ICT applications in public healthcare system in India: A review

RANGANAYAKULU BODAVALA ASCI JOURNAL OF MANAGEMENT 31(1&2), Copyright 2002 Administrative Staff College of India. ICT applications in public healthcare system in India: A review India s public healthcare network is five decades old. It is plagued by many problems like absenteeism of doctors, lack of proper facilities and most significantly lack of proper referral services to urban hospitals and specialist centers. Due to these reasons the utilization and confidence in the public healthcare system is very low. Successive governments have tried various measures to improve the system with marginal success. Application of ICT tools will improve access and delivery of healthcare services to India s vast majority of poor people living in rural areas. India s sagging public healthcare network Table 1 India s demographic and health profile 1 Total population 1,027,015,247 Rural population 741,660,293 Inhabited villages 0.58 million Birth rate urban (SRS) 21.4 Birth rate rural (SRS) 29.3 Death rate urban (SRS) 6.5 Death rate rural (SRS) 9.7 Infant mortality rate urban (SRS) Infant Mortality Rate rural (SRS) Source: Census-2001 46 78 India started building its primary healthcare infrastructure way back in 1952 as part of the community development program, much before it formally accepted the Alma Ata declaration of health for all through the primary care approach. The main stress of the national health policy as adopted by the Indian parliament in 1983 is the provision of preventive, promotive and rehabilitative health services to the people, thus representing a shift from medicare to healthcare and from urban to rural population. Since 74% of the Indian population lives in the villages, the delivery of health services to rural masses holds the key and forms an integral part of their socio-economic development. In essence, the prime objective is the provision of universally acceptable and affordable healthcare to communities. Table-1 gives an overview of India s demographic and health profile. Though the Government of India and state governments years invested large sums of money in developing primary and secondary healthcare infrastructure over 40 years, its operation and sustainability need much to be desired. Table-2 gives the profiles of rural health institutions. Table-2. Profiles of rural health institutions 2 Facility Sub-center Primary Health Center (PHC) No. of facilities (1997) Building Not having own buildings Equipment Community Health Center (CHC) 1,36,339 22,010 2,622 One room plus With small operation theatre, male and female wards (usually 6 beds). 30, 50, or 100 bedded hospital, major operation theatres etc. 72,142 8,323 224 Mostly kits for delivery, etc. Minimal lab and operation theatre equipment. Doctors/specialist None. 1 or 2. 30% do not have the Generally X- ray and other items. By norm, 4 specialists but

Paramedical Vehicles Location Others One nurse (ANM) in the PHC. None. Big village. Last link in the primary health chain. posts filled up and 70% do not turn up every day. As per the norms, 14 personnel. The real pillar of the PHC system. Around 20-30% have jeepcum-pickup vans. Major village called panchayat or mandal head- quarters. On an average, 5-7 sub-centers are attached. usually one or two doctors function. As per the norms, 21 personnel. 70-80% have jeep-cumpickup vans. Town of 20,000 and above population. First referral hospitals usually have 3-6 PHCs attached. Public healthcare system: A critical appraisal Primary healthcare: The government s emphasis in primary healthcare is more on developing physical assets like buildings and equipment. Every year, PHCs are added based on the population norm. Usually, PHCs are created by upgrading existing sub-centres. It takes a long time before the upgraded PHCs get regular facilities. PHCs largely concentrate on family planning services. Other mandated services are usually not attended to. To this extent, service norms are seriously diluted. Usually, budgets are available for drugs and supplies. These are rarely purchased in time and very few reach the last point of service delivery. The primary health center or PHC scheme of was launched in the early 1960s. More than 50% of PHCs have one doctor. At any given time, 20% of the PHCs do not have any doctor posted. Nearly 80% of the doctors do not stay in the PHC village. The rest maintain a notional presence in the village. Since most doctors do not stay in the PHC village, the staff also prefers not to stay in the PHC village. It is still worse with the sub-centers. Even nurses usually do not stay there. Only 30% of the doctors visit the PHCs in the outpatient hours. The rest prefer to visit once or twice in a week. The logic of developing PHCs outside the village also creates the problem of access. 