WORLD HEALTH DAY 2009

By M H Ahssan

World Health Day 2009 focuses on the safety of health facilities and the readiness of health workers who treat those affected by emergencies. Health centres and staff are critical lifelines for vulnerable people in disasters - treating injuries, preventing illnesses and caring for people's health needs.

They are cornerstones for primary health care in communities – meeting everyday needs, such as safe childbirth services, immunizations and chronic disease care that must continue in emergencies. Often, already fragile health systems are unable to keep functioning through a disaster, with immediate and future public health consequences.

This year, WHO and international partners are underscoring the importance of investing in health infrastructure that can withstand hazards and serve people in immediate need. They are also urging health facilities to implement systems to respond to internal emergencies, such as fires, and ensure the continuity of care.

Emergencies: global and local impact
Wars, cyclones, earthquakes, tsunamis, disease outbreaks, famine, radiological incidents and chemical spills – all are emergencies that, invariably, impact heavily on public health. Internal emergencies in health facilities – such as fires and loss of power or water – can damage buildings and equipment and affect staff and patients. In conflicts, reasons for hospital breakdowns include staff being forced to leave due to insecurity and the looting of equipment and drugs.

In 2008, 321 natural disasters killed 235 816 people – a death toll that was almost four times higher than the average annual total for the seven previous years. This increase was due to just two events. Cyclone Nargis left 138 366 people dead or missing in Myanmar, and a major earthquake in south-western China's Sichuan province killed 87 476 people, according to the United Nations’ International Strategy for Disaster Reduction (UNISDR). Asia, the worst-affected continent, was home to nine of the world’s top 10 countries for disaster-related deaths. Along with other weather-related events, floods remained one of the most frequent disasters last year, according to UNISDR. Conflicts around the globe have also led to great human suffering and have stretched health care services to the extreme.

Disasters also exact a devastating economic toll. In 2008, disasters cost an estimated US$ 181 billion – more than twice the US$ 81 billion annual average for 2000–2007. The Sichuan earthquake was estimated to cost some US$ 85 billion in damages, and Hurricane Ike in the United States cost some US$ 30 billion.

"The dramatic increase in human and economic losses from disasters in 2008 is alarming. Sadly, these losses could have been substantially reduced if buildings in China, particularly schools and hospitals, had been built to be more earthquake-resilient. An effective early warning system with good community preparedness could have also saved many lives in Myanmar if it had been implemented before Cyclone Nargis," said Salvano Briceno, the director of UNISDR.

Although only 11% of the people exposed to natural hazards live in developing countries, they account for more than 53% of global deaths due to natural disasters. The differences in impact suggest there is great potential to reduce the human death toll caused by natural disasters in developing countries – and that the key ingredient in these tragedies is human inaction.

This is only one part of the picture. There are many smaller-scale events that inflict an even greater toll in terms of human suffering, such as in the case of vehicle accidents and fires. Road traffic crashes kill 1.2 million people annually, or more than 3200 people a day, while a further 20–50 million people are injured or disabled every year. At least 90% of road and fire fatalities occur in low- and middle-income countries. There are also 300 000 deaths each year from fires alone.

Outbreaks of communicable diseases can spark emergencies that cause widespread death and suffering. In the 12 months up to 31 May 2008, WHO verified 162 outbreaks of infectious disease in 75 countries worldwide. More than a third of the outbreaks occurred in Africa. They included cholera, other diarrhoeal diseases, measles, haemorrhagic fevers and other severe emerging diseases.

"The risk for outbreaks is often presumed to be very high in the chaos that follows natural disasters, a fear likely derived from a perceived association between dead bodies and epidemics. However, the risk factors for outbreaks after disasters are associated primarily with population displacement (commonly linked to conflict)." Even a few cases of a given disease can give rise to the perception that the public faces a grave health risk, which can lead to major political, social and economic consequences.

Infectious diseases are major causes of death and illness in children in conflict settings, especially among refugees and the internally displaced.

How emergencies threaten health facilities and delivery of care?
Apart from their effects on people, emergencies can pose huge threats to hospitals, clinics and other health facilities. Structural and infrastructural damage may be devastating exactly at the time when health facilities are most needed. Health workers have been killed in collapsing hospitals. The number of other deaths and injuries is compounded when a hospital is destroyed or can function only partially. Health facilities should be the focus for assistance when disaster strikes but, if they are damaged or put out of action, the sick and injured have nowhere to get help.

The 2003 Algerian earthquake rendered 50% of health facilities in the affected region non-functional due to damage. In Pakistan's most-affected areas during the 2005 earthquake, 49% of health facilities were completely destroyed, from sophisticated hospitals to rural clinics and drug dispensaries. The December 2004 Indian Ocean tsunami affected national and local health systems that provided health services for millions of people. In Indonesia's northern Aceh province 61% of health facilities were damaged.

Despite international laws, health facilities continue to be targeted or used for military operations in conflicts. Health facilities in Bosnia and Herzegovina, Somalia, the Central African Republic and the Gaza Strip are among those that have been caught in the line of fire.

