Leveraging of existing resources by setting-up health-care call centers to provide affordable healthcare to all.

Transcription

1 Leveraging of existing resources by setting-up health-care call centers to provide affordable healthcare to all. India is a vast country with large number of people living in villages without proper education and health care facilities even in the 21st century. India has 6,38,365 villages and about 75% (900 millions) of population is living in villages. Most of the rural population of India do not have access of basic health care either due to lack of medical facilities, basic infrastructure, and trained medical and health care staff willing to work in rural areas. The houses are poorly built without proper ventilation, toilets, watersource and electricity. Rural population lives in an unhealthy atmosphere together with animals. Due to these prevailing unhygienic conditions, communicable diseases, viral fever, diarhoea, typhoid, are more common. The pregnant women are not hospitalised and the babies not immunised. People do not adopt family planning and other health care programme either due to illiteracy, or because of adamant beliefs. Major challenges are resurgence of communicable diseases, declining public investments and expenditures in health and healthcare, breakdown of the public health system, access to basic healthcare declining, absence of regulation and control, and quality standards India s medical infrastructure consists of 5097 hospitals, hospital beds, doctors, nurses, and 162 medical colleges. There is large demand/supply gap with existing 100 beds per population (WHO norms 300 beds), number of doctors per 1000 also low as per WHO norms. The majority of healthcare services in India are provided by the private sectors, and much of India s healthcare expenditure comes from private patients pockets. In 2004, national healthcare spending equalled about 5.2 per cent of nominal GDP or about US$ 34.9 billion. Healthcare spending in India is expected to rise by 12 per cent per annum. During , Public Health Infrastructure (PHI) in rural health facilities up from 725 to 163,000, which is still the shortfall by 16% in PHCs and 58% in CHCs. PHI is not satisfying as service delivery hampered by policy and management concerns, non availability of qualified staff, weak referral system, recurring funding shortfalls, lack of accountability for quality of care. There are also problems of very low use of massive PH infrastructure, poor availability and access, unsatisfactory services of the PHI. Because of these issues, the poor population is seeking private health care. Only 20% of OPD and 45% of inpatient care obtained from govt health infrastructure while the rest is from the private sector ( Private Healthcare in India accounts for 1.67 % of total 30,000 hospitals, 2.33 % of beds, and 3.60 % of 5 million doctors. People have more preference for public sector (Govt. Hospitals) inpatient care because of low cost rather than quality. In 2003, feecharging private companies accounted for 82% of India s $30.5 billion expenditure on healthcare. Private firms are now thought to provide about 60% of all outpatient care in India and as much as 40% of all in-patient care. It is estimated that nearly 70% of all hospitals and 40% of hospital beds in the country are in the private sector. Secondary and tertiary care is not mandatory to register and unregulated with serious complaints of poor quality, over charging, and unethical behaviour. Government of India has taken an initiative to institutionalise a mechanism of public private partnerships (PPP) in healthcare, right up from the district level. Government of India (GOI) has launched the National Rural Health Mission (NRHM) in 2005 to carry out necessary architectural

