Dr. Sanjiv Kumar is MBBS and MD from AIIMS, New Delhi, DNB in MCH and MBA in Strategic Management. He has 41 years of experience in public health across 29 countries. He started as Medical Officer in Indian Army. He taught Preventive and Social Medicine at University College of Medical Sciences, New Delhi. He then joined UNICEF and worked for 22 years at various levels in 29 countries. He worked as Executive Director at National Health Systems Resource Centre, New Delhi. Dr Sanjiv Kumar is back to teaching as Director, International Institute of Health Management and Research in New Delhi.
Dr. Nishikant Bele received his Doctorate in Computer Science from Utkal University, Bhubaneswar, Orissa and MCA from Amravati University Amravati, Maharashtra. Dr. Nishikant has over 16+ years of experience in teaching, training, administration and research with prominent organizations. He is a SAP certified ERP Solution consultant. He had published research papers in various journals of international repute and has attended and presented papers in many international and national conferences. His areas of interest are: Health Informatics, Business Analytics, ERP, Data Modeling & Database Designing, Web and Text Mining.
India has made substantial progress in health. This is also reflected in some of the millennium development goal MDG targets that have been achieved and for others substantial progress has been made. Under-five mortality rate has declined from 126 (1990) to 48 (2015) and maternal mortality ratio from 560 to 174 during the same period. Though India missed MDG target of 42 and 140 respectively for these two indicators but the progress is remarkable. The estimated number of child deaths have come down from 3.2 million in 1990 to 1.1 million in 2015 which means 3,300 child lives saved every day!
However this progress does not commensurate with the economic and technology progress India has made. Our neighbouring countries with lesser development have made better progress. For example, the under-five mortality rate in the neighbouring counties of Sri Lanka, Nepal and Bangladesh is 9, 36 and 38 respectively, against 48 in India (Kumar S, Bothra V, Mairembam DS, 2016). Innovations in program and technology offers an opportunity to accelerate improvement in health in India. The ministry of health and family welfare has actively encouraged the state governments to innovate, identify innovations that address the burden of diseases, are cost effective and replicable. The government provides technical and financial support to scale them up. We look at how technology innovations in public health system in India can help accelerate its progress in improving health.
Opportunities
There are many opportunities available in India today for innovations. Indians have provided substantial inputs to digital revolution across the world. However within India we have only recently started efforts to harvest the benefits for the Indian population. The recently launched ‘Digital India’ strategy in 2014, has made many government services available online cutting down delays, red tapism and corruptions. A common man is making payment for day today necessities online or through mobile telephones saving time and money. A related initiatives to accelerate innovations in the ‘Start-up India’ campaign facilitates bank financing and creates a favourable business environment for start-up ventures including technology innovations. Similarly, the ‘Make in India’ launched in 2014, encourages Indian and multinational companies to manufacture technology and medical devices in India.
The global statistics shows that the 4.61 billion mobile users in 2015 from 4.01 billion in 2013. In 2017 the number of mobile phone users is forecast to reach 4.77 billion. Considering the challenge in grabbing this opportunity, there is a need to respond with service innovation. Overall, consumers and society will reap the fruits of this technological and socio-economic development. Data consumption is growing 65 percent annually for accessing services such as e commerce and e-learning.
Bharat Net’s aim is to connect India’s 250,000 Panchayats at an estimated cost of $18 billion. Health and education have been identified as priority areas to benefit from this connectivity. There are alternative approaches to connect India, including cable TV pipes and White spaces (refers to the unused TV channels between the active ones). These and many other opportunities are available in abundance today. The Digital India, National Skill Development Corporation,Swachh Bharat Abhiyan and Kayakalp Awards, creating ‘Smart Cities’ are some more opportunities to mention.
Ministry of Health & Family Welfare promotes innovation in public health
Considering the tremendous potential in technology to compliment, accelerate effective implementation of health care, all the states have been encouraged to include innovations in the state programme implementation plans under National Health Mission (NHM). Annual national summits are held to recognize share successful efforts by the states. To facilitate this entire process including identification and review of such innovations a platform of ‘www.nhinp.org’ portal has been created. This allows uploading of innovations.
There are two categories of innovations program innovation and product innovation. Program innovation includes service delivery including referral, governance, treatment compliance, reduce cost of care or out of pocket expenditure etc. the product innovations include medical devices, innovative technologies including healthcare IT, m-health, and Tele-health/ E-health.