90% of the PHCs and 99% of the sub-centers do not have any telephone connection. One or two vehicles that are available have rarely carried any patient to the hospital based on a telephone call. Patients have to walk down to the PHC as public transport is generally not available. Facilities are developed and operated in an incoherent way. Severe water/electricity problem makes service delivery very difficult and deters patients from staying at the PHC. Disease surveillance is weak and ineffective. Every year government spends more money after the outbreak diseases like malaria, brain fever, etc. Rather than fix system failures, governments prefer to deal with epidemics on a contingency basis at a huge public cost. The district health administration does not even have any map displaying the location and names of all health centers and hospitals in villages. The PHC doctors and staff are ill trained. Secondary healthcare: State governments have created huge directorates that centralise every decision. While hospitals located in block/taluk headquarters are reasonably well equipped and staffed, a lot needs to be done for improving efficiency in terms of bed utilisation, ambulatory services and referral mechanisms. Most the referral hospitals located in cities and district headquarters in an average Indian state are insufficiently staffed and equipped. States like Andhra Pradesh, Maharashtra, Uttar Pradesh, Karnataka, West Bengal, Orissa and Punjab have borrowed a lot of money from The World Bank and have developed/developing secondary hospital infrastructure to a satisfactory level. 3 But the secondary public health infrastructure largely remains under great stress for a variety of reasons related to provisioning. Over the last two decades private initiative has led to establishment of nursing homes and large super-speciality hospitals in large cities and towns. Since these hospitals largely offer super-speciality services in advanced care, corporate organisations and even governments use these hospitals for treating their employees and their families, often bypassing the public healthcare system. Otherwise, services are very expensive and affordable only by the affluent. ICT initiatives in health and population sector There are interesting initiatives in the application of ICT in healthcare in India and a review of some projects is presented here for a broader appreciation of the march of ICT in India: Telemedicine projects: Most are model projects implemented on a very small scale (Table-3 and 4). Their impact and utility for large rural agglomerations is fairly limited and does not even account for 0.0001% of the beneficiaries. Generally the motive behind launching these model projects is to serve specific requirements of an NGO or demonstration of technology or gathering some limelight. Many of the projects have been started with a big fanfare and unveiled plans to link thousands of PHCs in the country. Now, these originally commissioned outfits are barely running. Table-3 Private-public partnership through telemedicine

Andhra Pradesh Vaidya Vidhana Parishad (APVVP), Apollo Hospitals, Care Foundation Rajkot Civil Hospital and U.N. Mehta Institute of Cardiology and Research Centre, Ahmedabad. Apollo-Aragonda Village telemedicine project Narayana Hrudayalaya tlelecardiology network Pune primary health telemedicine project The state-run APVVP that manages nearly 200 hospitals in Andhra Pradesh launched the Telemedicine Project in October 2001 in collaboration with local private partners. The responsibility of providing telemedicine-compatible diagnostic medical equipment (CT scan, ultrasound, color doppler, ECG, digital x-ray, etc.) in district hospitals lies with implementing partners. They are the major players in terms of running large hospital networks in cities like Hyderabad. They connect telemedicine systems to their base hospitals in Hyderabad and elsewhere. Each one of them, in turn, formed consortiums with software and hardware companies. The project is operational in Mahaboobnagar district. The Government has laid down rules for the collection of user charges as per three categories -- private, subsidized and free. Rajkot Civil Hospital developed a telemedicine link with U.N. Mehta Institute of Cardiology and Research Centre, Ahmedabad. The system can be used to transmit online ECG, CT scans, MRI, Cathlab reports, pathological reports, doctors' prescriptions, typed and even handwritten notes, and moving images. The important innovation employed in this system is the Event Recorder (ER). ER has no cords attached to it. The patient simply has to place it on his chest, push a button and wait for a minute for recording the ECG. This done, he/she has to dial the telephone number of his/her doctor and place the equipment on the mouthpiece as per directions given, and press the same button again. ER converts electronic signals into audio signals that again get converted into electronic signals on the doctor's PC. ER was tested on domestic flights, in moving vehicles, offices and parks. It worked to the satisfaction of medical experts. A 50 bed hospital in Aragonda village (population of 15,000) in Chittoor District of Andhra Pradesh is connected to Apollo Hospitals in Chennai and Hyderabad through a satellite link. The center is equipped with facilities such as an operating theatre, a CAT scanner and software. Doctors in the telemedicine center can scan, convert and send data images via satellite link to teleconsult stations at Hyderabad and Chennai. Narayana Hrudayalaya, located in Bangalore is developing as a hub for telecardiology networks as joint venture between the governments of West Bengal, Karnataka and the seven hill states and ISRO to create a chain of coronary care units in remote areas and offer modern cardiac care infrastructure. Communication between these areas will through ISRO s VSAT networks provided free of cost. A heart hospital is created as a welfare venture where 60% of the beds are reserved for working class families who will be offered treatment at subsidized rates. The charitable activities of the institution are supported various philanthropic organizations. The Pune district administration teamed up with doctoranywhere.com and Tata Council for Community Initiatives (TCCI) to launch telemedicine services from 3 PHCs targeted at rural masses. Pune has 88 PHCs covering 5-6 sub-centers. Each PHC has 2 doctors and basic medical facilities, including operation theatres, laboratory and a pharmacy. It also has 15 personnel who travel to sub-centers to implement government. The telemedicine project later aims to connect all PHCs in the district. Ten specialists (two each from each category) have been chosen from dermatology, nephrology, neurology, cardiology and gastroenterology. PHC doctors refer complicated cases to specialists who give their advice within 24 hours. The service has started at PHCs at Hole in Baramati tehsil, Otur in Junnar tehsil and Nirgudsar in Ambegaon tehsil. Table-4 Other telemedicine projects Post Graduate Institute, Chandigarh PGI is being connected to premier institutes like the All-India Institute of Medical Sciences, Delhi, and the Sanjay Gandhi Postgraduate Institute, Lucknow. Later, PGI will be connected to some more institutes. This facility will not only enable doctors to seek the opinion of experts from across the country but also save patients from the botheration of being referred to other hospitals. doctoranywhere.com Is a service that allows doctors to be doctors - anywhere - if they are on the net. The Internet based package provides affordable, efficient and time-sensitive platform for remote medical consultation to take place easily. As it is with any technology project, it is very easy to set up by installing a set of machines and links, but needs much more motivation to sustain it on a continuous basis. Except for one or two projects, the rest aimed at connecting one city-based hospital with a metropolitan hospital. The rural focus is fairy limited to couple of model projects. Governments must encourage viable models to offset lacunae in primary care access and coverage. Rather than do that, governments continue to follow the beaten track of constructing new PHCs and inadequately equipping these PHCs. Experience of ICT initiatives in healthcare also show that whereas dialup models are not effective, the costs and maintenance of VSAT based network requires specialized skills and is prohibitively expensive to set up and maintain. This hinders the opportunities for business and governments to mass replicate model projects. Essentially, rural India is not yet ready to afford costly models of telemedicine. GIS applications: Though geographic information systems or GIS have been extensively employed in the last five years or so in India in sectors like environment and forestry, efforts to employ it in healthcare and family welfare just started picking up. Few organisations like DANIDA and others (Table-5,6,7,8 and 9) have made a commendable beginning. The situation has more to do with the usage of computers in general and availability of databases on facilities, indicators, etc., in particular. Some key issues related to Health GIS in India are as follows: Absence of leadership: GIS efforts in health and family welfare sector share the same problem of computer usage development. Usually an enthusiastic officer pioneers the efforts. After he/she is moved from the respective position, the development efforts take a

