Tag Archives: Healthcare

Healthcare services in India … growing disparity between urban and rural population – can ‘Telemedicine’ play a significant role?

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Healthcare Industry in India is currently valued at US$ 35 billion. This industry is expected to record a turnover of US$ 75 billion in 2012 and US$ 150 billion in 2017, reports Technopak Advisors in their report titled “India Healthcare Trends 2008”.Growing Middle Class Population – the key growth driver:This growth is not expected to come from rural India where over 70% of Indian population lives and a vast majority of them do not have ‘access to modern medicines‘. The key driver of growth of this sector will be growing 150 million strong middle class population with increasing health awareness. Out of this population, 50 million have a disposable income of US$ 4,380 – US$21, 890,, reports McKinsey. Technopak Advisors report recommends an immediate investment of US$ 82 billion to meet this growing demand.

Medical Tourism - another potential growth driver:

Another growth driver is expected to be ‘Medical Tourism’. With a slogan: ‘First World Treatment at Third World Prices’, Medical Tourism is expected to become a US$ 2 billion industry by 2012 from US$ 350 million in 2006, reports a study done by McKinsey and CII. In 2008-09, over 200,000 foreigners, mainly from Middle East and South Asian countries came for medical treatment in India. Hospitals in India are now trying to attract patients from Afro-Asian countries who spend around US$ 20 billion outside their respective countries, towards medical treatment. Thus, the current number of patients visiting India for medical tourism is expected to grow by around 25 percent during next few years.

Medical expertise and facilities – a sharp contrast between the urban and rural India:

India Brand Equity Foundation (IBEF) reports that over a period of last few years besides cost advantage, high success rate, especially in the following areas has been attracting the medical tourists towards India:

• Over 500,000 major surgeries and over a million other surgical procedures including cardio-thoracic, neurological and cancer surgeries have been performed by the Indian specialists, with success rates at par with international standards.

• The success rate of cardiac bypass in India is 98.7 per cent against 97.5 per cent in the U.S.

• India’s success in 110 bone marrow transplants is 80 per cent.

• The success rate in 6,000 renal transplants is 95 per cent.

• India has the 2nd highest number of qualified doctors in the world.

It is worth noting, the centre of excellence of all these outstanding statistical records are located mainly in the urban areas. In sharp contrast to these most of the rural populations are denied of basic healthcare facilities services. Despite being second highest growing economy in the world after China and having world class healthcare facilities available in the country, a vast majority of rural population is denied of basic healthcare services. Even in those places where primary healthcare establishments are available, poor maintenance, understaffing, non-availability of medicines and antic medical equipment, deny the basic and standard healthcare services to the local population.

India is still the home for world’s ‘largest number of poor people in a single country’, even after 61 years of Independence. A study indicates that in India around 260 million people live below the poverty line (BPL). Out of this number about 193 million people live in rural areas and about 67 million live in urban areas. Over 75% of these poor people live in rural India.

The point to note here, although over 700 million people live in rural India, only 193 million of them belong to BPL families. Therefore, even those who can afford proper medical treatment in rural areas, do not have access to modern healthcare facilities, due lack of healthcare infrastructure and services.

Quoting Oxford University of the United Kingdom (UK), The Economic Times (ET) dated February 2, 2009 reported that due to lack of basic healthcare facilities, around one million women and children die every year in India. This is, once again, mainly because 700 million people in rural India have no access to specialists. 80% of medical specialists live in urban areas. ‘India Knowledge, Wharton’ reported recently that India would require an investment of US$ 20 billion over next 5 years to address this problem.

National Health Policy 1983 promised healthcare services to all by 2000 – has it delivered?

The National Health Policy 1983 announced commitment of the Government of India to provide ‘health care services to all by year 2000′. Unfortunately, even today only 35% of Indian population have access to affordable modern medicines, despite an appreciable growth of this sector during last four decades.

Per capita expenditure towards healthcare in India is one of lowest among Asian countries outside South Asia. The expenditure of the Government for healthcare has progressively grown over the years though, healthcare expenditure as a percentage of total government spending has decreased considerably. Only silver lining is that the private sector spending towards healthcare is steadily increasing at a much higher pace.

Can ‘Telemedicine’ improve access to healthcare in rural India?

Would creation of a cost-effective ‘Telemedicine’ infrastructure in rural areas be able to address this problem? In my view, this area is worth exploring seriously and should be tried out by the Government with Public Private Partnership (PPP) model, initially with pilot projects.

