One of the speakers at the ‘Innovation Beyond Borders’ seminar recently organised in Chennai by the Indian Institute of Management, Bangalore, was G. Shainesh, Associate Professor of Marketing from the Institute (http://bit.ly/F4TShaineshG). During the brief interaction with Business Line, he spoke about the change IT (information technology) is bringing to healthcare for the poor. Our conversation continued over the email.
Excerpts from the interview.
What are the most critical areas in healthcare where IT adoption is urgently needed?
The reach of healthcare services is so low in India that IT can be leveraged to improve quality and affordable healthcare to the masses. The most impactful applications will reduce cost for the poor while reaching the under-serviced areas in rural India.
The disparity in access to health services by different population segments (termed as service divide) is the result of the prevailing geographical and economic inequalities. Service divide, thus, segregates our population along the two dimensions of location and wealth, which we term as geographic divide and economic divide.
Geographic divide indicates the spread of the population in the geographical territory of the nation with disparate infrastructure, including infrastructure for health service. The bulk of India’s population lives in rural areas with lesser resources and weaker infrastructure as compared to urban areas. This leads to a divide in the services accessed, between the rural and urban areas.
Economic divide, on the other hand, indicates the disparity in income levels for different population segments. Population groups with higher income levels have greater ability to access services whereas people with lower income levels have lesser access to services.
IT offers an opportunity for delivering innovative service solutions that can reach the currently under-serviced segments of our population.
The following points highlight the extent of health service divide in India:
1) A recent report by the Ministry of Health (MOH), Government of India, states, “Over 75 per cent of the human resources and advanced medical technology, 68 per cent of an estimated 15,097 hospitals and 37 per cent of 6,23,819 total beds in the country are in the private sector. Most are located in urban areas. Of concern is the abysmally poor quality of services being provided at the rural periphery by the large number of unqualified persons.” (MOH, 2010)
2) Public healthcare spending in India at 20 per cent is among the lowest in the world, while private spending accounts for over 70 per cent of expenditure (NHAI, 2005). This high share of out-of-pocket (OOP) expenditure on healthcare forms a major barrier to health-seeking behaviour in India.
3) Lancet (2011) reports, “Health services in the public sector that can be accessed free or for a nominal fee are grossly inadequate. As a result, most Indians access private health care that is expensive, unaffordable, unreliable, and impoverishing. The absence of financial protection and the rising costs of treatment have been dissuading people from accessing much-needed health care. In 2004, 28 per cent of ailments in the rural areas went untreated because of financial reasons – up from 15 per cent in 1995-96. Similarly, in the urban areas, 20 per cent of ailments were untreated for financial reasons in 2004 – up from 10 per cent in 1995-96. 47 per cent of hospital admissions in rural India and 31 per cent in urban India were financed by loans and the sale of assets.”
It should be refreshing to know that IT is being used to provide healthcare services through continuing medical education (CME) to doctors and paramedics, for diagnosis in eye care at vision centres of Aravind Eye Care System (AECS), screening of Retinopathy of Prematurity (ROP) by Narayana Nethralaya, and diagnosis for cardiac care through telemedicine and Trans-Telephonic ECG (TT-ECG) by Narayana Nethralaya.
Are there any key lessons from some of the historically ineffective approaches to IT in healthcare, globally and in India?
Successful IT implementations have all evolved through trials, iterations, adaptations and experimentations. Many of the big bang approaches fail as they are not designed for sustainability – operation as well as financial. When funding is provided on a project mode, the focus is on capital expenditure while sustainability requires these investments to be running for a long time.
So, while IT can take the services to under-serviced areas and to the poor, the capacity to pay has to be provided through micro-insurance schemes like the Yeshaswini scheme piloted by Narayana Hrudayalaya and currently managed by the Government of Karnataka, or by governments as in Western Europe.
Can you describe a few success stories in healthcare IT that you participated in?
In our research titled ‘Service Innovations in Indian Healthcare Industry: From Digital Divide to Digitally Enabled Inclusion,’ Prof Shirish Srivastava of HEC Paris and I have studied telemedicine initiatives of Aravind Eye Care System (AECS) and Narayana Hrudayalaya / Nethralaya (NH / NN).
The AECS telemedicine initiative was designed to reach the rural masses efficiently and provide them quality service at affordable prices. When their utilisation studies found that eye camps reach only 7 per cent of the people who needed eye care, AECS started looking for a better touch-point option for eye care in rural areas in the face of a shortage of ophthalmologists willing to stay in these remote locations.