An emergency may be limited to the health facility infrastructure – for example, fire damage, power cut or loss of water supply. Chemical and radiological emergencies in or near a health facility can also disrupt the delivery of care. In addition, emergencies threaten health staff – the doctors, nurses, ambulance drivers and other staff working to save lives. When a hospital collapses, or an artillery shell destroys a ward or an ambulance, health staff are killed or injured. When staff are incapacitated and cannot do their work, health care is further interrupted.

Even if health facilities themselves are not affected during disease outbreaks and epidemics, their services and provision of safe care may be. Increased demands for services and a decreased workforce can impact on health care by disrupting communications, supplies and transport. Continuity of care is then in turn disrupted, including for chronic diseases like HIV and tuberculosis.

If measures to prevent and control infection are not effective, health-care facilities may act as "amplifiers" of outbreaks, generating cases of the disease among other patients or health-care workers and further decreasing the capacity to provide services.

Power cuts linked to disasters may disrupt water treatment and supply plants, thereby increasing the risk of waterborne diseases and affecting proper hospital functioning, including preserving the vaccine cold chain. A massive power outage in New York in 2003 was followed by an increase in diarrhoeal illness.

Why keep health facilities safe?
Safe health facilities in emergencies are a collective responsibility
Hospitals are more than just buildings. They are a vital asset at the heart of a community, the place where often life starts and ends. Due to the central role played by hospitals in our communities, we all share the responsibility of making sure they are resilient in the face of emergencies. Below are three reasons as to why we must make hospitals safe in emergencies.

1. Save lives, protect health
As they are occupied 24 hours a day, hospitals cannot be evacuated easily. They must remain working if their occupants – especially the most vulnerable such as newborn babies and patients in intensive care – are to survive. When the work of hospitals and other health facilities is disrupted or their buildings are damaged, both urgent and routine health care is interrupted and may be halted altogether – leaving the sick and injured without the care that they need.

Health "systems" rely on a range of public, private and nongovernmental facilities to work together to serve the community. In times of emergency, this is even more important. Hospitals, primary health care centres, laboratories, pharmacies and blood banks work with other non-health sectors, including energy, roads and transport, and the police to ensure the continuity of health services.

Health facilities are safe havens for people during an emergency. Hospitals and their staff must be regarded by all parties – particularly combatants during conflicts – as neutral and must not be subjected to any form of violence. Sadly, the provisions of international humanitarian law in this regard are often not respected. During emergencies, health facilities play a vital role. They:

provide emergency care to the injured (e.g. surgery and blood transfusions) and to the critically ill – as in outbreaks of communicable disease;
- collect and analyse data on illness and deaths in order to detect and prevent potential communicable disease outbreaks;
- deliver longer-term health care before and after an emergency. People need long-term nursing and medical care, maternal and child health services, rehabilitation of injuries, management of chronic diseases, and psychosocial support long after the emergency is over;
- provide immunization services to prevent outbreaks of communicable diseases such as measles that lead to the needless deaths of more children; and
provide other critical services – including laboratories, blood banks, ambulances, rehabilitation facilities, aged care facilities, and pharmacies.

2. Protect investment
The most costly health facility is the one that fails. Hospitals and health facilities are enormous investments for any country and their destruction or damage imposes major economic burdens. In some countries, up to 80% of the health budget is spent on hospitals and other health facilities. Rebuilding a hospital that has been destroyed virtually doubles the initial cost of the facility.

3. Safeguard social stability
Public morale can falter and political discord be ignited if health and emergency services fail during emergencies. Conversely, an effective emergency response and functional health service can reinforce social stability and cohesion. Hospitals are a haven for the public during conflicts and other emergencies due to their neutrality, impartiality and ability to protect a community's social and health capital.

Global efforts to make hospitals safe from disasters
Much has been done to ensure that health facilities can better cope with emergencies and to increase awareness of the vital role that health facilities play in emergencies. “Hospitals Safe from Disasters” is the theme of the 2008–2009 World Disaster Reduction Campaign, which focuses on natural disasters and the damage they can cause to hospitals in particular. The United Nations International Strategy for Disaster Reduction (ISDR), the World Bank and WHO are jointly involved in this campaign. WHO’s regional and country offices have been instrumental not only in helping to share best practices in health facility preparedness for emergencies but also in implementing such guidance and making hospitals and clinics more resilient and functional.

While much work has been done to raise the issue of emergency preparedness for health facilities and to build a "community" of people and parties dedicated to the cause, efforts remain sporadic and are neither sufficiently integrated into government development and emergency response plans nor properly harmonized with other sectors.

WHO's partners, including WHO's regional and country offices and ministries of health, are also leading the way in advocating how best to safeguard health facilities and their personnel and patients. The International Committee of the Red Cross, which advocates for the protection of health personnel and services in conflict settings, and its sister organization, the International Federation of the Red Cross and Red Crescent Societies, which works with communities on emergency preparedness at community level in natural disasters, play critical roles in making hospitals safe from disasters. Donors and financial institutions – including the World Bank, USAID and DIPECHO – have answered the call by offering funding to make health facilities safer.