There are norms set for inclusion and exclusion of innovations. The inclusion criteria are –relevance to health needs, address endemic health problems and or diseases, facilitates accessibility, affordability, reduce cost of care, ensure quality and safety of healthcare product and process, and bridge skill gap required in service delivery. Similarly, the exclusion criteria are – Specific drugs, surgical or medical procedures or practices that need evaluation through one or more of the processes such as- Randomized controlled trials, Systematic Reviews, Meta-analysis etc, and Incomplete Documentation. The screening processes well laid out. This involves a six member screening group at NHSRC and an in depth reviews held by product and program committee.
In health, states are encouraged to propose innovation in program implementation plans for approval. In addition, to encourage and recognize the successful efforts, National Summits on Good and Innovative practices were initiated. In continuation, National Health Innovation Portal was launched by Shri. J. P. Nadda, Hon’ble Health Minister of India, in the year 2015. To strengthen and sustain the efforts further, Health Technology Assessment Workshops were held. In all, six such workshops with 325 participants were trained. To strengthen the whole effort, there has been health technology assessment trainings being conducted for non-invasive Haemoglobinometer and Glucometer, urine strip analyzer, SMS enabled patient monitor etc.
Table 1: Technology can help India leapfrog to improve health by addressing challenges, some examples:
| Challenges | How technology can help: examples | |
|---|---|---|
| Preventive Care | ||
| Health Promotion | Lack of physical activity, dietary intake, stress level | Mobile Apps to monitor physical activity, stress level, foodintake etc |
| Lack of awareness of wellness, healthy lifestyle, mental illness, awareness on domestic violence | Films on Youtube and smartphone, mobile apps, SMS, Cloudbased screening and monitoring of mental health | |
| Family Health including MCH | Lack of health record | Electronic Family Health Record for all family membersincluding those with NCDs linking it to UID, ANM Online |
| Record of child and maternal care | Electronic Health record | |
| Lack of awareness | Mother and Child Tracking System Sending SMS to beneficiaries to alert them regarding services due to them, or services which have become overdue using M-health | |
| Curative care | ||
| Disease outbreak | Lack of clinical and personal health data | Machine Learning based Predictive Analytics for providing hyper-personal, actionable insights. |
| Lack of awareness and counselling (HIV/AIDS) | Mobile Apps for counselling, awareness, mobile apps for nurse, doctor for monitoring | |
| Lack of real time monitoring (Lymphatic Filariasis Mass Drug Administration) | SMS Reporting Program for ASHA | |
| Access and Quality | ||
| Access to health care | Shortage of Doctors | E consultations, Any Time Medicine |
| Shortage of specialists | Tele-medicine, tele-radiology, tele-ophthalmology | |
| Delay in fund flow and poor monitoring | Automation in Fund flow: PFMS | |
| Stock outs of drugs and other consummables | online tendering and monitoring linked to supply chain management such as E aushadhi in Rajasthan and similar initiatives in other states | |
| Quality Monitoring Performance | Unsatisfied beneficiaries and in extreme cases become violent against health care providers | Patient feedback and grievance redressal system usingtelephone, internet etc |
| long term patient records are not available | Interoperable Electronic Health Records connected electric family health record | |
| Delay in getting reports | Real time online dash boards | |
| Hospital care | Problems with Record keeping, symptom monitoring,Psychiatric Patient localization, inventory management,supply chain management, lack of real time monitoring of hospital activities and data, medical device tracking and management, dialogue between patients, or between patients and health professionals, health promotion | Linking Family Health records with Electronic Health Record, Radio Frequency Identifier Devices, Smart cards, Kiosk, dashboard for reatime hospital monitoring, Data Analytics, Social Media, Internet of Thing |
Whole of population approach for addressing population health:
The world is moving towards promoting health among those who are healthy. Technology can help us in achieving this as traditionally people approach healthcare providers only after falling sick. Technology can help us in providing health related inputs to the whole population. The conceptual framework (Kumar S, Preetha GS 2012) is useful while addressing and ensuring health in a population. This framework broadly categorises the whole population in four sections (Fig. 2):
a. H ealthy Population (with no risk factors and no disease)
b. P opulation with Risk Factors
c. P opulation with Disease but not aware
d. P opulation known to have Disease
With the above categorization, the health efforts can be strategized and concentrated, for example – provision of preventive and promotive health services to the population categorised as (a) Healthy population; screening and promotive health services, (b) building resilience for population categorised as Population with risk factors; early detection, treatment and care including limiting disability and rehabilitation along with healthy lifestyle for category (c); and compliance to treatment and care along with healthy lifestyle for category (d) which is known to have disease.
