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Telemedicine – one of the unsung advances towards improving access to healthcare services in India.

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Telemedicineis gradually becoming popular in India, like in many other countries of the world. This emerging technology based healthcare service, will surely meet the unmet needs of the patients located in the far flung areas, by providing them access to specialists to treat their even tertiary level of ailments, without requiring to travel outside their villages or small towns where they reside. Telemedicine is therefore emerging as a convenient and cost-effective way of treating even complicated diseases of the rural folks.The definition:The World Health Organisation (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”

The applications of Telemedicine:

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

2. 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, which involves transmission of stored diagnostics/medical data and other details of the patients to the specialists for assessing off-line and advice them at a time of convenience of the specialists.

These processes facilitate access to specialists’ healthcare services by the rural patients and the rural medical practitioners reducing avoidable travel time and related expenses. At the same time such interaction helps upgrading the knowledge of the rural medical practitioners and paramedics.

Relevance of Telemedicine in India:

Telemedicine is very relevant to India as it faces a scarcity of both hospitals and medical specialists. In India for every 10,000 of the population just 0.6 doctor is available. According to the Planning Commission, India is short of 600,000 doctors, 10 lakh nurses and 200,000 dental surgeons. Over 72 percent of Indians live in rural areas where facilities of healthcare are still grossly inadequate. Most of the specialists are reluctant to go to the rural areas. In addition, 80 percent of doctors, 75 percent of dispensaries and 60 percent of hospitals, are situated in urban India.

Telemedicine can bridge the healthcare divide:

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

The market of Telemedicine in India:

Frost & Sullivan has estimated the telemedicine market of India at US$3.4 million, which is expected to record a CAGR of over 21 percent between 2007 and 2014.

Practice of Telemedicine in India:

Not only the central government of India, many state governments and private players are also entering into telemedicine in a big way with the Indian Space Research Organization (ISRO) playing a pivotal role.

Telemedicine now shows an immense potential, within the frugal healthcare infrastructure of India, to catapult rural healthcare services, especially secondary and tertiary, 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.

In 1999, India based one of the largest healthcare providers in Asia, The Apollo Hospitals Group also entered into telemedicine space. Today, the group has quite successfully established over 115 telemedicine locations in India, It has been reported that a tele-consultation between the experts and the rural centre ranges from 15 to 30 minutes in these facilities.

The state governments and private hospitals are now required to allocate funds to further develop and improve penetration of Telemedicine facilities in India.

Issues with Telemedicine in India:

Telemedicine is not free from various complicated legal, social, technical and consumer related issues, which need to be addressed urgently.

- Many a time, doctors feel that for Telemedicine they need to work extra hours without commensurate monetary compensation, as per their expectations.

- The myth created that setting up and running a Telemedicine facility is expensive needs to be broken, as all these costs can be easily recovered by any hospital through nominal charges to the patients.

- Inadequate and uninterrupted availability of power supply could limit proper functioning of a telemedicine centre.

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

- Lack of trained manpower for Telemedicine can be addressed by making it a part of regular medical college curriculum.

- Legal implications, if arise, out of any Telemedicine treatment need to be clearly articulated.

- A system needs to be worked out to prevent any possible misuse or abuse of the confidential Telemedicine treatment data of a patient.

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

Conclusion:

Some significant and path breaking advances have indeed been made in the field of Telemedicine in India. It is unfortunate that not enough awareness has been created, as yet, on this novel technology based healthcare service for the common man. The pioneering role of ISRO in this field is also not known to many. It appears that advances of Telemedicine in India to extend quality healthcare services, especially, to our rural folks will continue to remain unsung for some more time. Until of course our all powerful ‘Fourth Estate’ steps in to initiate a healthy discussion on this subject within the civil society.

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.

Is the world now moving towards ‘Global Patent’ system?

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A brief background:
In June 19, 1970 an International patent law treaty was signed in Washington, initially with 18 contracting states. This treaty is called ‘The Patent Co-operation Treaty’ (PCT), which came into force on January 24, 1978 and was subsequently amended in 1979 and further modified in 1984 and 2001.In August, 1998 India joined the Patent Cooperation Treaty (PCT) by acceding to the Paris Convention on Intellectual Property. As on March 7, 2009, 141 states including all major industrialized countries, are signatories to the PCT.

PCT system, as we know, facilitates filing of patent applications under one roof with simpler procedure for search and examination of applications. This allows innovators of a PCT member country to obtain the effect of patent filings in any or all of the PCT countries.