WHO is devoting World Health Day 2009 to the theme of health facilities in emergencies – “Save lives. Make hospitals safe in emergencies” – to further strengthen the imperative that health facilities must be prepared to withstand emergencies so that they can treat patients both during crises and afterwards. The World Health Day campaign builds on the "Hospitals Safe from Disasters" campaign and calls for hospitals to be safer in all types of emergencies, including natural disasters, conflicts and outbreaks of communicable diseases.

World Health Day is more than just a one-day event. WHO, from its country and regional offices and headquarters, is continuously working with international and national partners to assist countries in preparing their health facilities and staff for emergencies. What 7 April 2009 marks is the launch of the next step of a campaign to build resilience into our health systems so that hospitals, clinics and staff can withstand the next crisis, whatever it may be, and provide the health care that their communities need in times of emergency.

Is Best Health Insurance An 'Expense' Or An 'Investment'?

SPONSORED: There are two schools of thought in India - one who believe in the concept of Health Insurance, are aware of the benefits and are pro-active about it. 

And the others, who feel that they are fit and can never fall ill, discard the need for health insurance; even though they are in agreement of the fact that the costs of hospitalisation and medical treatment have reached sky high in the last few years. So, to combat their queries, I thought of writing about Health Insurance in India, its penetration and importance and whether or not it should be mandatory, by law or by principle.

WEEKEND SPECIAL: Mental Health: Lost In Translation

By M H Ahssan

Bhagwati Kumar, 58, has been suffering from depression since past three years. She is on medication but is reluctant to disclose her condition to others in her neighborhood, even though they perceive her as unfriendly. "The depression medications make me sleepy and I find it hard to keep my appointments," she admits. Also, she feels drowsy and tends to yawn during conversations, something that people find rude. "It was different back home with family around. Here I have few neighbors as friends and now even some of them don't talk to me. Even I don't feel like talking to anyone most days," she says. Bhagwati lives in Ontario with her son in a two-bedroom apartment and doesn't have much company throughout the day. "My son has his own life and work. After I complete the cooking I don't really have a lot to do," she reveals.

Unfortunately, Bhagwati is not alone in her misery. There are many South Asian immigrants who are fighting depression and other mental health problems silently. Many are not even aware that they can easily seek help and get better.

So recently, despite the temperature hovering around 14 degrees Celsius and chances of showers, 600 people, mostly South Asians, donned their running shoes to participate in the Lions 5K Walk on raising awareness about mental health in their community in Ontario.

"Mental illness costs the Canadian economy a staggering $51 billion a year in health care and lost productivity. Only one-third of those who need mental health services in Canada actually receive them," emphasizes Gobind Sharma, Co-Chair, Lions 5K Walk. The walk was organized by Milliken Mills Lions Club, a Markham-Ontario chapter of the international voluntary organization, Lions Club and Social Services Network, a not-for-profit agency.

The immigrant communities, especially from India and Pakistan, are one of the last to get help when it comes to mental health problems, including depression, schizophrenia, bipolar disorder, substance abuse disorder and obsessive compulsive disorder. And there is an urgent need to raise awareness about mental health issues, especially within the South Asian community that still tends to ignore them.

Together, the walkers circled boulevards near the brick and glass building of Markham Civic Centre and the city town hall of Markham, an Ontario suburb that has one of the highest concentrations of South Asians. "The $30,000 raised through the walk will be used to raise awareness about mental health," said Sharma.

The reasons for engaging South Asians in a walk on mental health are not hard to find. The town of Malton is a ready proof of the fact that South Asians in Canada shy away from getting help when it comes to mental health. Malton is a part of Mississauga, Canada's sixth largest and fastest growing city, and a showcase of multiculturalism constituting immigrants of different nationalities. Yet, in comparison, a homogenous Malton is a long-forgotten and best-ignored part of Mississauga. It is commonly referred to as Mississauga's "ugly little brother." It has a small population of 38,174 of which 52 per cent are South Asians and 16 per cent are black. Punjabi, Urdu, Gujarati and Hindi are some of the most common mother tongues spoken in the town after English.

In March 2009, various not-for-profit groups, government health agencies, and prominent mental health institutions came together at Malton to discuss some of existing lacunae in accessing mental health. Many grim realties were discussed at this meeting, including the fact that people who do not speak English are less likely to receive treatment for their mental health problems and more likely to have their mental health disorders go untreated. This is because when it comes to mental illness, immigrant communities lack information. They are confused about "what questions to ask, who to ask and what the services are." Also information on mental health issues is not available in the languages they speak.

Aside from language barriers, another reason cited by experts was that, even after migrating to Canada, people tend to hold on to the mindsets prevalent in their home countries. "There is stigma attached to mental health," agrees Dr Ravi Kakar, a consultant psychiatrist practicing in Scarborough, Ontario. He says that in his practice it is not uncommon to come across clients who avoid seeking medical help for as long as possible. "They will seek help when things begin to fall apart. For instance, wait until the very end when their marriage is at breaking point because of mental illness," he says. And before coming to a psychiatrist, people like to explore other options, including seeking those who advocate witchcraft or getting rid of the evil eye. "Or they keep on dealing with a mental health issue as a karma of sins done in the past life," elaborates Kakar.

