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‘Digi Gaon’: Will It Augment Access To Affordable Health Care In India?

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In the Union Budget speech of 2017-18, Indian Finance Minister articulated his intent, among several others, to launch a new initiative named ‘Digi Gaon’, which would extend the broadband digital technology in rural India. Besides education and skills, ‘Digi Gaon’ would facilitate affordable access to e-healthcare in the in the hinterland of the country.

“Under the Bharat Net, optical fiber has been laid in 1,55,000 km. I have stepped up the allocation for Bharat Net projects to Rs 10,000 crore in 2017-18 and by the end of 2017-18, high speed broadband on optical fiber will be available in more than 1.5 lakh gram Panchayats with hotspots and access to digital services at low tariff,” the Finance Minister said.

“This will give a major fillip to mobilizing broadband and Digital India, for the benefit of people living in rural areas,” he further added.

Increased penetration of ‘Telemedicine’, per se, in the country has the potential to improving time, cost and the quality of access to affordable health care in rural India, as confirmed by several important studies.

A broad perspective:

A report of the World Health Organization (W.H.O), titled “Telemedicine – Opportunities and developments in the Member States”, states that the term ‘Telemedicine’, was coined in the 1970s, which literally means “healing at a distance”. It signifies the use of modern Information and Communication Technologies (ICTs), such as computers, the Internet, and cell phones, to improve patient outcomes by increasing access to care and medical information.

Recognizing that there is no one definitive definition of ‘Telemedicine’ – a 2007 W.H.O study, after reviewing 104 peer-reviewed definitions of this word, adopted the following broad description:

“The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities”

‘Telemedicine’ in India:

Before I get into other relevant details in this area, let me briefly explore in which segments of the three important areas – Market, Services and Providers, ‘Telemedicine’ has already started working in India, though with a varying degree of success.

 Market segments:

‘Telemedicine Market’ in India can broadly be segmented into nine key categories. A recent research report on “India E-Health Services Market Outlook to 2020” by Ken Research captures the top three of these segments as follows:

  • Tele-radiology: The top segment in India that involves the electronic transmission of radiographic images of patients, such as, X-Ray, CT scan or MRI from one location to another location for an expert interpretation by a radiologist sitting there to quickly facilitate appropriate treatment.
  • Tele-consultation: Ranked second in terms of revenue earning of the Indian telemedicine industry in 2015. It involves establishing a clear audio and video communication link between the patient and doctors of different disciplines, as required. Patients’ demand for online consultations with the doctors is fast increasing as it helps to get disease specific medical advice from the different experts located anywhere in the world.
  • Tele-ICU: Was ranked as the third largest segment. It involves the use of an off-site command center in which a critical care team (intensivists and critical care nurses) connects with patients in distant ICUs to exchange health information through real-time audio, visual, and electronic means.

The following are the other six segments, which I am presenting below with a brief definition of each, for convenience:

  • Tele-ophthalmology: It delivers eye care through digital medical equipment and on telecommunications technology platforms.
  • Tele-dermatology: It involves communication technology to connect patients with dermatologists to improve skin health. The technology allows the patient to be examined and even treated without making a physical trip to a dermatologist.
  • Tele-surgery: It is the ability for a doctor to help perform surgery on a patient even though they are not physically in the same location. It is a form of telepresence.
  • Tele-pathology: It involves the practice of pathology at a distance using telecommunications technology to facilitate the transfer of image-rich pathology data between distant locations for the purposes of diagnosis, education, and research.
  • Tele-psychiatry: it is the application of telemedicine to the specialty field of psychiatry. The term typically describes the delivery of psychiatric assessment and care through telecommunications technology, usually video-conferencing.
  • Tele-Home Care and Nursing: This is primarily meant for patients who prefer receiving various health care services at home, such as those suffering from serious chronic diseases, post-surgery, and to cater to the critical regular heath needs of elderly persons.

Service segments:

Similarly, various international literature has segmented the ‘Telemedicine services’ into two broad types, as hereunder:

  • Real Time telemedicine services: These services include telephonic call or video-conferencing where both the doctors and the patients need to be present at the same time, and real time interaction happens between them.
  • Store and Forward telemedicine services: These do not require both the doctor and the patient be present at the same time and transmission and assessment of the medical records can be done at any convenient time.

