or for taking immediate action to control epidemics or other diseases. Unfortunately, at present, public health sector in India has very poor knowledge management practice.
Status of Health in India
High infant mortality, low birth weight, under-nourishment, very high level of anemia in women (about 50%) reflects the sorry state of health status in Indian population. While providing home to 17% of the global population, India bears a disproportionate burden of 23% child deaths, 27% of maternal mortality, 20% maternal deaths, 30% TB cases, and 68% leprosy cases of the world.
Performance of the health care delivery system in India is reflected in the country's ranking in Human Development Index (HDI) and in the disease burden, including – waterborne diseases (10 million), malaria cases (75 million), filariasis cases (14 million), tuberculosis patients (14 million), blind people (9 million), disabled people (16.15 million), leprosy (1 million), STDs (50 million), and HIV/AIDS (4 million).
Scenario of health standards is unevenly distributed across the country. There is a great degree of variability of health standards across Indian states. As per indices computed based on National Family Health Surveys (NFHS) estimates of 1998-99, a severe under nutrition (weight-for-age) persists among children less than three years of age in the states of Bihar, Jharkhand, Madhya Pradesh, Chhatisgarh, Orissa, Uttar Pradesh, Uttarakhand and Rajasthan (ref: Figure 1).Vector-borne Disease Severity Index (VDSI) is computed based on spatial distribution of four diseases (malaria, kala-azar, filaria and dengue). State-wise data of 1992 was used for preparing the VDSI. Figure 2 shows that Bihar, Uttar Pradesh, Maharashtra and Karnataka are very high in composite vector-borne disease severity index.
Severe iron deficiency anemia in women persists in the state of Tamilnadu, although its per capita income level is relatively higher. Moderate iron deficiency anemia persists in women in the north-eastern states like Assam, Meghalaya and Sikkim. However mild iron deficiency anemia in women persists in the eastern states and some of the north-eastern states.
Status of Health Infrastructure in India
One of the major and persistent causes of malfunctioning of public healthcare infrastructure in the rural areas is a critical shortage of key health manpower, particularly of doctors, nurses, and laboratory technicians in public facilities (Ref: Table 1). This is partly due to management failures such as inadequate incentives, poor working conditions, and lack of transparency in posting of doctors in rural areas.
As per the estimation of the Ministry of Health and Family Welfare (as on 31.03.2001), shortfall of Community Health Centers (CHCs), Primary Health Centers (PHCs) and Sub-centers (SCs) in rural and tribal areas is shown in Table 2
Like the health scenario, the health infrastructure is also not distributed evenly across Indian states (Ref: Figure 3). Total health infrastructure (dispensary plus medical staff) is fairly good in states and Union Territories like Andaman and Nicobar Islands, Kerala, Pondicherry, Karnataka, Jammu and Kashmir, Himachal Pradesh, Punjab. Situation of the same is miserable in states like Bihar, Jharkhand, Haryana, Uttar Pradesh, Tripura, and Nagaland.
Public health infrastructure has a very strong urban bias. It is unfortunate that while the incidence of all diseases is twice higher in rural than urban areas, the rural people are denied to have access to proper health care, as systems and structures were built up mainly to serve the fairly well-off urban elites. While health care of the urban population is provided by a variety of hospitals and dispensaries run by corporate, private, voluntary and public sector organizations, the rural health care services, mainly immunization and family planning, are organized by ill-equipped rural hospitals, primary health centers (PHCs), and sub-centers.
Table 4 shows that the quantum of public health expenditure is insignificant considering the scale required to meet even the modest health needs. India's outlay on public health expenditure is much lower than the average public health expenditure of 2.8% of GDP for low and middle-income countries and the global average of 5.5% of GDP.
Governance Issues Related to Health Sector in India
The main governance issues related to health sector in India are mobilization of physical infrastructure; access, accountability and transparency; issues related to human resource motivation and gender concerns. Access to healthcare is hindered not only by geographic, social and cost barriers, but also by inherent systemic and structural weaknesses of the public healthcare system, some of them are as follows:
- Compartmentalized structures and inadequate definition of roles at all levels of care;
- Inadequate planning, management and monitoring of services/facilities;
- Inefficient distribution, use and management of human resources so that people have to contend with lack of key personnel, unmotivated staff, absenteeism, long waiting times, inconvenient clinic hours/outreach, service times, unauthorized patient charging.
- Displaying insensitivity to local/community needs; ineffective or non-existent referral systems, resulting in under-utilization of PHCs, over-utilization of hospital services, duplication of services and cost-ineffective provision of services;
- Inadequate systems to enforce accountability and assure quality.
- Inadequate attention to health education and public disclosure.
- Inadequate attention to attention to vulnerable groups
Under the circumstances, our search is for a model that makes for a just health care system as an ideal for rural India. The main criteria for this could be:
- Universal access, and access to an adequate level, and access without excessive burden;
- Fair distribution of financial costs for access and that of burden in rationing care and capacity; and a constant search for improvement to a more just system;
- Training providers for competence, empathy and accountability, pursuit of careful and cost-effective use of the results of relevant research; and
- Special attention to vulnerable groups such as children, women, disabled and the aged.
Spatial Health Management Information System
IT based information and knowledge sharing holds the key to good governance. The current state of information resource and knowledge management is inadequate. Hence there is an urgent need to initiate development of a Spatial Health Management Information System (SHMIS). The SHMIS would be ideally located at the Ministry of Health and Family Welfare, Government of India and there would be a server at this location which would accumulate the meta-data and also have accessibility to other servers. This server would be linked to National Spatial Data Infrastructure (NSDI) server. Apart from the central location there would be servers located at state and district level with state Health Departments. The hospital information network would be connected to the server at district level for ensuring online real time updating. The Research institutes and medical colleges will have servers which would be linked to either state level or directly to the central server depending on the operational area of the institute. Other players like pharmaceutical sector, civil society organisations can also have their information network linked to any one level (national, state or district). The district level server should also be updating taluka-wise and village-wise epidemiology and health infrastructure in the district. In order to ensure accountability, monitoring may be performed at District, Block and Village at CHCs, PHCs and SCs respectively. Civil Society Organisation (CSOs), citizens and other interest groups may also take part in the monitoring process. While the proposed SHMIS would provide a proper information flow, the decision system would be much more effective with the enriched analytical ability of GIS. The model SHMIS is shown in figure 4.
The lone model of information system aided by GIS can help in better and faster delivery of health services in following ways:
- No need for every agency to provide all types of data to the next level. It will have the discretion to filter the information by classifying shared and unshared data. e.g. every admission record at hospital need not be communicated to the next level, rather only the aggregate data may be shared.
- It will decrease the cost of storing and analyzing the information at the actual source, thus avoiding duplication and increasing accessibility through Internet.
- User can access the data of any level by logging into he central server without having the hassle of visiting every website – thus acting as a single-window service station.
- At each level, data would be viewed geo-spatially, which would help to take rational decisions and hence better health care planning.
Last, but not the least MIS depends on its effective opera-tionalisation. Better operationalisation of SHMIS would require following preconditions, such as distributed architecture; commitment to open source software; agreements on data interchange standards; web enablement; commitment to holistic capacity building and change management; the Ministry of Health and Family Welfare (MHFW) should be acting as integrator institution
Indian public health infrastructure and services are presently much below the acceptable standards of quantity, quality and accountability. Poor governance system and poor knowledge management is the major cause of concern. Once SHMIS is in place, the governance of health services and infrastructure in India can be expected to become much more easier and efficient.
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