backseat. GIS personnel, equipment and infrastructure developed during the predecessor tenure are dislocated and put to other tasks or lie unused. Absence of databases: In India where the population is heterogeneous, ethnic, religious and socio-economic differences influence illness concepts and demands for healthcare. The only available information on population is census data (obtained every 10 years). Even this does not coincide with actual catchment populations served by health facilities. Ideally, the health information system (HMIS) should reflect these concerns. But available data is incomplete and is mostly about care-seeking clients and their service statistics. A need exists for a more precise and complete description of the catchment population and health situation. Information at the village, community, and division levels needs to be mapped. 4 Table-5. DANLEP (DANIDA Leprosy Project) Mapping of health facilities and block-level boundaries in three states - Orissa, Madhya Pradesh and Tamil Nadu. The scale of the maps is 1: Pioneering effort. GIS can be very helpful in designing 250000. Up to sub-cente level campaigns, IEC activities, integration studies and the facilities are mapped. The awareness programs. Leprosy and TB endemicity is road, rail and drainage network prevalent in tribal areas. Studies in relation to poverty mapping is very useful. level, tribal settlements and accessibility have helped in optimizing location and reallocation of service delivery centres. DANLEP has undertaken studies to identify health hotspots by studying disease profiles across Orissa for multiple diseases. But most maps are not geo-referenced. So, distance calculations are not possible.. Table-6. UNICEF (CHILDINFO Database) Block-level boundaries of India Indicators obtained from state There are problems in collecting data from the states. governments on a regular basis UNICEF staff is well aware of the GIS capabilities and and used to develop maps. has plans to harness these capabilities. Usually district and state maps are used. Table-7 NATMO (Health Atlas of India) Health Atlas of India, National Atlas & Thematic Mapping Organis-ation (NATMO) 1.100000 scale is used. Number Useful data on availability of hospital beds and of disabled persons and the population at district level. But incomplete data for availability of hospital beds are nearly 40% of the districts As such, very limited themes. plotted district-wise. Table-8 Malaria Research Centre (Mapping of malaria vector in coastal areas) Mapping of malaria vector in coastal areas 1.6000000 scale. But some areas Pioneering work in one particular program area. Plans to like Orissa and Tamil Nadu were host it on the web. Disease surveillance for Dindigul developed at a higher scale for developed with ward/street level infor-mation. Training analysis. program developed for Tamil Nadu officers. Table-9 JICA (Village level health mapping in Madhya Pradesh) Village level mapping of health facilities and other indicators Village level mapping of health Excellent study. Able to suggest to government how to facilities/topographical features improve access to the sub-centers by rationalizing their for 5 districts of Sagar Division. coverage area/boundaries Technical capability and issue of boundaries: Unlike other GIS users, Health GIS users (largely medical practitioners) are relatively unexposed to GIS mapping. Though PHC staff have their own hand drawn (not to scale) mapping system, its applicability as a management support tool is limited due to its inability to integrate data sets and prepare combined maps for districts or states. The administrative divisions of health being different, revenue maps need to be modified for incorporating health boundaries. A PHC boundary is generally the most feasible administrative boundary for a national-level health GIS. Data sharing: Health being a humanitarian concern, all other projects that have developed digital maps should share their data sets

for health mapping. DANLEP has already set a commendable example by sharing its data with other development projects. Further, health being an interdisciplinary area, it needs socio-economic, environment, land use and other inputs. Such data generation is beyond the scope of any health sector programs and needs support of respective departments. Population databases: For delivery of health and family welfare services. Name based registry is essential as a tool for 100% vaccination, antenatal registration and higher institutional delivery. Share Mediciti Rural Health Center, located 40 kilometres from Hyderabad does offer regular family welfare services to a population of 40000 located in 41 rural villages. It opted to develop a name based population database, run different queries and placed various alerts on vaccination, nutrition, etc. It had to go through a learning cycle and now stands confident with 100% vaccination, 1% growth rate, and 20% infant mortality rate in that area. What is remarkable is that there are no special extra inputs and financial implications to track every mother, child and deliver service at their doorstep. The computers/database development cost them some 25 cents for each beneficiary. Handheld computers for filed staff: CMC Limited, in collaboration with the Government of Andhra Pradesh has been implementing a pilot project in Nalgonda District. The World Bank has given a grant for the pilot project. Under the project, palmtop computers (Compaq Ipaq) have been supplied to auxiliary nurse midwifes (ANMs) with the required software and training. The ANM is supposed to maintain information of 6000 