Types of Providers:

Ken Research Report categorized the ‘Telemedicine Providers’ available in India into the following three groups:

  • Private Hospitals, such as Apollo Tele Health Services, Narayana Health Telemedicine Centers and Aravind Eye Care and telemedicine centers of Medanta, besides others.
  • Government Hospitals and Medical Colleges, such as, AIIMS, SGPGI and several others have made alliances with various districts and sub-district hospitals of different states in India. Some States such as Punjab, Gujarat and Uttarakhand have adopted a PPP model.
  • NGO run centers, such as, World Health Partners are the largest NGO in India that has 1100 with a market share of 56.1 percent.

The critical barriers to overcome:

There are several critical barriers to the rapid penetration of ‘Telemedicine’ in India. However, in this article, I shall discuss only five of those, which India has not cared much to resolve over a long period, and need to be addressed, sooner than later:

  • Frugal broadband Internet network:

Probably realizing that this stark reality still exists, despite earlier initiatives of ‘Digital      India’ slogan, the Finance Minister in his 2017-18 budget speech announced a fresh budget allocation for the new ‘Digi Gaon’ project.

An efficient broadband Internet is an absolute must for any efficient ‘Telemedicine’ project, as most of the applications of ‘Telemedicine’, as mentioned above, would work effectively only in that environment. In 2016, India’s broadband Internet penetration was an abysmal 7 percent, as reported in a white paper of the International Telecommunication Union (ITU), and quoted by the chairperson of the Telecom Regulatory Authority of India (TRAI).

  • High initial cost of setting up a telemedicine network:

The initial cost of setting up a viable ‘Telemedicine’ network, including training of personnel, developing user-friendly smartphone-based apps with state of the art technology, is high with low current Return on Investments (ROI).

  • Availability and training of personnel:

- At the village end: Availability of proper technician, other IT staff and qualified local doctors and their periodic training and performance assessment.

- At the consulting centers: Appropriate training, coordination with other relevant staff and administration as required for compliance and monitoring performance standard.

  • No legal framework governing Telemedicine in India:

At present, there is no legal framework in India governing Telemedicine of the country. The Government would need to urgently consider this issue, as it creates related facilities and infrastructure in the country.

  • Lack of revenue generating business models for sustainability:

In India, ‘Telemedicine’ is generally considered as a part of ‘social responsibility’ of public, private, large corporate hospitals and NGOs. In the some of the private hospitals it is alleged that the underlying objective is to raise the bed occupancy rate when the patients on ‘Telemedicine’ require hospitalization.

Currently, there exists a dearth of revenue generating business models for ‘Telemedicine’ in India, taking it beyond the realm of just ‘social responsibility’, and enabling it to play an increasing role in the overall health care space for long-term sustainability, with a win-win outcome for both its investors and patients.

Thus, the Government would require playing the role of an enabler to encourage, attract and support more and more private players and startups coming up with sustainable commercial business models in this area. Simultaneously, it should also play an active role to help increase public awareness in ‘Telemedicine’, eliminating patient inhibition, enhancing competition and reducing patients’ cost for various services.

Is ‘Affordable health care’ a victim of circumstances?

India with its public spend as a percentage of GDP on health care being consistently one of the lowest in the world over a period of a very long time, despite being the fastest growing global economy, the importance of high penetration of ‘Telemedicine’ in the country assumes a high importance. More so, when grossly inadequate public health care facilities continue to pose serious health risks for many of the country’s population.

On the other hand, in Indian private health care space, including drugs and pharmaceuticals, where a sizeable section of global pharma players and their lobbyists are continually pushing hard, predominantly an Intellectual Property (IP) orientated blatant self-serving agenda. They want to sell more of high price monopoly products and services to earn more and more profit, depriving a huge majority of local patients. It’s happening, even when the image of the global pharma industry has plunged to a new low, and is still going south, despite tons of money allegedly being spent on lobbying of various nature, more than ever before.

No wonder, why the globally acclaimed doyen of the IT industry – Mr. Narayana Murthy also openly acknowledged this fact, suggesting some science and technology based remedial measures. While addressing the Bio Asia 2017 on February 08, 2017 in Hyderabad he said: “India has fallen behind in healthcare, but science and technology can indeed play a role in bridging the gaps. Science and technology can play a key role in diagnosis and management of disease, of mass application of drugs and availability of drugs on a scale and at an affordable cost,” as reported in the Economic Times.