The procedure currently followed by PCT is as follows:

“A single filing of an international application is made with a ‘Receiving Office’ (RO) in one language. It then results in a ‘search’ performed by an ‘International Searching Authority’ (ISA), accompanied by a written opinion regarding ‘patentability’ of the invention, which is the subject of application. This is optionally followed by a preliminary examination performed by an ‘International Preliminary Examination Authority’ (IPEA). Finally, the examination (if provided by national law) and grant procedures are handled by the relevant national and regional authorities.”

Currently the PCT does not lead to the grant of an ‘International Patent’.

WIPO recognizes Indian Patent Office as an ISA and IPEA:

Recently under PCT, ‘The World Intellectual Property Organization’ (WIPO) has recognized the Indian Patent Office (IPO) as an International Searching Authority (ISA) and International Preliminary Examining Authority (IPEA).

Besides India, other countries which have this recognition are Austria, Australia, Canada, China, EU, Spain, Finland, Japan, Korea, Russia, Sweden and the USA.

This recognition will help India the following ways:

1. Through PCT route India will now receive international patent applications from WIPO for search and preliminary examinations. This will enable IPO to generate revenue in form of fees paid to ISA and IPEA.

2. This recognition would help the innovators of the country to avail patentability search, obtain IPER and written opinions much faster and at a cheaper rate.

Is the world now moving towards ‘Global Patent’ system?

Recently a document has been published by WIPO for the meeting of PCT working group scheduled at Geneva from May 4 to May 8, 2009. The outcome of the meeting is not known to me, as yet. This document includes a proposal from the United States Patent and Trade Mark Office (USPTO) for having a relook at the existing international patent system. This relook and discussion could translate into development of an entirely new Patent Cooperation Treaty (PCT), which perhaps would be termed as PCT II.

The key feature of the proposed PCT II is that all patent applications, which will successfully pass through scrutiny of both international/national processing system would automatically receive patent grants in all the member countries.

While discussing this process within the PCT working group, it is anticipated that following two key issues will crop up for an intense debate:

1. Harmonization
2. Sovereignty

However, many feel that an appropriate protocol system could be put in place to take care of both these concerns, where after release of an affirmative international patentability report, each member country will be given certain period of time to refuse the grant patent in that particular country, clearly specifying the reasons for the same.

In true sense it may not mean grant of a global patent, but definitely could be considered as a bold step towards that direction. PCT II, if sees the light of the day, is expected to create a much easier type of patent granting procedure.

To make it effective, existing PCT structure will need to undergo some significant changes. The new structure is expected to ensure a very high quality output. The member countries, who will work in tandem, should find the new procedures and systems much more user-friendly and at the same time efficient in ensuring comprehensive search between multiple offices that incorporate prior art submissions by the applicants and third parties.

However, if PCT II gets accepted in principle by all the member countries, a detail mechanism to effectively operate such a complex system to be worked out with great precision, ensuring full satisfaction to all concerned.

In India, this new development will certainly be examined with a ‘tooth comb’ and rightly so. It is expected that all pros and cons will be carefully examined by the country, getting fully involved in this international debate, before arriving at a final decision. On the face of it ‘PCT II’ appears to be a novel concept, which deserves due consideration by all the stakeholders and in no case to be summarily brushed aside following the shrill voices of some skeptics.

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.

An integrated approach towards Public Private Partnership (PPP) initiatives to improve access to healthcare in India is the way forward.

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Despite so much of stringent government control, debate and activism on the affordability of modern medicines in India, on the one hand, and the success of the government to make medicines available in the country at a price, which is cheaper than even Pakistan, Bangladesh and Sri Lanka, on the other, the fact still remains, about 65% of Indian population do not have access to affordable modern medicines, compared to 15% in China and 22% in Africa.The moot question therefore is, despite all these stringent price regulation measures by the government and prolonged public debates over nearly four decades or so to ensure better ‘affordability of medicines’, why then the situation on ‘access to modern medicines’has remained so abysmal to a vast majority of the population, in India?This, in my view, is mainly because; no single minister or ministry can now be held accountable by the civil society for such a dismal performance in the access to healthcare, in India.

Poor healthcare infrastructure:

As per the Government’s own estimate, India records:

1. A shortage of 4803 Primary Health Centres (PHC)

2. A shortage of 2653 Community Health Centres (CHC)

3. No large Public Hospitals in rural areas where over 70% of the populations live

4. Density of doctors in India is just 0.6 per 1000 population against 1.4 and 0.8 per 1000 population in China and Pakistan respectively, as reported by WHO.