Health care providers agree that they too have their own set of problems, which makes it hard to bring the relevant services to immigrant communities. Lack of data is the primary reason for the delay. This was what Kwsai Kafele, the Director of Corporate Diversity at the Center of Addiction and Mental Health, Canada's largest mental health and addiction teaching hospital, emphasized when he spoke at a workshop at Brampton Civic hospital recently. He pointed out that the health monitoring system does not keep statistics by race. This means that there is limited comprehensive data on how ethnic communities fare when it comes to mental health issues and illnesses.

As a result, people facing mental health issues are not under the radar of health care providers, even as experts agree that immigrant communities are among those most in need of accessing mental health services.

One big reason for this is the process of immigration itself. The "healthy immigrant effect" is a reality in Canada. Immigrants come with better health, which deteriorates as they try and adjust to their new surroundings. Here, health includes both their mental and physical health.

"Immigration is a stressful process. You uproot yourself and try and settle in a different culture. You have to find a new job, learn a new language and take on challenges. Many people have anxiety problems and require counselling for balanced mental health," said Kakar.

Some of these issues are not unique to South Asians. "Mental health is a big issue in the Caribbean community and there is a need to demystify it," said Kafele, speaking at the workshop "Building Awareness of the Caribbean Community's Health." He said he tried to get an article published in a local ethnic Caribbean newspapers on mental health but was not able to do so because of the "stigma." Like Kakar, he believes that immigrants have to deal with chronic stress problems that are exacerbated not only by the process of immigration but also the poverty and racism that often accompany it.

However, voices are now being raised within the communities to generate awareness about mental health issues. "Our walk got a tremendous response from politicians and support from mental health institutes and the public at large," said Sharma. He is hopeful that these "small steps" will result in creating greater awareness about mental health.

Missing: A 'healthy' debate

By M H Ahssan

If public health systems are failing on account of certain causes, the solution should lie in fixing them. However, it appears instead that the state seems to be looking for an escape route from the problems of its own inefficiencies.

When I first heard of the recently launched Rashtriya Swasthya Bima Yojana (RSBY) - a health insurance scheme to provide cover to Below Poverty Line (BPL) families - my first reaction was to feel happy that there is such a scheme. RSBY is an idea that has its origins in the Ministry of Labour, and is designed as yet another way to provide social security to people below the poverty line. Under the scheme, BPL families (up to a total of 5 members per family), will get insurance cover of up to Rs.30,000 per person per year.

It is well recorded that in India, those people who are economically below the poverty line or are at the margins need just one prolonged illness or hospitalisation to be pushed to the verge of bankruptcy. But a little more thinking about RSBY and our health sector, made me ask some questions: Why do we need an insurance scheme for BPL families?

Is it because we do not have adequate government medical facilities or trained doctors that people can access? Or is it because many government-run health care centres simply do not run the way they are supposed to? Or, could it be that, people have so little faith in our public health facilities that they simply do not go there even though they might become bankrupt paying for private health care? Or is it because there is an explicit policy statement in which we have said that we must encourage private provision of health care, because we have come to the conclusion that government facilities are beyond redemption?

Our opinions on the role of RSBY will vary, depending on the answers and explanations to these and other similar questions. In any event, the scheme is symptomatic of a larger problem. The health ministry has failed to deliver essential health care services to the population through the government health care system, and to overcome this failure, a different ministry wants to provide insurance to a section of the population so that they can access private health care.

How fruitful will the Ministry of Labour's labours on this front be? That remains to be seen. But one thing is clear - for the first time, the government has signalled to a large percentage of the population (over 20 percent) that they should access health care offered by private providers and that the government would be willing to work with insurance companies to finance this arrangement. Already, around 85 million people are covered under schemes such as Employees State Insurance Corporation, Central Government Health Scheme, etc. That number is a relatively small fraction of the total population. With RSBY, the push towards privately provided care will receive a much bigger boost.

Vouchers for private education
There are parallels to this in other sectors, notably education. RSBY is like saying that all children of BPL families will get an education voucher that will pay school fees (up to a certain limit) for children who wish to go to private schools. Education vouchers allow children to choose the private school they wish to go to depending on their perception of quality of the school, and any other relevant factors. The government gives a voucher to the child which she can present in the private school as her fees. The school then exchanges that voucher with the government for cash.

The argument goes that the schools will have to be perceived as "good" if more children have to enrol. This fosters competition amongst schools, where non-performing schools will lose in enrolment and the "good" schools will increase. So there is fillip for private providers of education services, and there is direct competition between government and private providers of education.

People vote with their feet. The hollowing out of government schools in urban areas, and increasingly in semi-urban areas and rural areas is a good example of this. If people believe that private schools provide better education, then they will be willing to pay for them and attend them. In many urban areas, children who go to government schools often have little choice, for they belong to the poorest of families, and in several instances, their parents have had very little education.

It is interesting to note that while we, as a nation, seem to be less than receptive to education vouchers as a policy intervention but in stark contrast are embracing health insurance as an option. Arguing that education and health care are two different kinds of public services would be missing the forest for the trees. The broad questions in this comparison are still relevant.