Thus, sandwiched between either side, ‘Affordable health care’ continues to remain a major victim of the circumstances, and is desperately looking for a strong Government intervention, just as what’s now happening in several developed countries, including the United States.

Conclusion:

Although ‘Telemedicine’ is an important enabler and enhancer, I reckon, it’s not a panacea. It would never replace brick and mortar high quality generally affordable health care facilities, along with affordable modern life saving medicines, any time in the foreseeable future.

The announcement of ‘Digi Gaon’ to facilitate ‘Telemedicine’ in India, without a well-charted roadmap and overcoming its critical success barriers, is intriguing. Nevertheless, this initiative has an underlying potential to transform ‘Telemedicine’ into a robust revenue generating model, even at the village level entrepreneurship, with sharp application of creative minds.

It’s a matter of great concern that in the space of Governance in India, public health care is increasingly becoming more a subject of a general lip service, rather than immaculate execution of a robust, comprehensive, time-bound National Health Policy with assigned accountability for each project and backed by requisite budgetary allocation, both by the Central and the State Governments. Consequently, one would seldom witness any such well hyped announcements on various public health care projects seldom coming to fruition on the ground, as promised.

Even if the recently announced ‘Digi Gaon’ initiative is considered as a standalone project for greater access to ‘Telemedicine’ in the hinterland of the country, it is important to understand that, in the short term, investment in ‘Telemedicine’ won’t be a magic wand for India to demonstrate a commensurate increase in health outcomes, along with reaping its consequential economic benefits.

To succeed in this area, several critical barriers need to be effectively overcome, soon. This would help showcasing ‘Telemedicine’ as an integral part of everyday e-health care solution for many. Otherwise, the Government is likely to face enormous challenges to leverage the true potential of ‘Digi Gaon’ for alleviation of acute miseries caused by poor, or lack of access to affordable health care, especially in rural India.

By: Tapan J. Ray 

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

RHDS: A Simmering Promise in Despondency

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Eric Topol, a leading cardiologist who has embraced the study of genomics and the latest advances in technology to treat chronic disease says, “We’ll soon use our smartphones to monitor our vital signs and chronic conditions in future.”

By clicking on this video clipping, you can watch how Dr. Topol in his talk titled “The Wireless Future of Medicine”, highlights several of the most important wireless devices in medicine’s future – all helping to keep more patients out of hospital beds.

In achieving similar objectives, India’s potential is indeed immense. The good news is, though in India Internet penetration has just crossed 16 percent of its total population, in absolute numbers this percentage reportedly works out to nearly 10 times the population of Australia. According to a report released by the Internet and Mobile Association of India (IMAI) and IMRB, there will be around 243 million internet users in India by June 2014, overtaking the US as the world’s second largest internet base after China. This situation must be leveraged to improve access to healthcare in the country significantly.

‘Remote Healthcare Delivery Solutions (RHDS)’

However, for several other reasons the situation is quite challenging in India. Out of its total population of over 1.2 billion, nearly 72.2 percent live in the hinterland and remote rural areas spreading across over 700,000 villages. In all these places, despite huge prevalence of diseases, inadequate healthcare infrastructure and delivery mechanisms offer an ideal backdrop to explore innovative healthcare solutions such as, ‘Remote Healthcare Delivery Solutions (RHDS)’ or ‘Telemedicine’. In that endeavor, smartphones could play a key role in improving access to healthcare for a very large number of population.

The World Health Organization (WHO) has defined ‘Telemedicine’ as:

“The use of information and communications technology (ICT) to deliver healthcare, particularly in settings where access to medical services is insufficient.”

Thus, to effectively improve access to healthcare, especially in rural India, RHDS holds a great promise.

A complex mix:

Healthcare space in India is generally a complex mix of issues related to access, availability, affordability and quality of healthcare, compounded by inadequate public healthcare infrastructure and delivery system on the one hand and expensive private healthcare facilities on the other. The degree of this complexity is rather stark in rural areas.

