In this paper, we take an overview of primary health care scenario in India, the contours of health sector reforms agenda under the National Rural health Mission: the principles of eHealth, possible loci of synergy under NRHM and possible technology options for accelerated health sector reforms in the country.
India has achieved multifaceted socio-economic progress since Independence. There is however, globally, a shift in the Government's approach in favour of universalisation and entitlements. This is where India has much to catch up.
The health indicators in India have shown a steady improvement over the years.
Health Sector reform in India
Health sector reform involves fundamental change in policy and institutional arrangements. All aspects of the sector from manpower to infrastructure to logistics to monitoring to participation of stakeholders are subject matter of this process. Health sector reforms have come centre stage since 1980s essentially from frustration of the citizens in receiving any semblance of health care from the public system. By 1990s the process had taken concrete shape. In India, the health sector reforms broadly cover the following areas :
- Reorganisation and restructuring of existing government health care system
- Involving Community in health service delivery and provision
- Health Management Information System
- Quality of care
Health sector reform is not new to the policy maker in India. Since middle of the Tenth Five year Plan (2004 -05 onwards) however, the process has taken on unprecedented urgency. Health sector reform is now one of the flag ship agendas of the Government of India.
National Rural Health Mission
Health care is now one of the thrust areas for the Government of India. The Government mandates an increase in expenditure in health sector, with main focus on Primary Health Care from current level of 0.9% of GDP to 2-3% of GDP over the next five years. The National Rural Health Mission (NRHM) which is the main vehicle for giving effect to the above mandate was launched in April 2005. NRHM is an overarching umbrella initiative which subsumes the existing programmes of Health and Family Welfare and seeks to be the omnibus vehicle for sector wide reform in India.
NRHM has the following vision:-
- Implemented throughout the country with special focus on 18 states with weak public health indicators and / or weak infrastructure.
- Improve availability of and access to quality health care especially in rural areas for poor and vulnerable sections of the population.
- Build synergy between health and determinants of good health like nutrition, sanitation, hygiene and safe drinking water.
- Mainstream Indian Systems of Medicine in Public Health system.
- Increase the absorptive capacity of health delivery system to enable it to handle increased allocations.
- Decentralise the planning process to the community.
The NRHM also revisits the Community Health Worker (CHW) strategy in India after 1982 when the support of VHG scheme was transferred to the states effectively bringing it to an abrupt end. The CHWs reappear in Public Health in India in the form of the Accredited Social Health Activists (ASHA).
Knowledge as Tool of Governance
Governments are by nature information intensive organizations. Rapid and sweeping technological advances over the last few years have radically redefined the abilities of Government to hold information. The empowerment of hitherto unsung stakeholders in the info transactions has created new framework for info management. Health sector has most to benefit from governance processes in which Information and Communication Technology plays a significant role.
Mapping PUBLIC Health Status in India:
Ms. Shailaja Chandra, Executive Director, National Population Stabilisation Fund, speaks with eHEALTH team
The “Jansankhya Sthirata Kosh” (JSK) (National Population Stabilisation Fund) has been registered as an autonomous Society established under the Societies Registration Act of 1860. JSK has to promote and undertake activities aimed at achieving population stabilisation at a level consistent with the needs of sustainable economic growth, social development and environment protection, by 2045.
The Union Health Minister heads the General Body of the JSK and the Secretaries of the Ministries of Health and Family Welfare, Department of School Education & Literacy, Women and Child Development, Planning Commission, Rural Development, and the State Health Secretaries are members of the General Body of JSK. Besides this the General Body comprises demographers, representatives of Industry & Trade, NGOs, medical and para-medical associations, general citizens, institutions etc. JSK is expected to run as a civil society movement.
What is the main focus of JSK?
JSK was set up in 2003 to promote and support the Schemes, Projects, and initiatives that were to meet the unmet needs for Contraception and Reproductive and Child health. Rs. 100 crore were put in relief bonds in 2003, and the interest thereon has become available for us to work with.
Please share with us the structure and road map proposed for JSK?
Our memorandum says, civil society has to be involved, if we want to see change. And for the civil society to get involved, they have to see some actual work being done; which they might feel needs encouragement.
So first and foremost, JSK has to carve a niche area, which goes beyond what governments and NGOs are already doing.
