Featured image: A medical worker treats a patient suffering from the coronavirus disease (COVID-19), at the Intensive Care Unit (ICU) of the Max Smart Super Speciality Hospital in New Delhi, India, September 5, 2020. Photo: Reuters/Danish Siddiqui
Ours is a large country, and its healthcare needs are thus immense.
Advanced and specialised healthcare is still a privilege for rural India, which makes up about two-thirds of our population. Only 13% of the people in rural India have access to a primary health centre, 33% to a sub-center and 9.6% to a hospital.
The digital transformation of health services has been projected as an important process which will profoundly affect the various phases of healthcare delivery, including health promotion, prevention, primary care and specialised care.
But India’s public health system is still in its developing stage and the COVID-19 pandemic has exposed the flaws in our existing health system.
India has a shortage of an estimated 6,00,000 doctors and 20,00,000 nurses. India only has one government doctor for every 1,139 people. This has resulted in far more increased working hours for healthcare workers during the pandemic.
There are only 0.7 hospital beds per 1,000 people in India with variations across the states, as per World Bank estimations. This clearly shows us why we failed to admit and isolate every patient who tested positive for COVID-19, in hospital settings.
The enabler of services here is the government, both at the central and state levels. It must take immediate steps to improve health facilities.
When the pandemic first began gaining pace, we did not have well-equipped public health labs required for conducting RT-PCR tests for the diagnosis of COVID-19. Let alone district hospitals, major medical colleges both in government and the private sector did not have this facility.
This is one point which serves as a humbling reminder as to where we stand today.
The low doctor-patient ratio both in urban and rural areas is also a matter of concern as it affects quality care services.
The digital health mission announced by the government is an ambitious plan to address India’s public health crisis. But what is most worrying is the timing during which it is being rolled out.
The key components of the mission include a health ID, telemedicine, health records, health registry, along with digi-doctor and e-pharmacy services. In an India where we still need to pursue the basic goals of healthcare that include high quality care, efficiency, equity, affordability and accessibility to care, implementation of a digital health effort must be evaluated thoroughly.
The building blocks of this digital health mission as mentioned in reports includes two layers. The first comprises infrastructure and the second, data hubs. The objective of the infrastructure layer is to ensure health data and its transfer is always secure and assuages privacy concerns. The first layer comprises secure health networks, health clouds and a security and privacy operations centre. The security operations centre will continuously monitor health data round the clock and will have the power to catch any breach in data flow.
The second layer, the data hub, which makes up the fundamental working block of the mission, forces us to think on its practicality when faced with ground realities.
Most of the major hospitals are already facing a shortage of required doctors, and allied health staff. Low salaries, a practice of contractual appointments and a poor working environment are some of the major worries healthcare workers face. Many of them are forced to go on strike many times in the course of their careers.
A recent strike by nurses at AIIMS, Patna, and frontline ASHA workers in Delhi are few examples in this regard. With acute shortage of specialist doctors, the aim of providing quality and specialised care to all will be a difficult one to fulfil.
Challenge of internet accessibility
The key difference between creativity and innovation is execution.
This IT-based initiative has been termed a potential game changer but the truth remains that it is expected to face obstacles, especially in rural India, considering unequal access to internet services, problems of slow speed and lack of all-pervading digital health resources.
Digital literacy and accessibility of digital records is a particular concern area in rural regions.
Prime Minister Narendra Modi, in his speech announcing the mission, said that COVID-19 had shown India the need for self-reliance. Modi said the digital health mission is an important step towards realisation of universal health coverage.
At present, we can certainly look forward to telemedicine, digi-doctor and e-pharmacy facilities when regular outpatient departments are closed. Provided it has all checks and balances in place, teleconsultation has the capacity to provide holistic care to all.
A report published by Practo titled, How India Accessed Healthcare provides valuable insight in this regard. Online consultation queries have increased by more than 200% and overall telemedicine calls have increased by 500% since March.
Digital models of health systems ensure better delivery of preventive, curative, and rehabilitative health services to people grappling with chronic diseases, irrespective of their geographical location. With its innovative management models, tele-health breeds smart information systems that can deliver instant messages, even in the remotest of domains.
We have certain good examples in this regard.
Lucknow-based Digidoctor is an app which has been functional for the last 4-5 months. It was developed by Criterion Tech and Era Medical College and provides specialised tele-consultation services in almost all broad speciality medicine subjects.
It has, till now, provided free consultations to more than 1,000 patients at a time.
Other telemedicine apps like Remedico for dermatology problems and Mentdoc for telepsychiatry have come to the rescue of patients at a time when in-person visits are risky and difficult considering infection transmission risk.
Specialised public sector hospitals such as AIIMS, JIPMER, PGI, Maulana Azad, etc. must expand their existing tele-health departments so that they reach remote parts of country so that cost-effective digital health services are provided to the needy. Existing primary healthcare centres, health and wellness centres, and sub-centres must start a telemedicine element in their centres. These must be clubbed with higher, specialised hospitals, to provide digital consultation.
This also requires timely recruitment of doctors, allied health staff and a few IT operators to turn the digital health mission into an actual, serving model. Establishing model digital health centres in rural settings with at least one MBBS, or an Ayush doctor, along with a pharmacist and IT operator may prove to be a game changer in this regard.
This ultimately requires government willingness and investment.
Government’s mega Jan Aushadhi Yojana must be clubbed with an e-pharmacy drive so that low cost drug delivery is ensured. Tie-ups with e-pharmacies such as 1mg, Netmeds, 1tab, medlife, etc. needed to be considered.
The proposed digital health mission also aims to create different types of medical directories including doctors, facilities, nurses and paramedics, and so on. This is completely incomprehensible.
It’s difficult to understand the objective behind such a large database as we already have systems in existence which can easily provide us with this information. The Indian Medical Register maintained by the Medical Council of India which is updated every year, contains the record of all the practising doctors.
Similar is the case with the record of hospitals, nursing homes, diagnostic laboratories, and health workers, including paramedics, along with ASHA and Anganwadi workers. The National Accreditation Board for Hospitals & Healthcare Providers
and National Accreditation Board for Testing and Calibration Laboratories maintain the data of hospitals and labs accredited to it and regularly checks for proper protocol.
In 2005, England’s National Health Service started working on a similar project to create electronic health records of its citizens for a centralised health record system by 2010. Many hospitals and organisations were roped in but ultimately due to technical glitches and complexities, the programme was dismantled after a cost of £ 12 billion to UK’s exchequer.
It is still considered as one of the biggest instances of healthcare-IT failure and forces us to think whether it is prudent to invest in digitising the health records of billion of Indians.
Dr R.V. Asokan, who serves as general secretary of the Indian Medical Association is of the view that it is a ‘hyped’ programme and does not serve a purpose for patients. “The government has said that it needs to make surveys and collect data for various health programmes like the National Family Health Survey. Nevertheless, this cannot be a reason to get hands-on public health data on such a large scale,” Asokan said.
“Our priority area should be strengthening multi-speciality government hospitals, level-2 district hospitals and our existing PHCs and CHCs at urban and rural level,” he said.
Increasing public health spending, building a robust health infrastructure and equipping it with advanced devices along with filling vacant healthcare positions to carry out the required tasks are also urgent needs.
This is only possible if we have enough specialist doctors and post-graduates passing every year and an adequate part of GDP is directed to the health sector.
With coordinated efforts from both central and state governments along with those of the private sector, we must hope for a healthy India.
Dr Faiz Abbas Abidi is a junior doctor working on biomedical research, public health issues and digital health interventions. He tweets at @doc_faiz.