In a situation like this, RHDS holds a great promise to satisfy healthcare needs of the hinterland and rural India, as this would entail effective medical care, despite understaffed Primary Healthcare Centers (PHCs) and undertrained healthcare staff, with low start-up costs.

Equipped with modern Internet enabled technologies, RHDS would facilitate transmission of patient related information through SMS, email, audio, video, or other image transmissions, like MRI and CT Scans to relevant specialists of different disciplines of medical sciences located in other places. With RHDS, these specialists can monitor even blood pressure or blood glucose levels of patients on computer screens without examining them in person.

Key advantages:

The key advantages of a structured and well committed implementation of RHDS or ‘Telemedicine’ in india are as follows:

  • Elimination of many costs, including travel expenses for specialists and patient transfers – especially in a critical health situation, improving access to quality healthcare.
  • Reduction of feeling of isolation of the rural medical practitioners by upgrading their knowledge through Tele-education or Tele-Continuing Medical Education (CME) programs.

RHDS in India:

In India, RHDS initiative in form of telemedicine commenced more than a decade ago in 1999, when the Indian Space Research Organization (ISRO) deployed a SATCOM-based telemedicine network across the country. ISRO’s telemedicine program has now been reportedly enhanced to multi-point systems with a network of 400 centers across India.

The good news is, besides Department of Information Technology, the Ministry of Health & Family Welfare and many state governments, some well-reputed medical and technical institutes, corporates and academia have also started taking active interest in this area, especially oriented for the rural population of India.

In this context it is worth mentioning that in March 2014, Biocon Foundation reportedly partnered with Canara Bank and the Odisha Government for an e-healthcare program that aims at setting up of diagnostic facilities in PHCs to improve healthcare access to  51,000 villages.

Simultaneously, the Department of Information Technology has put in place the ‘Standards for Telemedicine Systems’ and the Ministry of Health & Family Welfare has constituted the National Telemedicine Task Force to provide further thrust to RHDS in India,.

To cite an example, US based World Health Partners (WHP) have reportedly set up an extensive Tele-Medicine network in the state of Uttar Pradesh (UP), which has received almost 35,000 calls in two years requesting for services. After receiving the calls, the patients requiring intervention were directed to WHP’s franchisee clinics in the respective areas. This model included three areas namely, Meerut, Bijnor and Muzzafarnagar.

Apollo group, Narayana Hruduyalaya, Aravind Eye Hospital and Asia Heart Foundation are also running similar system in India. Unfortunately, none of these or even all put together can extend such facilities to patients across the whole of India, just yet.

The Market:

According to a report of Infinity research the global market for telemedicine is around US$ 9 billion with a CAGR of 20 percent. However, another report quoting KSA Technopak indicates that the Indian market is currently relatively very small with a market size of around US$ 7.5 Million. Considering future growth opportunities, as deliberated here, RHDS market holds a great promise.

Telemedicine or RHDS market is classified based on the type of technology and services used and usually analyzed on the basis of telemedicine applications, such as Tele-consultation, Tele-cardiology or Tele-dermatology etc. However, Tele-consultation reportedly dominates the telemedicine services market.

To give an idea of its market potential, the BRIC (Brazil, Russia, India and China) telemedicine market was reportedly at US$ 200.5 million in 2009 and was expected to expand at a CAGR of 15.8 percent from 2009 to 2014.

The telemedicine technology market segment forms the largest segment of the overall BRIC telemedicine market and is expected to be US$ 307.4 million by end 2014 with a CAGR of 16.6 percent from 2009 to 2014. The services segment in the overall BRIC telemedicine market is expected to reach US$ 111 million in 2014 with a CAGR of 13.8 percent.

The Challenges in India:

Again there are following two critical challenges in this areas:

  • The biggest challenge is undoubtedly the broadband Internet connectivity.
  • Transmitting patients’ medical records through Internet could infringe upon patient privacy giving rise to ethics related issues, besides avoidable litigations.

I reckon, these concerns can be well addressed, if both the private healthcare providers and the Government together resolve and chart a time-bound pathway to improve access to quality healthcare in a cost effective manner to a large majority of Indian population.

Conclusion:

Various public and private RHDS solution providers are gradually getting actively engaged, though incoherent way, to create awareness about telemedicine in the country. This  brings with it a never before hope of ensuring access to quality healthcare to almost the entire population of the country.