‘Telemedicine’ has been defined as the use of electronic information and communication technologies to provide health care support to patients from distant locations. Thus ‘Telemedicine’ could be used to provide healthcare services where it does not exist at all and at the same will help to improve healthcare services considerably, where something already exists.

With the advancement in telecommunication and satellite communication technology in the recent years, the scope of creating and gradually expanding the ‘Telemedicine’ facilities in India indeed throw open a new avenue to improve ‘access to quality healthcare services’, in rural India.

Besides lack of basic primary healthcare services in rural areas where over 70% of Indian population live, 90% of secondary and tertiary healthcare facilities are also located in large cities and towns.

Thus, in addition to primary healthcare services, even secondary and tertiary healthcare needs of a large number of rural populations can be successfully met locally through consultations with the experts located in distant cities and towns without anyone having to travel to those far off cities and towns.

‘Telemedicine‘, therefore, could also offer solutions to the problem of expert medical assistance during serious or critical illness of people living in rural India. The role of ‘Telemedicine’ on healthcare services will be very meaningful under such circumstances.

‘Telemedicine’ services have already started in a smaller scale though, in Kerala, West Bengal and North-eastern states of India. It is slowly coming up in some other southern states, as well. What is required now is a concerted and integrated approach, spear-headed by the Government of India, taking all State Governments on board, with a robust policy initiative.

However, there are some key concerns with this initiative, as well. The most important of which is related to costs of such treatment for the rural households, besides other regulatory issues.

Appropriate regulatory and policy frameworks should be thoughtfully worked out to extend such innovative services to rural India, under PPP. If the concept of ‘Telemedicine’ can be made to work effectively in rural areas, leveraging world class expertise in information technology available within the country, India will emerge as a role model in the field of ‘Telemedicine’ for the developing nations of the world.

Moreover, over a period of time the ‘Telemedicine’ platform can also be effectively utilized for many other healthcare initiatives, like for example, disease prevention programs, medical/para medical staff training etc.

When ‘e-chaupal’ initiative of ITC for rural farmers of India could be so successful, why not ‘Telemedicine’ for rural patients of India?

The promise of “Healthcare services to all by year 2000” as enunciated in the National Health Policy, 1983 of the Government of India, could still be achievable, albeit late, by the next decade of this new millennium with ‘Telemedicine’.

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.

National Rural Health Mission (NRHM), a much hyped public healthcare initiative – has it delivered since its inception in 2005?

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National Rural Health Mission (NRHM), a very ambitious and noble initiative for the rural population of India was launched by the Government of India on April 12, 2005. The interim budget allocation of NRHM for the year 2009–10 has been increased to Rs. 12,070 crore. The primary purpose of NRHM, as announced by the Government, was to improve access to quality healthcare for the poor population of 18 states, to start with, of rural India.

Along with such a commendable initiative, the Government declared an increase in its spending towards public health from mere 0.9% to 2–3% of the GDP over a five year period. This decision was in line with the well articulated prime focus of the Government on public health and education.

During the launch of NRHM, the Health Minister of India announced that the nation would see the results of these efforts in three years time.

Three years are over now. Let us, therefore, have a look at the key achievement areas of this ambitious scheme for the budget year 2008-09, as announced by the Finance Minister recently in his interim budget speech for 2009–10.

The performance areas were highlighted as follows:

• 462,000 Associated Social Health Activists were trained
• 177,924 villages have sanitation committees functional
• 323 district hospitals have been taken for up gradation

Against such a soft performance parameters of the Government, let us see some hard facts, which are real indicators of performance of NRHM. A report on the recent study done by Chronic Care Foundation indicates that in India about 86% of highly populated rural districts still do not have provisions for basic diagnostic tests for chronic ailments.

The study also highlights that in rural areas, as a percentage of total expenses, out of pocket healthcare costs are more than the urban areas, with hospitalization expenses contributing the most to the total costs. In many rural areas the healthcare costs have been reported to be as high as around 80% of the total expenses. Such a high out of pocket expenses have mainly been attributed to the lack of facilities in these rural areas, requiring patients to travel to distant areas for medical treatment. It was also reported that even in rural areas due to inefficient and inadequate services at the Government healthcare units, there has been a very high dependence on more expensive private healthcare facilities.

After almost four years from the inception of NRHM, if this is the state of affairs for rural public healthcare, the obvious questions which come to my mind are as follows:

• Where is the huge money allocated for NRHM going?
• Who is or are accountable for such a poor performance of this great scheme?