The Government spending in India towards healthcare is just 1.1% of GDP, against 2% by China and 1.6% by Sri Lanka, as reported by the WHO.

Some good but sporadic public healthcare initiatives:

The government allocation of around US$ 2.3 billion for the National Rural Health Mission (NRHM), is a good initiative to bring about uniformity in quality of preventive and curative healthcare in rural areas across the country.
While hoping for the success of NRHM, inadequacy of the current rural healthcare infrastructure with about 80 percent of doctors, 75 percent dispensaries and 60 percent of hospitals located only in the urban India, may encourage skepticism.

Addressing the issue of improving access to healthcare:

While addressing the issue of improving access of healthcare, following three important ‘Public Private Partnership (PPP)’ initiatives would be most appropriate.

1. PPP to improve affordability:

To address this vexing problem, industry associations had jointly suggested a policy shift towards public-private-partnership (PPP) model to the government in 2006-07, instead of a stringent price control mechanism, which has not worked thus far to improve access of modern medicines, in India. Instead, the associations seemed to have suggested that the pharmaceutical industry will supply to the government the essential medicines at 50% of their Maximum Retail Price (MRP), to cater to the need of below the poverty line (BPL) families.

It is worth mentioning, many OPPI member companies like, Novartis, GSK, Pfizer, Sanofi-Aventis etc. have their own access to medicines programs in India.

Although the government did not respond to this proposal, to make it effective the ministry of health will require to quickly initiate significant ‘capacity building’ exercises, both in the primary and also in the secondary public healthcare facilities in the country. FICCI is reported to have suggested to the Government for an investment of around US$ 80 billion to create over 2 million hospital beds, for such capacity building exercises .

Frugal budget allocation by the government towards healthcare of the country, suggests that Government is gradually shifting its role in this very important area, primarily from healthcare provider to healthcare facilitator for the private sectors to develop it further. If it is so, it is imperative for the government to realize that the lack of even basic primary healthcare infrastructure, leave aside other incentives, impede effective penetration of private sectors into semi-urban and rural areas. Effective PPP model should be worked out to address such issues, without further delay.

2. PPP to leverage the strength of Information Technology (IT) to considerably neutralize the system weaknesses:

Excellence in ‘Information Technology’ (IT) is one of the well recognized strengths that India currently possesses. This strengths needs to be adequately leveraged through PPP to neutralize the above weaknesses. Harnessing IT strengths, especially in the areas of drug procurement and delivery processes, especially in remote places, could hone the healthcare delivery mechanism, immensely.

Another IT enabled technology that India can widely use across the nation to address rural healthcare issues is ‘‘Telemedicine’ for distant diagnosis and treatment of ailments. Required medicines for treatment could be made available to the patients through ‘Jan Aushadhi’ initiative of the Department of Pharmaceuticals (DoP), by utilising the Government controlled distribution outlets like, public distribution system (ration shops) and post offices, which are located even in far flung and remote villages of India.

3. PPP in healthcare financing for all:

Unlike many other countries, even as compared to China, over 72 percent of Indian population pay out of pocket to meet their healthcare expenses.

Out of a population of 1.3 billion in China, 250 million are covered by insurance; another 250 million are partially covered by insurance and balance 800 million are not covered by any insurance. Converse to this scenario, in India total number of population who may have some sort of healthcare financing coverage will be around 200 million with penetration of health insurance at just around 3.5% of the population. India is fast losing grounds to China mainly due to better response to healthcare infrastructure.

Even after leveraging IT for ‘Telemedicine’ and improving healthcare delivery processes, together with availability of low priced quality medicines from ‘Jan Aushadhi’ outlets, a robust healthcare financing model for all strata of society to make healthcare products/services affordable to a vast majority of the population, will remain an essential requirement for the country to address the issue of improving access to healthcare to all.

According to a survey done by National Sample Survey Organisation (NSSO), 40% of the people hospitalised in India borrow money or sell assets to cover their medical expenses. A large number of populations cannot afford to pay for the required treatment, at all.

Conclusion:

In my view an integrated approach for creating effective healthcare infrastructure throughout the country, leveraging IT in the entire healthcare space, appropriately structured ‘Health Insurance’ schemes for all strata of society ably supported by well spread out ‘Jan Aushadhi’ outlets even in far flung rural areas, deserve careful consideration by the Government.

A PPP model in all these three areas needs to be worked out in detail to address the pressing issue of improving ‘Access to Affordable Integrated Healthcare to ALL’.

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.