Is technology innovation addressing major killers?
At this stage, it is very essential that we look at what are the major causes of death in India and address these. The seven major causes of deaths in India were prominently evident from WHO’s India Country Profile of Burden of Disease, NCD 2014. Accordingly, in all 98, 16,000 lakhs estimated deaths took place in India. An estimated 27,48,480 (28%) deaths can be attributed to communicable, maternal, perinatal and nutritional conditions put together, 25, 52,160 (26%) to cardiovascular diseases, 12,76,080 (13%) to chronic respiratory diseases, injuries taking toll of 11,77,920 (12%), cancers causing 6,871,20 (7%), diabetes 1,96,320 (2%) and other NCDs being 11,77,920 (12%).
Above understanding regarding causes of deaths in India shall not only inform the overall planning towards actions required for addressal but could be complemented by technological.
Some Innovations that can revolutionise healthcare in India:
Family health folders:
This has been another initiative which looks at family as a unit and tries to maintain health record for each and every member which could be linked and segregated for individual service like immunization, antenatal care, postnatal care, spacing methods, next month’s medicines, BP records etc. this initiative has been piloted in AIIMS and INCLEN projects in some of the states like Rajasthan called Jan Swasthya, Madhya Pradesh and in Himachal Pradesh by the name of ANMOL. There is a provision of print work plan for next day/ week/ fortnight/ month. Also, it can be linked with the Electronic Medical Record (EMR).
Electronic Health Records (EHR):
Government is working on EHR to ensure continuity and quality of care. EHR will help in recording disease episodes and core plans and would allow data portability between different providers. Also, the metadata and data standards have been developed for it. Not only between clinical systems but also between support systems such as HR, Finance, Logistics, Lab, Emergency Transport FHR etc.There is also a possibility of establishing linkage to UID (Aadhar card).
Access: Free essential drugs:
To widen the accessibility of free drug services, there is a web based supply chain management system (e-Aushadhi) has been created. This system allows online tracking of drug inventory. It enables steamlining of inter-drug warehouse transfer and efficient control of inventory. Also, it enables multi users and multi-location for storage. This initiative has been implemented by various states like Rajasthan, Tamil Nadu, Andhra Pradesh, Odisha, Jammu& Kashmir and at various stage in other states.
Access: Healthcare Any Time Medicine (ATM):
Presently, there are about 25 percent PHCs without a doctor, in India. This calls for innovative approach to address the challenges and originated an innovation called AT M. AT M, piloted by National Health Systems Resource Centre, New Delhi, provides Tele-consultation supported with mobile phone and the generic drug vending machine. The pilots have been conducted in five states [HP, Odisha, MP (3-4 each), UP (100) and AP (100). Total cost of this initiative per facility has been only 3 lakhs.
Access: Telemedicine:
Yet another example for use of technology is ‘Telemedicine’ which is very successfully piloted in states like Tripura, Andhra Pradesh, Bihar, Maharashtra and Assam. With this technology, images and scans can be easily sent across the specialists for diagnosis and consultation for treatment; especially when specialized treatment is required and is not easily available nearby.
Automation of fund flow:
It has been the experience so far that programme activities suffer due to delay in fund transfer and in this context establishing public fund management system with the use of technology is a bliss. With this, automation of recording, verification and calculation of payments are done a smoother and faster way and electronic fund transfer (EFT) towards payments into recipient’s bank account becomes easy. This technology has been utilized in states like Rajasthan- with ASHA Soft, in Bihar- namely HOPE and Delhi.
To simply sum up, it is obvious that the technology can address access to and quality of health care in India. Many initiatives across the country exist and therefore there is a need to identify cost effective, scalable innovations which address bottlenecks and the burden of diseases. To enable this, there is a platform provisioned called National Health Innovation Portal, in India. This is an effort of Ministry of Health & Family Welfare commitment to support scale up of good and replicable practices in public health in India. There is a need to encourage innovations and the government must make resources available to scale up the promising innovations to reach the last beneficiary.
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