2 correction in the basic health care delivery system. The Mission adopts a synergistic approach by relating health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian systems of medicine to facilitate health care. The NRHM aims to increase public expenditure on health, to reduce regional imbalance in health infrastructure pooling resources, to integrate of organizational structures, to optimise of health manpower, to bring decentralization and district management of health programmes, to increase community participation and ownership of assets, to induce management and financial personnel into district health system, to facilitate the community health centres (CHCs) into fully functional hospitals, and to achieve Indian public health standards in each block of the country ( Another GOI initiative is to establish the Public Health Foundation of India (PHFI) in a response to redress the limited institutional capacity for strengthening training, research and policy development in the area of Public Health. It is a public private partnership that was collaboratively evolved through consultations with multiple constituencies. PHFI is structured as an independent foundation, adopts a broad and integrative approach to public health, and tailoring its endeavours to Indian conditions. The PHFI focuses on broad dimensions of public health that encompass promotive, preventive and therapeutic services, many of which are frequently lost sight of in policy planning as well as in popular understanding ( In India, Health sector is the responsibility of the state, local and also the Central government. But in terms of service delivery it is more concerned with the state. The Central government is responsible for health services in union territories without a legislature and is also responsible for developing and monitoring national standards and regulations, linking the states with funding agencies, and sponsoring numerous schemes for implementation by state governments. Both the Central government and state governments have a joint responsibility for programs listed under the concurrent list. Still the majority of healthcare services in India are provided by the private sector. Healthcare delivery in public health sector in India consists of Primary Health Care Centres (PHCs), Community Health Centres (CHCs), District Hospitals/Health centres (Secondary), and Specialist Hospitals / Teaching Hospitals (Tertiary Level). Gujarat state is characterized by sea-coastal, tribal, desert and geographically hostile terrain having sparse and scattered population at the periphery. Administratively, the state has been divided into 26 districts, sub-divided into 172 blocks, having 20,738 villages and 242 towns. The population of the state is 6,03,83,628. The Total Fertility Rate of the State is 2.5. The Infant Mortality Rate is 44 and Maternal Mortality Ratio is 148 (SRS ), which are lower than the National average. The Sex Ratio in the State is 918 (as compared to 940 for the country). Comparative figures of major health and demographic indicators are as follows: Infant Mortality Rate (SRS 2010) in Gujarat is 44 (India 47), Maternal Mortality Rate (SRS ) is 148 (India 212), Total Fertility Rate (SRS 2010) is 2.5 (India 2.5), Crude Birth Rate (SRS 2010) is 21.8 (India 22.1), Crude Death Rate (SRS 2010) is 6.7 (India 7.2), Sex Ratio (Census 2011) is 918 (India 940), Child Sex Ratio (Census 2011) is 886 (India 914), and Total Literacy Rate (%) (Census 2011) is (India 74.04). Gujarat is fairing is key health statistic compared to national level except in sex ratios. The available health infrastructure Gujarat has 2508 health subcenters (with shortfall of 798), 1123 Primary Health Centers (with shortfall of 157), 318 Community

3 Health Center (with short fall of 305), 778 Doctor at PHCs (with short fall of 345). Shortage of human resource is one of the biggest challenges faced by the state, particularly specialists, obstetricians & gynecologists, pediatricians and anesthetists, there are about 60-80% of specialist positions are vacant. According to the National Health policy 2002, the goals are to reduce IMR to 30 and MMR to 100/Lakh, to Increase utilization of public health facilities from current level of < 20% to >75%, to establish an integrated system of surveillance, to increase health expenditure by Government as a % of GDP from the existing 0.9 to 2.0%, increase share of the central grants to constitute at least 25% of total health sharing, and to increase state sector health spending from 5.5% to 8% of the budget 2010 (Source: National Health Policy 2002). India lives in her villages said Mahatma Gandhi. After 64 year of Independence, the rural health scenario is very alarming, bundled with inadequate health care experts, lack of equipments and infrastructure. Poverty coupled with superstitions is also main cause of worry related to rural health. NRHM initiative by Government for many years has not yielded desirable results even in Gujarat state. The health goals could be achieved though investing in preventative health care to reduce health problem and by establishing robust curative health care to treat health conditions. The preventative health care includes the access of nutritious food and clean drinking water, prevalence sanitation and hygienic living condition, preventative health check-ups, and awareness and adoption of healthy life style. Many of the diseases could be prevented by preventative health care particularly in rural areas by leveraging strong community environment in villages through sustainable and enabling health awareness programme through voluntary organisations, self-help groups, and women empowerment. Health workers selected from these organisation can be trained and used for educating the rural on various health related topics through regular health classes / notices / channels / local SMS. They may be educated about the importance of sanitation and hygienic measures use of pure drinking water either by boiling or chlorination making toilets and leach pits away from well, management of animal / and farm / kitchen waste disposal through recycling by composting. Producing insecticides free vegetable and fruits for their own use in the kitchen garden, importance of immunization, family planning, nutritious food habit etc. They should also be warned against the consequences of enormous use of pan chewing, smoking and alcoholic. The Curative health care includes all level of healthcare delivery to treat diseases and health conditions. There are serious problems in curative health care, major one in lack of infrastructure and availability of trained manpower. The bottlenecks related to the access of quality health care could be removed by leveraging existing facilities and trained manpower by telemedicine and through delivery of medical services by community participations. For example, free medical camps could be organised by local voluntary organisations for eye test, dental care, and blood test once in two months may be carried out. A local co-ordinator may be selected, trained and paid. Through the medical camps, the awareness about safe motherhood, childcare, pregnancy complications, communicable diseases, cancer, diabetes, etc, could be spread. Another issue is lack of trained manpower, only 25% of India s specialist physicians reside in semi-urban areas, and a mere 3 % live in rural areas. As a result, rural areas, with a population approaching 900 million, continue to be deprived of proper healthcare facilities. One solution is