Telemedicine emerged as a potential solution, and they planned for a permanent set up in the form of a vision centre in rural areas to create a trusted service touch-point for the villagers.
The real-time tele-connectivity decouples eye care service into three interconnected but different components: (1) patient examination (by the vision centre technician); (2) diagnosis (by the specialist in the base hospital); and (3) dispensation of medicines and/or spectacles (by the technician at the vision centre).
The first vision centre (VC) was piloted at Ambasamudram in Southern Tamil Nadu by connecting to the Theni base hospital through a wireless network based on WiFi 802.11b technology in 2004. In the last two years, AECS has switched to broadband connections as it works out to be more economical compared to dedicated wireless networks. In 2009-10, the 31 vision centres provided eye care consultations to over 1,60,000 patients. They charge a nominal Rs 20 for consultation. At present, almost all the 36 vision centres are financially self-sufficient.
Similar to AECS, NH realised that the bulk of the potential patients are in rural areas hence the need to leverage ICT to reach this group of patients. Starting in 2001, doctors at NH have provided remote consultations to over 53,000 patients through its 143 telemedicine centres, including 53 centres located in the African continent. Since 2004, cardiologists at NH have also started using the Trans-Telephonic ECG (TT ECG) network to diagnose, provide opinion and recommend treatment plan on the ECG reports sent by physicians from across the country
At Narayana Nethralaya (NN), IT is leveraged to screen a potentially blinding condition (prevalent among pre-term babies) called Retinopathy of Prematurity (ROP) which is the largest cause of infant blindness in developed countries. Dr Anand Vinekar, Head of Department of Paediatric Retina, NN, describes the magnitude of the problem in India: “Every year, more than 2.3 million (8.8 per cent) of the over 27 million births in India are born pre-term or underweight, i.e. less than 2000 grams. Almost 47 per cent (1.08 million) of these infants are prone to ROP and over 15 per cent (0.16 million) require specialised treatment. ROP is curable, but requires early screening and timely treatment within 4 weeks of birth to prevent irreversible blindness.”
In early 2008, NN initiated the Karnataka Internet Assisted Diagnosis of ROP (KIDROP) project by leveraging the power of the Internet. The Tele-ROP component provides ROP screening in the rural areas through digital imaging of infant retinas using a specialised retina camera (RETCAM).
The dedicated team travels with the RETCAM in a bus to hospitals in the rural areas on a fixed schedule every week. The trained technician uses the RETCAM to image the eye in the Neo-Natal Intensive Care Unit (NICU) of partner hospitals. Then s/he uploads the images instantly through broadband to a secure server accessible to the retina specialist in Bangalore for diagnosis.
In addition, the specialist has real-time access to these images on an Apple iPhone through an application developed by i2i Telesystems, the Bangalore-based technology partner for the project. The technician is trained to image, save, retrieve, analyse the images and report ROP using ‘pattern recognition.’
This innovation substitutes a retina specialist with a trained non-physician for screening from an underserved rural location and uses the broadband and mobile networks to instantly transmit images to the specialist, located in the city, for quick diagnosis. In turn, the expert’s report is transmitted to the rural technician, and treatment, if required, is provided at the rural centre by the KIDROP team experts or locally-trained ophthalmologists.
The programme started in April 2008 and within the first 30 months (i.e. till November 2010) the programme has helped screen over 3,200 infants across 24 centres within a radius 160 km around Bangalore. For 62 per cent of the patients, the service was offered free of cost, 16 per cent patients received heavy subsidy, while the rest were charged. Fees collected from those who can afford to pay helps cover the operational costs, thus allowing the programme to break even.
Where do you see roadblocks in replicating such IT successes?
A strong value system, commitment, passion, a very effective delivery system and innovations are prerequisites for sustainability. IT is really an enabler in all success stories.
How should Indian IT industry respond to the country’s healthcare needs? (2-3 things that they should do in your view.)
1) Partner with the players in the healthcare service to create low-cost solutions; and
2) Create an ecosystem with insurance providers, telecom service providers and healthcare providers to ensure sustainability.
Any other points of interest.
The recent decision by the RBI to allow ‘mobile wallet’ opens the doors for spreading micro-finance to individuals who can now afford health insurance by paying small amounts (Rs 15-20) every month as premium. The mobile penetration of almost 700 million can be leveraged to reduce transaction costs deterring the growth of micro-insurance.