Meeting India’s healthcare challenges

KIRAN MAZUMDAR SHAW

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INDIA, home to 17.5% of the world’s population, accounts for 20% of the global disease burden. Poverty, mal-nutrition and an enormous disease burden are interconnected in a vicious circle – poverty leads to malnutrition, leading to disease. The dual burden of communicable and non-communicable diseases (NCDs) poses a grave socio-economic challenge. One in four Indians is at risk of dying from an NCD before reaching the age of 70. More than 70% of health expenditure in India is out of pocket, against a world average of 18%, as less than one-fifth of the population is covered under health insurance. Consequently, over 63 million people are faced with poverty every year due to catastrophic healthcare expenditure. It is estimated that NCDs alone will cost India US$ 6.2 trillion by 2030.

To break this cycle of disease, death and destitution, India urgently needs to implement a robust universal healthcare programme that ensures equitable access to essential medicines, vaccines and technologies of assured quality, safety, efficacy and cost effectiveness. For this, the government needs to raise its spending on healthcare to at least 2.5% of GDP. Whereas total healthcare expenditure worldwide stands at 9.94% of GDP, India spends a mere 4.7%. Of this, the government’s share of healthcare spending is a measly 1.4% of GDP, which is among the lowest globally.

Not only does the government spend too little but it also spends badly and thus fails in performing its role of a healthcare provider. A severe lack of resources means that in comparison to World Health Organization’s (WHO) stipulated minimum doctor to patient ratio of 1:1,000, India has only 0.7 doctors per 1,000 patients. Moreover, in comparison to WHO’s stipulated minimum ratio of 2.5:1000, India has only 1.7 nurses per 1,000 patients. WHO’s World Health Report ranks India’s healthcare system at 112 out of 190.

This resource shortage has resulted in the unavailability of quality healthcare that is affordable and easily accessible. The effort by non-governmental organizations (NGOs) is largely limited to sanitation, sexual health and prevention of infectious diseases, leaving a wide gap in access to a broader array of health services.

Making healthcare affordable and accessible becomes more challenging as close to 68% of India’s population lives in rural areas, with over 30% living below the poverty level. This is compounded by India’s weak public healthcare infrastructure, lack of advanced laboratory facilities and equipment, inadequate health workforce and a poor healthcare delivery mechanism.

The biggest gap in services is in delivering preventive and primary healthcare. At present there is a disproportionate focus on specialist care even though primary and preventive healthcare can play a more effective role in tackling the day-to-day needs of Indians.

If healthcare providers shift the focus to holistic and preventive services by offering innovatively priced products and services, they should be able to make a major impact on reducing the cases of chronic diseases in the country. Cardiovascular diseases, cancers, chronic respiratory diseases, diabetes, and other NCDs are estimated to account for 60% of all deaths in India, making them the leading cause of death – ahead of injuries and communicable, maternal, prenatal, and nutritional conditions. NCDs not only affect health, but also productivity and economic growth. The probability of death during the most productive years (ages 30-70) from one of the four main NCDs is as high as 26%.

 

Most of these chronic diseases can be remedied in their early stages by primary care providers. A robust and effective primary care programme supported by strong preventive health education and early screening and diagnosis, can mitigate the burden on hospitals and the healthcare system and, more importantly, improve health indicators of communities. Primary healthcare, which is the first level of care provided to the community for basic health problems, is the best way to ensure access to healthcare for all and equity in health outcomes.

Take for example cancer, which today accounts for one in seven deaths worldwide. Studies have shown that the implementation of prevention, early detection, and treatment strategies could potentially save 2.4 million-3.7 million lives globally every year – the vast majority of them in low and middle income countries – yielding an economic benefit in excess of US$ 400 billion.

A robust and effective primary care programme supported by strong preventive health education, and early screening and diagnosis, can mitigate the burden on hospitals and the healthcare system, and more importantly, can improve health indicators of communities.

 

India has recently seen the emergence of several startups that offer affordable solutions for the early detection of cancer. Companies like UE Life Sciences, OncoStem Diagnostics and mapmygenome are lever-aging ‘affordable innovation’ to come up with business models that can make early cancer detection available and accessible.