In my opinion, to make NRHM work satisfactorily the Government should outline, decide and announce the key success parameters for performance evaluation of the scheme. This is to be done disclosing the names and designations of the responsible senior Government officials who will be held accountable for the success or failure to deliver the deliverables. All these details should be uploaded on to the website of the Ministry of Health for public scrutiny, at least half yearly. With tax-payers money being utilised for this important and critical public health arena, no non-performance should escape attention and go unpunished.

Moreover, with the help of experts, the Government should decide, which elements of each identified success parameters the Government will be able to deliver better with its own internal resources and which are those areas where the Government should outsource.

Such an approach when worked out in great details will be able to ensure whether through NHRM the country is making progress to improve access to quality healthcare for a vast majority of its rural population. Otherwise this scheme may well be treated just as one of those which failed to deliver and vanished in the oblivion.

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.

65% of Indians do not have access to affordable modern medical treatment – why?

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India is indeed a country of many paradoxes. Not just peaceful co-existence of luxurious sky scrapers and dilapidated shanties side by side. In the healthcare sector as well, we witness on one side booming medical tourism of foreign nationals to get various types of ailments treated with the best possible medical amenities, just when on the other side common diseases like, malaria and tuberculosis are taking the common man on a rampage. Is India, therefore, ignoring the crying need to strike a balance between extending cost competitive healthcare benefits to the ‘haves’ of the world without neglecting the domestic ‘have nots’?Another paradox, when India caters significantly to the growing needs of the world for low cost generic medicines, 65% of Indian population cannot afford the same and do not have access even to a doctor.In a situation like this, what sort of equitable distribution of healthcare benefits are we then talking about? Isolated attempts of opening low cost generic medicine shops, enforcing rigorous non-transparent price control, attempt to divert the debate on the price of patented medicines which contribute miniscule decimal points on the total pharma market in India, can at best be termed as populist measures, instead of trying to look at the macro picture to address the pressing healthcare issues of the country.

When we talk about affordability, why do we not talk about affordability of medical treatment as a whole and not just affordability of medicine, for one or many ailments that the common man suffers from? Will our government try to address this bigger issue in a holistic way?

What could possibly be the reasons for such inaction? Is it because improper co-ordination, if not lack of co-ordination, between various Government departments, the ultimate victim of which is the common man?

Such a situation reminds me of an old story of three blind men and an elephant. After touching the trunk of the elephant, one blind man describes the elephant as a large Python, touching a leg of the elephant, the other blind man describes it as a pillar. The third blind man while touching the body of the elephant describes it as a strong wall. Unfortunately no one could describe the elephant as it really is and no one in this particular case was helping them to do so, either.

Could it be that various departments of our Governments are acting like these blind men and are not seeing the big picture – the elephant of the above story? It appears that the Pharmaceutical department of the Ministry of Chemicals and Fertilizers believes that only the price of medicines is the key issue for an ailing patient while going for a medical treatment and not the cost of total treatment. Thus, they seem to be working full time to drive down only the price of medicines.

The Ministry of Health is also trying to do a little bit of something in some not so known areas. The Ministry possibly believes that they are effectively helping everybody to address the pressing healthcare issues. It does not so appear that the Ministry realizes that majority of our population does not have access to affordable modern treatment for the ailments that they are suffering from. Number of doctors, nurses, hospital beds etc. per 1000 of Indian population is still abysmally low even compared to some developing nations. Cost of getting a disease diagnosed even before any medicine is prescribed is sky rocketing, at a break neck speed. Which Government department is trying to address the cost of disease burden and trying to alleviate it for all of us, in a holistic way?

Here comes another paradox. While the Pharmaceutical Department intends to bring down the price to make the drug affordable, the Finance Ministry keeps the transaction cost of medicines at a high level by levying various taxes to improve its revenue collection, ultimately making the same medicine less affordable.

In the developed nations and also in many emerging markets healthcare financing or health insurance for all strata of the society is being successfully implemented to address the key issue of improving access to affordable modern treatment to a vast majority of the population. Even after 61 years of independence we have not been able to address this critical healthcare financing issue effectively.

Piece meal approach of our Government has not succeeded much to address this important issue of the country. Taking one-off populist measures of various types and creating media hype may not help sorting out this issue, at all.

The way forward, very broadly speaking, is to bring the entire healthcare policy making and implementation functions under one ministry. If that is not possible, the concerned ministries should work in unison, with effective procedural interfaces being put in place for proper co-ordination with a clear goal of improving access to affordable modern treatment to all.

Is it not a shame on us that even today, 65% of Indian population does not have access to affordable modern medical treatment?

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.