Without debate
Interestingly enough, the 2004 General Election manifestos of the Congress and the BJP both explicitly state that they will start an insurance-based health security scheme if elected. The Common Minimum Programme makes a similar statement. It would seem logical that before making an important choice like this one, it would be necessary to evaluate various existing and possible new approaches to addressing the problem from the point of view of effectiveness and costs, and then make an informed policy choice.

Our health care sector is at a stage of evolution where we can still make better choices - how much private provision would we like vis-a-vis government provision of health care services? In simpler words, what percentage of people would we like to depend on government hospitals as compared to private hospitals for treatment? This is a question we ought to ask now, given the relatively small scale of organised private health care. If the government actively promotes private provision of health care now (through programmes such as RSBY), then in two or three decades from now, it would be too late to ask how much private healthcare should our country have.

This is by no means an ideological stance, supporting government efforts and criticising the private sector. Rather, it is about short-term benefits and losses, and the likely long term impact. This debate is about asking these important pragmatic questions early enough, so that the choices and their implications are fully understood.

In the short term, the BPL families who benefit from RSBY will greatly appreciate the programme, despite the scheme's imperfections and shortcomings. It does in fact make better health care more accessible for those who might otherwise have had to spend significant amounts of money despite being unable to afford it. In the short term, given that our demographics are slanted towards a younger population, the insurance premiums that the government will need to pay will also be relatively low. As our population ages, the cost of such payments to insurance companies will naturally increase.

Under these circumstances of massive structural changes sweeping the sector, it would be pertinent to examine the kind of debates taking place. There are two kinds of conversations that dominate the discourse. One set of people are deeply concerned about the implementation of various government health schemes such as the Janani Suraksha Yojana (that attempts to promote institutional deliveries), or such other important programmatic interventions that will have a direct bearing on health outcomes. There is another set of people who are talking about health financing, and what options exist to make the necessary finance available to the health sector - be it government funding, raising private resources, insurance mechanisms, etc.

The National Health Policy 2002, talks about a number of things, but falls short of articulating a national vision for the structure of our health care system 10 years from now.

The Report of the National Commission on Macroeconomics and Health submitted in 2005 has some very high quality papers. This Commission chaired jointly by the Health Minister and the Finance Minister identifies some important issues facing the health care sector. In a candid assessment of the health care sector in India, the report says: "The principal challenge for India is the building of a sustainable health system. Selective and fragmented strategies and lack of resources have made the health care system unaccountable, disconnected to public health goals, inadequately equipped to address people's growing expectations". The reasons for failure can be attributed to three broad factors: poor governance and the dysfunctional role of the State; lack of a strategic vision; and weak management."

It would seem that if the health sector is failing on account of these three causes, the solution should lie in fixing them. However, it appears instead that the state seems to be looking for an escape route from the problems of its own inefficiencies by conceding a bigger role for the private sector.

In discussing the role of the private sector in health care delivery, the report goes on to say: "... the trade-offs in terms of welfare implications however cannot be ignored. It will raise the overall cost of health care in the country and generate pressures for increased budgetary allocations for government hospitals to stay competitive."

And then the same report while discussing the 'way forward' goes on to recommend that in order to improve the quality of health care, the country should "Gradually shift the role of the State from being a provider to a purchaser of care."

This stance raises some elementary questions: what is the likely impact on equity, cost and quality of services as a result of this shift in the medium to long run? What are the projections of the costs 10-20 years down the line? How sensitive are these numbers to any changes in demographics, or a mid-course change in policy? These questions have not been discussed in depth in policy circles, let alone in public debates across the country.

If there is one question that we need to ask now, it is this: have we as a nation reflected on the policy choices that we are faced with now? If we are unable to answer this question with enough conviction, we may end up losing another generation to poor quality health care for the majority of the people in the country. Is that something that we can afford?

Fighting for Social Justice - 'Preying on Patients'

By M H Ahssan

It's not hard to find people caught in the gap between India's dreams of greatness and the awful reality of its broken health system. Most of the country lives there. Take Rani Bai. He would be a normal kid but for the fact that nine years after his birth with a bladder defect, his family is still struggling to get him what should be a simple and relatively cheap operation.

Like many sick people, Rani is both symptom and cause. Her lack of proper treatment is reason enough for national shame but his ill health hurts the country in turn, not only forcing the frail-looking boy to miss school for a week or two every few months while he searches hospital by hospital for some relief, but dragging his uninsured family into debt when they should be benefiting from India's economic boom. Together, Rani\'s parents — her mother Sunita is a clerk in a local private office in the Husnabad of Karimnagar, her father Sunil works in a small clothes shop — make just under Rs.2000 a month, no fortune but enough to buy a small TV for their modest home. They would have bought a motorbike too, Sunil says, perhaps even a patch of land somewhere, were it were not for the hospital bills that never seem to end.

Standing in the crowded entrance hall in the outpatients department of Nizams Institute of Medical Sciences (NIMS), one of AP's best public hospitals, Sunil explains that because there are no decent public hospitals in Husnabad, he and his wife take Rani to Hyderabad about twelve times a year for checkups and to try to get her the operation she needs. Last year, after years bouncing between hospitals and clinics, their daughter got an appointment to have the vital tests he needs before an operation. The family scraped together the Rs.1500 fee and traveled the 180 miles (290 km) to Hyderabad by poorly maintained state run RTC bus. But when they arrived they discovered the machine at the government hospital they had been visiting was broken and unlikely to be working anytime soon. Which is how the family came to be at NIMS one morning late last year, hoping, cajoling, pleading for an appointment at the better-equipped hospital, and praying that one day they could make the system work for them. "Nine years is a very long time," says Sunil. "My daughter should have been operated on and recovered years ago."