population in the palmtop and visit the PHC once in a month to synchronise it with the database in the main computer. The main computer software generates reports, field schedules, feedback, etc. Technically the project is very good, but some implementation issues (field survey and utilisation of existing household survey data, which was full of errors), technical issues like inadequate memory to run a huge database, low speed software (sometime it takes 10 minutes to retrieve a single record) have delayed the completion of the pilot phase. Since it has generated enormous interest, knowledge and experience, it is high time that it be implemented on a larger scale. Web based initiatives: Several state governments health departments have set-up their web sites and ritualistically post a bit of static information on such web sites. Some of the better examples are: Himachal Pradesh ( http://hphealth.nic.in/index. htm), Tamil Nadu (http://www.tnhealth.org/index.htm) and Madhya Pradesh ( http ://www.mp.nic.in/cohis). A good beginning has been made by several state governments but a lot needs to be done in terms of posting reports, regular documents, detailed statistics, and more important, responding to queries that come through the web pages. Emerging opportunities Broadband wireless networking technologies: Present great opportunities for cheaper networking of rural hospitals for telemedicine and others applications. Most telemedicine solutions have been developed in western countries where bandwidth is the not the issue (save some reservations in America). Solutions tend to take the issue of connectivity at higher speeds as guaranteed. In countries like India, even the copper pair is not properly availa-ble to villages. The importance of bandwidth can be gauged from Table-10. Table 5 Typical time taken to transmit a standard X -Ray 28.8 Kbps dial-up connection T1 line at 1.5 Mbps 30 minutes 30 seconds DS3 circuit 1 second Broadband wireless technologies (through speed spectrum technology) that connect wide area networks (WAN) are becoming very cheap day by day. Today it is possible to connect two computers/networks with 11 Mbps speeds over 40 kilometers without out any bridge/amplifier in between. 11 Mbps bandwidth means it is possible to stream two-way video, voice and data of a very high quality. The cost for each wireless client has come down drastically. It is now around $ 700-800 for a wireless card, antenna and software bundle. By providing suitable bridges and amplifiers (which cost less than $1000), the signal can be sent to any remote place in a typical Indian district that generally caters to 1-2 million people. It is possible today to develop a cost effective broadband WAN in a typical Indian district which consists of one district hospital and 5-10 other hospitals and 30-70 PHCs for as much as $10,0000 for telemedicine, tele-health, etc.

Name-based population databases: A country like India has 20 national programs in the health sector operated in 500 districts either by governments or NGOs (each district is like a separate country in terms of size, economic development and cultural differences). Decision making in the planning and program management process is based on broad aggregates. Today, databases (MS Access) are powerful enough to capture comprehensive information for one million population and industrial databases (like Oracle) can capture information even for one billion population. Is it possible to develop name-based registry for the entire country. It can help track every child for immunisation and nutrition and every mother for antenatal/postnatal care, among others. GIS: Ideal for disease mapping, facilities planning and optimisation. It has become very popular and affordable. The cost of software has come down. Digital maps are easily available now for most of the districts in India. Since communicable diseases recur every year in a set pattern in some pockets, such patterns can be mapped for focused attention. While setting up new facilities, one has to consider the existing coverage/access by through mapping of populations and also study interrelationship between health and other aspects (irrigation, education, etc.) Studies in geography of health need to adopt a welfare approach in order to improve the quality of life. In this context, the interplay of social, economic and political processes in the inequity and inequality in healthcare services, the changing environment and the resultant environmental hazards need to be researched intensively to plan for effective health management strategies. GIS as a planning and management tool can substantially help in reducing the monitoring and implementation costs of health sector programs. With the advent of Internet mapping, information and data dissemination have become a lot easier, facilitating setting up of a National Health GIS. Palmtops: The cost of handheld computers has come down so drastically that some of the models are available from $100 onwards. Today