Our governing board consists of government officers who are supposed to act as umpires and facilitators, and civil society partners which comprises FICCI, CII,renowned NGOs, demographers, preventive medicine experts, medical specialists, paramedics, nurses, so that we get a blend of professionals
backed by government, so that no one sector becomes the over-riding interest group.
What prompted you into taking up this novel initiative of mapping of health facilities using GIS maps?
We are supposed to raise donations and resources for which we've been given 100% tax exemption. But you cannot raise resources till you yourself show that you are capable of using resources. So in the last one-year we had to plan initiatives and start implementing them because no one will take you seriously till you show something on the ground. And I must say that we have been supported very strongly by our governing board. They have allowed JSK to be as innovative as we wished.
What kind of response have you seen in the different parts of the country after your GIS mapping initiative?
The purple areas on the GIS maps show areas where nobody has been working not even the NGOs. (On the other hand) I have visited talukas where people want to get a vasectomy done but don't know where to go. If we give the service they come in large numbers. On one day in Gujarat in one district alone, they had done 1000 vasectomy operations. The motivators in these places were ANMs, anganwadi workers, self-help group people, peons and sweepers in the primary health centres. The health secretary was very encouraging which motivated them enormously.
The response we got in Gujarat was spectacular, MP was also very good, some parts of Rajasthan have also shown some initiative, but other northern states have not taken off…
We have done mapping to show where the total fertility rates are very high. The southern states, Himachal and Punjab have reached the fertility rate that the national population policy prescribes which is 2.1. The green states are soon going to achieve it. The red ones are going to take years to stabilize.
What role do you foresee for the private players in the healthcare sector?
There are plenty of new options for contraception, but we don't have enough people trained to provide services. What we need is for private providers to be first trained to use certain skills and then to pay them to carry out these new methods. The government scheme is now very generous. It allows private providers to partner such projects. If JSK can partner with a private provider, empanelled with the state, instead of the per case cost he receives for single cases, JSK is willing to let him do a hundred cases and pay upfront. JSK is willing to do any handholding required, such as if they want to transport people from the purple areas, then JSK will support it as a pilot project to see if that really has an effect. JSK is willing to pilot one or two districts; if it works then the programme can be upscaled.
Having the GIS mapping for the whole country, it is possible to use the maps to pinpoint areas that deserve our focused attention.
Please share with us some future initiatives that you have planned for JSK.
We have planned to set up a call centre, which would give information on sexual health and everything to do with women's and men's health, from adolescence to infertility and menopause. All this information is available on our portal, and is in the process of being translated into Hindi. One also has the facility to even do a comparison of the different kinds of contraceptives/family planning methods available.
All this information is helpful if you are web-savvy which some may not be, so we want to set up a call centre. Such people can then pick up an ordinary phone and have a normal conversation with an actual person not some automated recording. There will obviously be with a disclaimer that it does not substitute for a doctor's consultation.
We are now in the process of looking for a BPO to run it and for recruiting capable people to act as communicators.
We have also organised events in the past, where we have brought a large number of people from the purple (high fertility) areas where we setup sessions encouraging them to go back and become the ambassadors for these issues of gender discrimination, early marriage and population stabilisation.
We are also trying to encourage the district collectors; we are trying to get industry involved by using their hospitals (through FICCI). We're also trying to see if we can work directly with the panchayats.
We are also setting up a Virtual Resource Centre, which would have audio visual material, film clips, images, posters which are on a meta- database so that anything (audio-visual) that comes gets uploaded; films on female foeticide, and related subjects.
What kind of help and infrastructure did you have on the technical front for the GIS initiative?
National Informatics Centre (NIC) has been very helpful. On the technical front, they gave us the server free of cost; in fact this whole thing was created by NIC. They had the GIS maps and the census data, and on my asking they said that one could superimpose the same data on the maps but they just did not have the time to do that. So I found them someone they agreed to train, but it was all done under their supervision and of JSK.
And we had the ranking of the districts done side by side, with bar charts by a young demographer straight out of International Institute of Population Studies.