A survey conducted in the United States highlighted that 85 percent of patients expressed satisfaction with their telemedicine consultation. Back home in India, a similar study in Odisha reported a satisfaction rate as high as 99 percent post telemedicine consultation.

Having a large base of medical and IT manpower with requisite expertise in RHDS, India holds a great promise to become a major telemedicine hub even for its neighboring countries, transforming the healthcare delivery scenario in all those places significantly.

Bundling all these, together with the increasing use of Internet enabled smartphones as explained by Dr. Eric Topol in his video clipping above, RHDS does offer a simmering promise in an otherwise despondent healthcare scenario of India.

By: Tapan J. Ray

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

e-healthcare: A new vista to improve access to quality and affordable healthcare in India

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The concept of e-healthcare started germinating in India since 1999, when the ‘Indian Space Research Organization (ISRO)’ initiated its pioneering step towards telemedicine in the country by deploying a SATCOM-based telemedicine network. This network is currently playing a key role in the evolution and development of e-healthcare in the country. ISRO, with its fine blending of application of world class satellite communication technology with modern medical science and information technology (IT), has engaged itself very seriously to ensure availability of quality and affordable specialty healthcare services right at the doorsteps of a vast majority of population living even in the distant and remote places of the rural India.

However, despite telemedicine gaining slow momentum in India, there is no law in place for ethical, affordable and patient friendly use of e-healthcare facilities in the country.  Considering its vast scope of improving access to healthcare, cost effectiveness and a convenient ways to deliver e-healthcare services to a very large number of patients, especially, located in the distant locations of the country, the law makers should urgently ensure that this important healthcare service is not misused or abused by unscrupulous elements, in any way.

Very recently, taking into consideration this critical legal requirement the Medical Council of India (MCI) has decided to soon forming a panel to address the ethical issues related to e-healthcare in India.

Delivery of e-healthcare through telemedicine:

The World Health Organization (WHO) has defined telemedicine as follows: “The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.”

As stated above, telemedicine is gradually gaining popularity in India, like in many other countries of the world. This emerging e- healthcare service has the potential to meet the unmet needs of the patients located in the far flung areas, by providing access to medical specialists for treatment of even tertiary level of their ailments, without requiring traveling outside their villages or small towns where they reside.

The key objectives of e-healthcare:

1. To provide affordable quality healthcare services even to those places where these are not available due to lack of basic healthcare infrastructure and delivery issues.

2. Speedy electronic transmission of clinical information of both synchronous and asynchronous types, involving voice and data transfer of patients to distantly located experts and get their treatment advice online.

3. To effectively train the medics and the paramedics located in distant places and proper management of healthcare delivery/service systems.

4. Disaster management.

The Process:

The process can be: – ‘Real time’ or synchronous when through a telecommunication link real time interaction between the patients and doctors/experts can take place. This technology can be used even for tele-robotic surgery. – ‘Non-real time’ or asynchronous type when through a telecommunication link, stored diagnostics/medical data and other details of the patients are transmitted to the specialists for off-line assessment and advice at a time of convenience of the specialists.

These processes facilitate access to specialists’ healthcare services by the rural patients and the medical practitioners alike by reducing avoidable travel time and related expenses. At the same time, such interaction would help upgrading the knowledge of rural medical practitioners and paramedics to hone their skill sets.

The Promise:

e-healthcare is capable of taking modern healthcare to remote rural areas using Information Technology (IT), as specialists are mostly located in the cities. As majority of the diseases do not require surgery, e-healthcare would prove to be very conducive to such patients and economical too.

Relevance of e-healthcare in India:

With its over 1.2 billion population and equally huge disease burden, spreading across distant semi-urban and rural areas, where over 70 per cent of the population of the country lives, India should focus on e-healthcare to meet unmet healthcare needs of the common man, at least, located in far-flung areas. e-healthcare, therefore, is very relevant for the country, as it faces a scarcity of both hospitals and medical specialists. In India for every 10,000 of the population just 0.6 doctors are available.

According to the Planning Commission, India is short of 600,000 doctors, 1 million nurses and 200,000 dental surgeons. It is interesting to note that 80 percent of doctors, 75 percent of dispensaries and 60 percent of hospitals, are situated in urban India.