The same could be said of india's health system. Sixty years after independence, India remains one of the unhealthiest places on earth. Millions of people still suffer from diseases and ailments that simply no longer exist almost anywhere else on the planet. Four out of five children are anemic. Almost one in four women who give birth receives no antenatal care. What makes the picture even bleaker is the fact that India\'s economic boom has had, so far at least, little impact on health standards. Think of it this way: in the five years between 2001 and 2006 India\'s economy grew almost 50%, the country\'s biggest expansion in decades. Meantime, its child-malnutrition rate, a number that measures the percentage of children under 3 who are moderately or severely underweight, dropped just a single percentage point, to 46%. That\'s worse than in most African countries, and means almost half India\'s children remain at risk of "health problems such as stunted growth, mental retardation, and increased susceptibility to infectious diseases," according to the most recent National Family Health Survey, a study of more than 230,000 people, from which the figures are taken.

Perversely, the incredible economic growth is having an impact in other ways, driving up rates of rich-world diseases such as obesity and diabetes and encouraging high-end health services, some of which offer world-class care but remain far beyond the reach of the vast majority of Indians. It\'s these services — think of last year\'s surgery to save an Indian girl born with four arms and four legs — and the skill of India\'s world-class doctors that the country brags about when its marketers sell India as a medical-tourism destination and an emerging health-services giant. The truth behind the glossy advertising is less incredible: India remains the sick man of Asia, malnourished and obese at the same time, beset by epidemics of AIDS and diabetes, and with spending levels on public health that even Prime Minister Manmohan Singh has conceded "are seriously lagging behind other developing countries in Asia."

The sorry state of India\'s medical services might not matter so much if tens of millions of Indians weren\'t already so sick. Part of the problem is the lack of infrastructure — not fancy hospitals or equipment but basic services such as clean water, a functioning sewage system, power. The World Health Organization estimates that more than 900,000 Indians die every year from drinking bad water and breathing bad air. The Indian government says that 55% of households have no toilet facilities. Many cities lack sewers. The missing infrastructure is not unique to India. Parts of Africa face similar underdevelopment. But some public-health experts believe that India\'s massive population adds to the burden, overloading systems where they do exist and aiding the spread of disease in the many places they don\'t.

There are other reasons for India\'s ill health. Over the past decade or so, funding for public-health initiatives such as immunization drives and programs to control the spread of communicable diseases has been cut; some critics blame shifting government priorities. One of the best ways a country can improve its health, for instance, is by making sure its children are immunized against measles, polio and other life-threatening illnesses. But immunization rates in India are significantly lower than in other developing nations such as Bangladesh, China and Indonesia. Just 43.5% of very young children are fully immunized. "It\'s shameful," says A.K. Shiva Kumar, an economist and public-health expert who consults to the United Nations Children Fund in India and was a member of the government\'s recently disbanded National Advisory Council. "All this high income, this growth of the past few years is well and good, but numbers like this show you can\'t get complacent about health or you\'ll go nowhere."

In the past few years, diseases such as dengue fever, viral hepatitis, tuberculosis, malaria and pneumonia "have returned in force or have developed a stubborn resistance to drugs," according to a report on health care in India by consultancy PricewaterhouseCoopers. "This troubling trend can be attributed in part to substandard housing, inadequate water, sewage and waste management systems, a crumbling public health infrastructure, and increased air travel." Pylore Krishnaier Rajagopalan, who was head of the government Vector Control Research Centre in the southern city of Pondicherry between 1975 and 1990, blames policies that concentrate on the latest scientific techniques and not enough on basic controls. "Field work is almost dead," Rajagopalan says. "These mosquitoes are sun loving. How can a shade-loving, lab-bound, white-coated scientist control the mosquitoes through research? It may be the future but millions of people in India are suffering and dying now because we\'re not doing the basics."

If all that explains why Indians are so sick, look to public hospitals and medical services to understand why they are not getting better. In many parts of the country, but especially in rural India, where two-thirds of the population lives, health services are poor to nonexistent. Clinics are badly maintained and equipped. India needs hundreds of thousands more doctors and more than a million more nurses. Current staff often don\'t turn up for work. "It is a well-recognized fact that the system of public delivery of health services in India today is in crisis," begins the paper "Understanding Government Failure in Public Health Services" published in the influential Economic and Political Weekly last October. "Recent analyses show that high absenteeism, low quality in clinical care, low satisfaction with care and rampant corruption plague the system."