For more information on National Population Stabilisation Fund log on to www.jsk.gov.in
eHealth in India
eHealth offers some ready products for accelerating the health sector reforms in India. The shortage of infrastructure, manpower and services in health sector in India is mainly attributable to the large gap in overall development between rural and urban areas. This gap levies substantial disincentive on health manpower for working in rural areas. eHealth offers a good option wherein a significant proportion of patients in remote locations can be successfully managed locally with advice/ guidance from specialists in cities, without having to travel far. This allows linking patients in remote areas to urban standard services without delinking urban service providers from their mileu. The arrangement offers easier, cost effective consultation, prescription mechanism and allows a referral chain. e-Enabling also improves depth, range and refresh rate for disease surveillance and response.
However, this change over to digital way of thinking in the health sector has rather high initial costs. The licensing terms and conditions, bilateral and interconnection agreements, non-existence of regulations, security and trade issues are serious bottlenecks which need to be addressed.
India is the ideal setting for telemedicine assisted health care. We already have a strong fiber backbone and indigenous satellite communication technology with large trained manpower in this sector. Various state governments, departments of the Government of India, private institutions and NGOs have been running a number of eHealth projects over recent past with successful outcome. In this scenario, a country level eHealth plan is long due to steer eHealth.
The enhanced allocations for eHealth over the XI Plan can be used for the following major activities to accelerate and expand the reach of the architectural correction in the health system which is envisaged under the NRHM:
Training, Education & Capacity Building
NRHM raises enormous demands on the training and apacity building infrastructure. e-Enabling the training infrastructure assists in optimal utilisation of the capacities. A tele training centre is accordingly envisaged at the National Institute of Health and Family Welfare (NIHFW). The Medical Colleges can be networked with the district hospitals and nursing institutions for CME and in service trainings.
The lack of a functional MIS at various levels has been a critical shortcoming in the health sector in India. uch of this problem can be conclusively solved using IT solutions. Under NRHM, monitoring and evaluation, using ICT tools is planned so as to create smart data corridors which are usable by both the planners and the implmentors.
GIS Resource Mapping
The preparation of District Health plans under NRHM presuppose the availability of updated information regarding the health sector resources. This includes the location of health facilities (both public and private sector), medical investigation centres and labs, training centres, trained manpower. The geo spatial mapping capacities in the country offer a major tool for addressing this critical issue. Many states including Gujarat, Rajasthan, Orissa etc. have made good progress in this area. Under NRHM this activity is proposed to be undertaken for a country wide roll out.
Several ICT enabled service delivery initiatives in the areas of Cancer network, Ophthalmology services, disease surveillance are already in operation in many states. These are proposed to be scaled up and supported by the Govt of India. A formal protocol for tele consultations and a regular tele health helpline is also proposed.
The networking of all major hospitals with the district hospitals, CHCs and PHCs would substantially enhance the reach and range of services available to the citizens from the public system. The large number of mobile medical units can also be e-Enabled so as to expand the range of services which can be made available through them.
The large number of eHealth initiatives are already operating in the country (either under the State Government patronage or in a private institution). These are proposed to be evaluated and examined for support under the GoI ehealth efforts.
The scaled up shift over to digital method of thinking in the development sector would however need to be a cautious transition. There are several obvious pitfalls in digitalization of governance and public sector service delivery. The most important being, accentuation of the existing analogue divide with an additional digital divide. Furthermore, the acceptability of eHealth as a viable initiative would need to be developed amongst the service providers. A study of existing telemedicine initiatives has pointed out that eHealth sessions are most likely to be cancelled (primarily) due to non availability of the doctor at the remote or the expert end for conducting the session.
It would therefore be necessary to create a strong sense of motivation among doctors and design eHealth programmes on basis of felt needs. There would also be need for regular monitoring, follow ups and independent evaluations of the initiatives. The contours of ownership of eHealth initiatives in respective division, state or institutions would need to be clarified. It would also be necessary to set up e-Literate management structures to support the day to day requirements of eHealth initiatives in public health setup.
IT enabling of health sector can take on a life, logic and legitimacy of its own. In this process, the real issues of health delivery and other health sector necessities would have to be prevented from becoming subordinate to the technology. The digitalization of public health delivery system would therefore need to be patient centered rather than technology centered. Never the less, the public health system in India can no longer afford to delay a large scale shift to eHealth.
Clearly, the NRHM has created the right environment for this transition.