Progress of e-healthcare in India:

Equitable access to healthcare is the overriding goal of the National Health Policy 2002. e-healthcare has a great potential to ensure that the inequities in the access to healthcare services are adequately addressed by the country.

Very encouragingly, a good number of even super-specialty hospitals like, Apollo Group of Hospitals have unfolded the launch plan of ‘Healthcare India Pharmaceutical Registry (HIPAAR)’, which is an electronic drug database for reference by the doctors and patients.  Apollo Group feels that HIPAAR module will enable the patients to know whether right medications have been used or not to treat the ailment that the concerned patient is suffering from along with the information of possible adverse effects of the medicines prescribed to them.

Currently, in the dedicated e-healthcare centers of ‘Narayana Hrudayalaya group’ pioneered by Dr Devi Shetty, patients from far-flung areas can have consultations with doctors in Bangalore.

Similarly, Asia Heart Foundation (Kolkata) and Regional Institute of Medical Science (Imphal, Manipur) are currently providing multi-specialty e-healthcare through telemedicine to 10 district hospitals, which will be extended to 75 District Hospitals, shortly. At the same time, some Government hospitals also have started extending e-healthcare through telemedicine facilities, which among others will handle e-transfer of medical data of patients like, X-ray, CT scan and MRI for not only diagnosing the disease, but also for treatment and medical consultation. Department of telemedicine of Sir Ganga Ram Hospital of New Delhi is one such example.

Well reputed cancer hospital of India, Tata Memorial Hospital (TMH) of Mumbai is now well connected with B.Barooah Cancer Institute of Guwahati, Assam and K.L Walawalkar Cancer Center of Chiplun, Maharashtra. Over a short period of time TMH plans to connect with 19 such regional cancer institutes.

Today the Center for Health Market Innovations (CHMI), a global network of partners that seeks to improve the functioning of health markets in developing countries to deliver better results for the poor, profiles more than 55 telemedicine programs globally including 24 in India.

Public Private Partnership:

As the Ministry of Health and Family welfare has now constituted a ‘National Telemedicine Taskforce’, some private healthcare institutions, as mentioned above, and various State Governments like, Tamil Nadu, Andhra Pradesh, Kerala and West Bengal have started taking admirable initiatives to translate the concept of e-healthcare into reality, especially for the rural India. Subsequently, private e-healthcare solution providers have also started coming-up, though in a sporadic manner.  Active participation of the civil society and meaningful Public Private Partnership (PPP) projects are essential not only to get engaged in creating awareness for e-healthcare within India, but also to ensure that required blend of a high quality technical and medical manpower that the country currently possesses are effectively utilized to establish India as a pioneering nation and a model to emulate, in the field of e-healthcare.

The market of e-healthcare in India:

Frost & Sullivan (2007) estimated the e-healthcare (telemedicine) market of India at US$3.4 million is expected to record a CAGR of over 21 percent between 2007 and 2014.

More fund required for e-healthcare:

e-healthcare shows an immense potential within the fragile brick and mortar public healthcare infrastructure of India to catapult rural healthcare services, especially secondary and tertiary healthcare, to a different level altogether. Current data indicate that over 278 hospitals in India have already been provided with telemedicine facilities. 235 small hospitals including those in rural areas are now connected to 43 specialty hospitals. ISRO provides the hospitals with telemedicine systems including software, hardware, communication equipment and even satellite bandwidth. The state governments and private hospitals are now required to allocate adequate funds to further develop and improve penetration of Telemedicine facilities in India.

Issues with e-healthcare in India:

– Telemedicine will not be immune to various complicated legal, social, technical and consumer related issues.

- Some government doctors could feel that for e-healthcare they need to work extra hours without commensurate monetary compensation

- The myth created that setting up and running any e-healthcare facility is expensive, needs to be broken, as all the related costs can be easily recovered by a hospital through nominal charges to a large number of patients, who will be willing to avail e-healthcare facilities, especially from distant parts of India.

- Inadequate and uninterrupted availability of power supply could limit proper functioning of the e-healthcare centers.

- High quality of telemedicine related voice and data transfer is of utmost importance. Any compromise in this area could have a significant impact on the treatment outcome of a patient.