it is possible to run a database of 10000 population in one of these devices. Handheld computers can reduce the enormous load of record maintenance and report writing by field workers. These can help the field worker to track a patient, potential mother, child for a particular immunisation, etc. Handheld wireless devices: Today, there are no communication linkages to the field nurse and many PHCs. Since the cellular network covers India s substantial land area, it is possible to get cellular connection packages for as low as $5 a month. One can utilise this technology to reach the last point of service delivery (a filed nurse who generally covers 5-10 villages) and improve emergency communication, establish tele-health and administrative monitoring. India is going to implement wireless in local loop technology with which it is possible to give wireless phone connections that work up to 40 kilometre distance without wires and the service costs as much as the landline. Networked ambulances: Citizen band radio has become so popular in the west that some brands of handsets are available for as little as $20-30. These can be fixed to ambulances. Services can be considerably improved by strategically locating these ambulances to reach any village or habitation within one hour. Community radio: A country like India has been trying to popularise family planning, health and hygiene through various methods with limited success. The core issue is that IEC is run through centralised government run radio and television. NGOs have done some good work but on a limited scale. There are nearly 2000 languages spoken in India but metropolitan radio stations sometimes covering as much as 30 million populations are mostly inadequate and incompetent to address local issues and sustain high levels of motivation. Community radio is very old technology and very cheap (from $1000 onwards) and easy to operate by communities themselves (say 100,000 to 200,000 population), the available frequency space can provide for 40,000 stations (government has some 100). The Commonwealth of Learning Media Empowerment (COLME) programme provides comprehensive material and links to community radio resources. 5 Industrial ERP packages: There are a vast number of ERP packages and developed processes in the industry to address the needs of personnel management of doctors and staff, inventory management of drugs and supplies, equipment management and others. One can directly deploy these packages in health administration directorates to ensure timely availability of drugs, equipment and personnel to attend to the needs of patients. The Internet: Has emerged as a powerful and cost effective medium for disseminating information on diseases, indicators, programs, plans, expenditures and outcomes. Today, it is possible to host a 1 GB web site for $20 a month and this means putting up 200,000 data items, 500 reports and other documents and 20 years of all government orders, etc., at such a small cost. It creates an online storehouse of information and reduces enormous duplication, saves cost and time besides eliminating delays and confusion associated with the collection or utilisation of health information that is scattered in several institutions, offices and projects. Conclusion It is not the number of employees that decides the quality of service but their efficiency. In public health, resources are few,

time is extremely limited (with the threats of outbreak of epidemics like AIDS) and results have to be achieved in a limited time frame. Therefore, there is need for more and better ICT tools. Any additional aid makes tasks easy and efficient. India spends 85% of the government budget on personnel. Employment of additional personnel or creation of one department or a post will not automatically ensure achievement of the set objectives in improving the health status of women and children. Public health is a proactive and developmental function. The personnel need implements, tools, technologies, and training to effectively discharge their duties. Author Ranganayakulu Bodavala is President, THRIVE (Volunteers for Rural Health, Education & Information Technology), Chintaplli Mandal HQ, Nalgonda District, Andhra Pradesh (Phone: +91-8691-33886; e-mail: ranga@indiahealthinfo.org). Notes 1. 2001 Census notes - http://www.censusindia.net/results/population.html 2. Bulletin on rural health statistics in India (June 1997), issued by the Rural Health Division, Directorate General of Health Services, Ministry of Health and Family Welfare Government of India, New Delhi. 3. Project implementation plans for improving the secondary infrastructure in various states through World Bank loans. 4. Health GIS in India - Dr. B.F.A.M. Peters, GIS development net (http://www. gisdevelopment.net/application/health/overview/healtho0009.htm).http://www.bushradio.co.za/about/about.htm and http://www.radio4all.org/index.html Bodavala - ICT applications in public healthcare system in India: A review