UE Lifesciences is addressing a huge unmet medical need of early detection of breast cancer with portable devices like the iBreastExam™ (or iBE). This innovative, FDA approved hand-held device is being used by frontline health workers in India to conduct standardized breast examinations accurately and easily. This device is a huge improvement over traditional mammography and other detection techniques involving radiography that are harmful as well as expensive and, hence, unaffordable in the Indian context. It costs an average of Rs 60 per scan with the IBE device.

The launch of the device is timely as India is experiencing an unprecedented rise in breast cancer incidence across all sections of society. A recent study of breast cancer risk in India has revealed that one in 28 women develops breast cancer during her lifetime, making it the most common cancer among women in India. However, early detection using devices like IBE can save thousands of women from having to spend an average of Rs 350,000 on treatment of full-blown breast cancer as well as spare them the accompanying physical and mental trauma.

Similarly, Manjiri Bakre’s Onco-Stem Diagnostics is developing novel diagnostic tests to predict the risk of cancer recurrence in patients within the first five years of their initial diagnosis, based on the characteristics of their tumour sample. The knowledge of a patient’s risk profile can be critical in tailoring treatment regimens to minimize recurrence.

Mapmygenome, founded by Anu Acharya, is a molecular diagnostics and predictive health analytics company offering a full range of tests to identify an individual’s genetic predisposition to lifestyle, metabolic, cardiovascular, ocular, skin and hair, orthopaedic, and gender specific conditions. Based on the test results, Mapmygenome counsels people on how to reduce these health risks through lifestyle modification.

 

Unlike in the past when everyone with a particular disease received a ‘one size fits all’ therapy, the medical community is today defining diseases more precisely based on molecular characteristics and by matching subsets of patients with targeted therapies. Advances in biomarkers and genomics sciences have made it possible to develop innovative diagnostic tools that can identify the right drug for patient pools with specific genetic mutations. This has led to the advent of precision medicines that can be defined as ‘individualized matching of therapies and regimens to a person’s disease.’

Strand Life Sciences based in Bangalore has taken the lead in developing an innovative yet affordable precision medicine diagnostic technology, which uses multigene panels to map cancer mutations. This technology enables early detection as well as aids personalized treatment which leads to much better patient outcomes. The price of these tests is a fraction of what it would cost in the US, thus enabling better access.

Biocon Foundation, the CSR arm of Biocon, has implemented a mobile phone based health (mHealth) platform for early detection, prevention and treatment of oral cancer. This comprehensive, evidence based oral cancer screening programme facilitates early detection at the doorstep. By empowering the frontline health worker to conduct cancer screening in a low resource setting, this programme has ensured that healthcare reaches remote pockets in a cost-effective manner. By linking oral cancer specialists with the rural population through telemedicine, the mHealth platform has created an opportunity for diagnosis, follow-up and referral.

Adoption of telemedicine technology, which enables doctors to monitor and diagnose patients remotely, is helping address increased pressure on healthcare resources due to a growing population.

 

Several studies have shown that strategic investment in health systems and the ability to innovate and adapt to resource limitations are among the key attributes that have helped some countries or regions achieve substantially better health outcomes than others at similar levels of development. It is in this context that the adoption of Information and Communication Technologies (ICTs) can provide policymakers in India with a very effective tool for improving healthcare delivery. E-health initiatives can help transform the public healthcare scenario in India, particularly in rural and remote areas.

Improving access to healthcare services in developing countries through ICTs has received special attention since the first World Tele-communication Development Conference (WTDC) in 1994. The World Health Assembly, the decision-making body of the WHO, had in 2005 recognized E-health as ‘the cost-effective and secure use of ICTs in support of health and health-related fields.’ The WHO had then urged member states to consider drawing up long-term strategic plans for developing and implementing E-health services and infrastructure in their health sectors.

 

Biocon Foundation is leveraging the power of technology in enabling the transformation of the public healthcare scenario in India, particularly in rural and remote areas. The foundation has implemented the unique eLAJ project to deliver evidence based healthcare for the benefit of communities with poor access to quality healthcare in Karnataka and Rajasthan. eLAJ clinics are staffed with doctors, technicians and pharmacists who are trained to handle state of the art diagnostic equipment and clinic management software. The multi parameter monitors (MPM) in the clinics collect vitals like blood pressure, temperature, blood sugar level, SpO2, pulse rate, and weight. Data captured on the eLAJ electronic medical record system is linked to an individual’s Aadhaar or unique identification number. This innovative model could be leveraged for long-term health tracking and facilitate effective preventive and primary healthcare interventions.