- Lack of trained manpower for e-healthcare services needs to be addressed quickly by making it a part of regular medical college curriculum, just as the University of Queensland in Australia has it for their Graduate Certificate in e-Healthcare (GCeH). A pool of competent professionals for e-healthcare services in the country will be a step in the right direction.

- Reimbursement procedure of e-healthcare treatment costs by the medical insurance companies needs to be effectively addressed.

Conclusion:

For an integrated and sustainable healthcare delivery model covering the entire population of the country, a robust e-healthcare strategy is absolutely essential.  Three critical success factors for e-Healthcare initiatives may be considered as follows:

  1. A comprehensive government policy
  2. Increasing level of literacy
  3. Power and telecommunications infrastructure

Unlike common perception, for greater effectiveness and better acceptance of any sustainable e-healthcare service project, the focus should be the same or rather a little more on non-technological areas like consumer mindset and competent healthcare providers than technological factors such as biomedical engineering or information technology.

A very large rural population of India living in remote areas could get access to affordable and quality health related services through e-healthcare facilities, which, I reckon, should be made to play a very special and critical role to address the healthcare needs of the common man. With its gradually increasing coverage, it is imperative that required regulatory standards and guidelines for e-healthcare are put in place across the country, sooner. Technological expertise to make e-healthcare successful is already available in India. The pioneering role that ISRO has been playing in this field is still not known to many.

Thus, to make e-healthcare successful, the country needs to create an appropriate groundswell for the same. All powerful and effective ‘Fourth Estate’ of the country should demonstrate greater interest to initiate a healthy discussion on e-healthcare by all stakeholders and play the role of a facilitator to ensure access to quality and affordable healthcare to all the people of India.

By: Tapan J Ray

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

Healthcare services in India … growing disparity between urban and rural population – can ‘Telemedicine’ play a significant role?

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Healthcare Industry in India is currently valued at US$ 35 billion. This industry is expected to record a turnover of US$ 75 billion in 2012 and US$ 150 billion in 2017, reports Technopak Advisors in their report titled “India Healthcare Trends 2008”.Growing Middle Class Population – the key growth driver:This growth is not expected to come from rural India where over 70% of Indian population lives and a vast majority of them do not have ‘access to modern medicines‘. The key driver of growth of this sector will be growing 150 million strong middle class population with increasing health awareness. Out of this population, 50 million have a disposable income of US$ 4,380 – US$21, 890,, reports McKinsey. Technopak Advisors report recommends an immediate investment of US$ 82 billion to meet this growing demand.

Medical Tourism - another potential growth driver:

Another growth driver is expected to be ‘Medical Tourism’. With a slogan: ‘First World Treatment at Third World Prices’, Medical Tourism is expected to become a US$ 2 billion industry by 2012 from US$ 350 million in 2006, reports a study done by McKinsey and CII. In 2008-09, over 200,000 foreigners, mainly from Middle East and South Asian countries came for medical treatment in India. Hospitals in India are now trying to attract patients from Afro-Asian countries who spend around US$ 20 billion outside their respective countries, towards medical treatment. Thus, the current number of patients visiting India for medical tourism is expected to grow by around 25 percent during next few years.

Medical expertise and facilities – a sharp contrast between the urban and rural India:

India Brand Equity Foundation (IBEF) reports that over a period of last few years besides cost advantage, high success rate, especially in the following areas has been attracting the medical tourists towards India:

• Over 500,000 major surgeries and over a million other surgical procedures including cardio-thoracic, neurological and cancer surgeries have been performed by the Indian specialists, with success rates at par with international standards.

• The success rate of cardiac bypass in India is 98.7 per cent against 97.5 per cent in the U.S.

• India’s success in 110 bone marrow transplants is 80 per cent.

• The success rate in 6,000 renal transplants is 95 per cent.

• India has the 2nd highest number of qualified doctors in the world.

It is worth noting, the centre of excellence of all these outstanding statistical records are located mainly in the urban areas. In sharp contrast to these most of the rural populations are denied of basic healthcare facilities services. Despite being second highest growing economy in the world after China and having world class healthcare facilities available in the country, a vast majority of rural population is denied of basic healthcare services. Even in those places where primary healthcare establishments are available, poor maintenance, understaffing, non-availability of medicines and antic medical equipment, deny the basic and standard healthcare services to the local population.