Such dire conditions force millions of people to head to the better public hospitals in India's cities. The Dr. Ram Manohar Lohia Hospital (RML) in New Delhi is well maintained, relatively clean and is probably one of the best. Unlike most hospitals, which get their funding from state governments, the RML is financed directly by the central government and caters to the thousands of public servants and senior government officers, including members of Parliament, who are lucky enough to have state-funded medical insurance. But its high standards are also a magnet for sick people for hundreds of miles around. About 60% of the 4,500 patients the hospital sees every day travel not from the New Delhi area but from neighboring states. Some of them are complicated cases that have rightly been referred to a tertiary-care hospital, but many are simple cases of malaria or dengue fever that other hospitals should treat easily. "The challenge is that our facilities are totally at saturation point," says Dr. Nishith K. Chaturvedi, the hospital's medical superintendent. "If states were doing a better job it would cut our case load by 35%."

The crush of numbers means that the RML is sometimes forced to have patients share beds. "For a short period only," Dr. Chaturvedi says, looking slightly sheepish. "But it happens." A tour of the emergency and outpatient departments brings the problem into stark relief: the crowds of patients and visiting relatives are as thick and suffocating as the heady fug of chloroform and the sounds of children screaming. A few cases on trolley beds wait outside under a small awning. Though generally well kept, "it's very hard to maintain cleanliness even if you clean every half an hour," says the head of the outpatient department, Dr. P.K. Misra, waving his hand at a heap of bloodied sheets in a corner. "I have visited a few hospitals in the U.S. They are like five-star hotels for us. But we can never match that. It's the population load."

Later, taking a break in an unoccupied office, a tired Misra laments the state of public health. "This place is one of the good ones," he says. "I have seen hospitals with dogs below the beds." After graduating, Misra spent a few years in India's northeast, one of the poorest parts of the country. "I went to the rural area to serve the people but the government doesn't recognize that," he says, explaining that classmates who went to big cities "are now professors and earning big bucks." The system, he says, is set up so that rural areas will never have good doctors or other medical staff, tens of thousands of whom leave to work in cities or abroad. "It's better to start a practice in the city than go to the country and ruin your life."

With such problems in the public system, it's little wonder that private operators have boomed. Some 80% of all spending on health care in India is now private, some of it by large companies insuring their staff, some by nongovernmental groups running health programs, and a bit by rich Indians using the best private facilities. But the overwhelming majority of the spending is by poor citizens. Money is so tight that many rural Indians skip doctors and rely on advice from local pharmacists, who too often prescribe cough syrup or tablets that do nothing to help. Because only one in 10 Indians has any form of health insurance, out-of-pocket payments for medical care amount to 98.4% of total health expenditures by households, according to the PricewaterhouseCoopers study, which estimates that 20 million people in India fall below the poverty line each year because of indebtedness due to health-care needs. In Brazil and China, both countries India often compares itself with, the public share of health-care spending is around 40%, while the average for G7 countries is 70%. In India it is just 17%.

The good news is that the current Indian government seems to get it. "Health is slowly becoming an important focus," says Krishna Rao, who heads health economics and funding for the Public Health Foundation of India. The organization was set up in 2006 by the government, NGOs like the Bill and Melinda Gates Foundation and private health providers to influence policy and research, and to set up world-class public-health schools around the country. The government has also promised more money for rural health through its ambitious National Rural Health Mission. The Congress Party, which leads India's coalition government, says it will increase public-health spending from the current 1% of India's GDP to up to 3% by 2010, but that's still just half the rate at which countries with comparable per capita incomes such as Senegal and Mongolia fund their health sectors. "What has been a fatal flaw in our approach is that we have gradually abandoned comprehensive health care and a public-health perspective for focused attention on selective diseases," Prime Minister Singh said at the April 2005 launch of the National Rural Health Mission. "We have grievously erred in the design of many of our health programs. We have created a delivery model that fragments resources and dissipates energies. Most importantly we have paid inadequate attention to the public-health issues and the possibilities of social and preventive medicine."

If that is to change, one of the first myths that need to go is the idea that economic growth alone will lead to better health. Though health indicators vary widely across India, the link between wealth and good health isn't clear cut. Poor states such as Orissa and Chhattisgarh that have made efforts in child immunization over the past few years now have better coverage than richer states, where immunization has actually slipped.

Other sacred cows will need to be challenged. India's old socialist system may have had its problems, says Imrana Qadeer, one of India's foremost public-health experts, but the belief that private enterprise can cure all of India's woes is dangerously misguided. "The private sector doesn't want to do basic things like treating diarrhea, improving nutrition, immunizing babies because that's not where the money is," says Qadeer. "In India we cannot live without a strong public sector."

In the end that will mean spending hundreds of billions of dollars more on public health, perhaps even creating a basic national insurance scheme. "Unfortunately there may not be any low-cost solutions," says public-health expert Kumar, who believes current government promises do not go far enough. "India needs to be prepared to spend on health but whenever it's mentioned there's always this debate about cost. Why don't we have the same debate when we spend tens of billions on new arms? It's totally unacceptable to shortchange a system that will save lives." And it's hard to be an economic superpower if you're too sick to work.

Access To Health: Nowhere Near To Being A Healthy Nation

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SPECIAL REPORT
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The out-of-pocket health expenditure by the poor is spiraling and the government spending on public health care is reducing. The existing public health programes and insurance schemes are failing; private health care sector is not properly regulated; INNLIVE finds the health of our nation worrisome.