4 telemedicine the remote diagnosis, monitoring and treatment of patients via videoconferencing or the Internet. To provide quality health care and all the required facilities and infrastructure in all villages will require lots of investments and trained manpower, which might not be feasible to afford at this point. But available telecommunication infrastructure (mobile phones, and internet) and cheaper medical diagnosis medical devices could be utilized to provide a quality healthcare to all. Telemedicine is a fast-emerging trend in India, supported by exponential growth in the country s information and communications technology (ICT) sector, and plummeting telecom costs. Several major private hospitals have adopted telemedicine services, and a number of hospitals have developed publicprivate partnerships (PPPs), among them Apollo, AIIMS, Narayana Hrudayalaya, Aravind Hospitals, and Sankara Nethralaya. Though, the telemedicine is operational but full potential to provide quality health care to almost everyone is not achieved yet. One of the ways is to establish a healthcare call centre. Majority of rural population now has access to mobile phones. Currently in India, almost 700 millions cell phone are in use, means almost every households have an access of at least one cell phone. The state governments could take initiative by establishing healthcare call centres with a unique but easy to dial number (for example three digit number, like police or emergency number). The number could be dialled with any phone from anywhere. By dialling unique number, every household will be able to access the quality healthcare without much straining the existing resources. The preliminary design and operational structure of healthcare call centre should include two important components for the success: 1) Call Centre with Integrated Network with Doctors and Hospitals, and 2) Primary Health Care Centre (PHCs). 1. Health Care Call Centre: The call centre will be located in every district, or one for every 100,000 people in the area. Most of the staff should be recruited from the local area only, so that they can speak and communicate in local language and dialect without any difficulty. It is important, because many people cannot articulate their complete health problems without the help of local dialects and words. The call centre should be equipped to handle at least 100 calls at any given time point. There should be at least 10 ambulances available to dispatch and fetch the patients as needed. The call centre should be linked to rural health care centre equipped with basic infrastructure. Every call should be responded by trained local nurse, who can easily understand the local language and interpret the caller (patient) health problems, and if needed, could direct the call to the specialist or doctor. The responding nurse at the centre should also able to communicate with rural health care centre and the local nurse staffed at the health care centre. The nurse should able to make decision to dispatch ambulance to fetch the patient after the doctor/specialist consultation. The call centre should have access and have contract with local doctors, specialists and local multi-specialty hospitals as need bases. The staff nurses of the rural healthcare centre and call centre nurses should be connected with doctors and hospitals and able to communicate with them over phone and Internet without any problem. 2. Primary Health Care Centre (PHC): To make call centre successful, every village should have a local PHCs (or at least per 1000 of population) with basic medical check-up equipments, which are critical to assess the patient health condition. The equipments to measure weight, height, body temperature,

5 blood pressure, blood glucose level, and blood lipid profiles should be available at all PHCs. These equipments are available nowadays, at very reasonable cost and easy to operate without significant maintenance. The centre should have telephone and Internet facilities, and equipped with digicam to take picture of patient and affected body part. A trained local nurse should be available at the centre to do basic medical check-up (weight, height, temperature), and if needed to conduct the basic medical tests to measure blood glucose, lipids, and take picture of patient and affected part. The nurse should communicate via telephone and Internet about health condition of patient with call centre and doctors/specialists to make aware about patient health condition and pictures if requested. The heath care centre should be well stocked with common medicine, and the nurse should able to prescribe and provide the common medicines to the patient after the doctor consultation over phone. By this way the PHCs could be managed by a trained nurse, and existing services of doctors and specialist and tertiary care in urban area could leveraged to achieve the goal of quality care. In end, many of the excellent programs fail because of insufficient control and weak monitoring structure. The health service delivery also will not be successful without robust monitoring and evaluation. Measures should be taken to ensure sufficient trained staff to audit and monitor the delivery of preventative and curative health services at frequent intervals at all levels. Long Live Healthy Bharat! Jai Hind! Jai Bharat! (C) Dr Bhagwan D Aggarwal