India is still the home for world’s ‘largest number of poor people in a single country’, even after 61 years of Independence. A study indicates that in India around 260 million people live below the poverty line (BPL). Out of this number about 193 million people live in rural areas and about 67 million live in urban areas. Over 75% of these poor people live in rural India.

The point to note here, although over 700 million people live in rural India, only 193 million of them belong to BPL families. Therefore, even those who can afford proper medical treatment in rural areas, do not have access to modern healthcare facilities, due lack of healthcare infrastructure and services.

Quoting Oxford University of the United Kingdom (UK), The Economic Times (ET) dated February 2, 2009 reported that due to lack of basic healthcare facilities, around one million women and children die every year in India. This is, once again, mainly because 700 million people in rural India have no access to specialists. 80% of medical specialists live in urban areas. ‘India Knowledge, Wharton’ reported recently that India would require an investment of US$ 20 billion over next 5 years to address this problem.

National Health Policy 1983 promised healthcare services to all by 2000 – has it delivered?

The National Health Policy 1983 announced commitment of the Government of India to provide ‘health care services to all by year 2000′. Unfortunately, even today only 35% of Indian population have access to affordable modern medicines, despite an appreciable growth of this sector during last four decades.

Per capita expenditure towards healthcare in India is one of lowest among Asian countries outside South Asia. The expenditure of the Government for healthcare has progressively grown over the years though, healthcare expenditure as a percentage of total government spending has decreased considerably. Only silver lining is that the private sector spending towards healthcare is steadily increasing at a much higher pace.

Can ‘Telemedicine’ improve access to healthcare in rural India?

Would creation of a cost-effective ‘Telemedicine’ infrastructure in rural areas be able to address this problem? In my view, this area is worth exploring seriously and should be tried out by the Government with Public Private Partnership (PPP) model, initially with pilot projects.

‘Telemedicine’ has been defined as the use of electronic information and communication technologies to provide health care support to patients from distant locations. Thus ‘Telemedicine’ could be used to provide healthcare services where it does not exist at all and at the same will help to improve healthcare services considerably, where something already exists.

With the advancement in telecommunication and satellite communication technology in the recent years, the scope of creating and gradually expanding the ‘Telemedicine’ facilities in India indeed throw open a new avenue to improve ‘access to quality healthcare services’, in rural India.

Besides lack of basic primary healthcare services in rural areas where over 70% of Indian population live, 90% of secondary and tertiary healthcare facilities are also located in large cities and towns.

Thus, in addition to primary healthcare services, even secondary and tertiary healthcare needs of a large number of rural populations can be successfully met locally through consultations with the experts located in distant cities and towns without anyone having to travel to those far off cities and towns.

‘Telemedicine‘, therefore, could also offer solutions to the problem of expert medical assistance during serious or critical illness of people living in rural India. The role of ‘Telemedicine’ on healthcare services will be very meaningful under such circumstances.

‘Telemedicine’ services have already started in a smaller scale though, in Kerala, West Bengal and North-eastern states of India. It is slowly coming up in some other southern states, as well. What is required now is a concerted and integrated approach, spear-headed by the Government of India, taking all State Governments on board, with a robust policy initiative.

However, there are some key concerns with this initiative, as well. The most important of which is related to costs of such treatment for the rural households, besides other regulatory issues.

Appropriate regulatory and policy frameworks should be thoughtfully worked out to extend such innovative services to rural India, under PPP. If the concept of ‘Telemedicine’ can be made to work effectively in rural areas, leveraging world class expertise in information technology available within the country, India will emerge as a role model in the field of ‘Telemedicine’ for the developing nations of the world.

Moreover, over a period of time the ‘Telemedicine’ platform can also be effectively utilized for many other healthcare initiatives, like for example, disease prevention programs, medical/para medical staff training etc.

When ‘e-chaupal’ initiative of ITC for rural farmers of India could be so successful, why not ‘Telemedicine’ for rural patients of India?

The promise of “Healthcare services to all by year 2000” as enunciated in the National Health Policy, 1983 of the Government of India, could still be achievable, albeit late, by the next decade of this new millennium with ‘Telemedicine’.

By Tapan Ray

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.