Biocon Foundation’s eLAJ clinics are providing access to preventive and primary healthcare, supported with a digital record of patients’ case files on the eLAJ electronic medical record system, and robust screening and early detection programmes. Government agencies can fine-tune healthcare strategies by leveraging this data, which is based on baseline socio-demographic and health indicators coupled with the disease profile of the community.

The deployment of tools such as telemedicine, teleradiology, hospital management information systems, online or electronic medical records in India can drive various benefits such as easy accessibility of data irrespective of geographical location, fewer errors, fast response in times of emergencies, patient convenience, among others.

However, the biggest challenge of using big data in India is the lack of standardization of healthcare data, which is currently being generated and collected by multiple agents in many different forms – from insurance claims to physician notes within the medical record, patient scans, conversations about health in social media, and information from monitoring devices. Then again, different health care organizations have different software management systems and infrastructure. The lack of standardization makes extraction and integration of this data a real challenge.

A highly complex compliance regime and heavy bureaucratic interference also presents regulatory hurdles for the roll-out of healthcare technology in the country.

 

India needs to implement a modern ICT based universal healthcare system for addressing the demand-supply gaps in terms of doctors and health facilities. It should be aimed at providing access to quality healthcare to all socioeconomic strata of the society by reaching out to the most remote locations. The e-healthcare programme will have to focus on leveraging modern diagnostics in primary healthcare for early detection and treatment, while using telemedicine to bridge the deficit of specialists at the primary care level. Finally, the programme should provide for cloud based data collection to collate epidemiological and patient centric data to profile and map the disease burden at the district level.

India will need strong integration between primary and tertiary care providers. Also, linkages need to be established between health research and national health programmes to ensure research findings are leveraged in decision making in public health. The deficit of skilled medical graduates, especially in rural India, will also need to be addressed. Investments in training and educating a skilled healthcare workforce will ensure that public health facilities are staffed by qualified people.

In this context it is heartening to know that India’s central government is in the process of giving final shape to the proposed National eHealth Authority, which will be the nodal authority responsible for development of an Integrated Health Information System (including Telemedicine and mHealth) in India.

 

This authority has been envisaged to support the formulation and management of all health informatics standards for India, laying down data management, policies, standards and guidelines in accordance with statutory provisions, promote setting up of state health records repositories and health information exchanges, and to deal with privacy and confidentiality aspects of electronic health records. It will need to spearhead the adoption of E-health solutions in a manner that meaningful aggregation of health and governance data and storage/exchange of electronic health records happen at various levels in a cost-effective manner. This will facilitate integration of multiple health IT systems through health information exchanges.

India has a vast population and thus myriad healthcare challenges. To make matters worse, a major portion of the population lives in rural areas or are too poor to afford healthcare services. On top of it, a majority of this population is catered for via poor public health infrastructure. Despite the challenges, the benefits of implementing an efficient universal healthcare system are too great to be ignored.

 

As Amartya Sen points out, Kerala’s success in running an effective UHC programme contributed greatly to its having the longest life expectancy in India and the lowest rates of infant and child mortality. In fact, universal healthcare and universal schooling have enabled Kerala to record the highest per capita income among all the states in India. Similarly, substantial progress in the provision of education and basic healthcare for all in Tamil Nadu and Himachal Pradesh have placed them among the richer Indian states.

The current public healthcare scenario in India urgently needs collaboration of the private sector in supporting the government to use innovative solutions in healthcare delivery. In attempting to fulfil the needs of ‘affordability’, ‘availability’ and ‘access’ for its citizens, India has an excellent opportunity for creating a highly effective ICT based system of universal healthcare that can set a global benchmark.

 

References:

V. Mahishale, ‘Universal Health Coverage in India: Reality or Just a Dream?’, Journal of the Scientific Society 43(1), 2016, pp. 3-5.

Economics of Non-Communicable Diseases In India. WHO, World Health Statistics 2015 (Print).

Gilberto Lopes, ‘Investing In Cancer Prevention and Control to Reduce Global Economic Burden’, ASCO Daily News, 2016 (Web. 31 July 2016). ASCO Annual Meeting Collective Wisdom.

Nilay Shah and Jyotishman Pathak. ‘Why Health Care May Finally be Ready for Big Data’, Harvard Business Review, 2014 (Web. 8 August 2016).

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