Despite our efforts and best wishes, our modus vivendi, work atmosphere and environment often lead to situations where we have to consult medics and get treatment. The Country Cooperation Strategy brief of the World Health Organization (WHO) informs that India accounts for 21 percent of the world’s global burden of disease.

Avoid 'These Mistakes' While Buying A 'Best Health Plan'

SPONSORED: Health insurance has been getting a lot of attention lately. The sales of health policies are rising not only in the metro cities where the awareness levels are relatively higher but also in smaller towns and rural areas. 

People in India have realized that the only way to fight the spiraling cost of health care and safeguard them against critical illness is by buying a comprehensive health insurance plan. 

Every day thousands of visitors search for health insurance plans on MyInsuranceClub but most of them have no idea on how to pick one for themselves or their family.

How Motherhood Is No Longer The “Frightful Experience It Used To Be” In The Villages Of Odisha State?

Binita Kanhara, 32, a tribal woman from Rajikakhol village in Chakapada block of Kandhamal district in Odisha was very happy the day she learnt that she was expecting her first child. 

Nine months later, when the day came, her mother-in-law decided that the delivery would take place at home. Unfortunately, the newborn child did not survive as it was weak and anaemic and needed medical care. The incident left Binita traumatised for months on end.

The Doctor Only Knows Economics

This could be the UPA’s worst cut to its beloved aam admi. Healthcare has virtually been handed over to privateers. Govt seems to have abandoned healthcare to the private sector.

Diagnosing An Ailing Republic

• 70 per cent of India still lives in the villages, where only two per cent of qualified allopathic doctors are available
• Due to lack of access to medical care, rural India relies on homoeopathy, Ayurveda, nature cure, and village doctors
• While the world trend is to move towards public health systems, India is moving in the opposite direction: 80 per cent of healthcare is now in private sector
• India faces a shortage of 65 lakh allied health workers. This is apart from the nurse-doctor shortage.
• According to World Health Statistics,  2011, the density of doctors in India is 6 for a population of 10,000, while that of nurses and midwives is 13 per 10,000
• India has a doctor: population ratio of 0.5: 1000 in comparison to 0.3 in Thailand, 0.4 in Sri Lanka, 1.6 in China, 5.4 in the UK, and 5.5 in the United States of America
• Fifty-six per cent of all newborn deaths occur in five states: UP, Rajasthan, Orissa, MP and Andhra Pradesh
• Forty-nine per cent of pregnant women still do not have three ante-natal visits to a doctor during pregnancy
• An estimated 60,000 to 100,000 child deaths occur annually due to measles, a treatable disease
• Uttar Pradesh, the most populated state in the country, does not have a single speciality hospital for cancer
• The top three causes of death in India are malaria, tuberculosis and diarrhea, all treatable
• The WHO ranked India’s public healthcare system 112th on a roster of 190 countries
• Post-independence India’s most noteworthy achievement in the public health arena has been the eradication of polio and smallpox
• Affair of the states
• Best Public Health Kerala, Tamil Nadu,  Maharashtra, West Bengal
• Worst Public Health Rajasthan, Bihar, Uttar Pradesh, Madhya Pradesh, Orissa

India is taking firm steps to a certain health disaster. All of 80 per cent of healthcare is now privatised and caters to a minuscule, privileged section. The metros are better off: they have at least a few excellent public health facilities,  crowded though they might be. Tier II and III towns mostly have no public healthcare to speak of. As the government sector retreats, the private booms. In villages, if you are poor and sick, no one really cares, even if the government pretends to. 

You go to the untrained village “doctor”; you pray, you get better perhaps; all too often, you die of something curable. “India is the only country in the world that’s trying to have a health transition on the basis of a private healthcare that does not exist,” Amartya Sen said recently in Calcutta. “It doesn’t happen anywhere else in the world. We have an out-of-the-pocket system, occasionally supplemented by government hospitals, but the whole trend in the world is towards public health systems. Even the US has come partly under the so-called Obamacare.”

Sadly, even the few initiatives the Indian state takes are badly implemented. Hear the story of Suresh, 45, who lost his younger sister to cancer, eight months ago. He’s a guard at the guesthouse of a pharmaceutical company in Mumbai and could not afford her treatment, so he sold some ancestral farmland in Gujarat. That money covered but a few months of bills from a private hospital. He then turned to a government hospital, but it didn’t have cancer care. It didn’t help in any way for Suresh that he worked for a pharmaceutical company: his job didn’t come with medical benefits. “We brought her back home, hoping that if we saved on the hospital bills, we would be able to buy her medication. Finally, the money I had was too little to provide her basic help. Maybe if I had been able to buy her medicines, she would have been alive today.”

But the state could have ensured that Suresh’s sister lived had he been able to utilise the ambitious health insurance scheme announced in Maharashtra in 1997. The Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) is on paper supposed to provide for 972 surgeries, therapies or procedures, along with 121 follow-up packages in 30 specialised categories. It provides each family coverage of up to Rs 1.5 lakh in hospitalisation charges at empanelled hospitals. It even allows for treatment at private hospitals. But poor implementation has ensured Suresh and hundreds of families like his do not know of such a scheme. This is true of other schemes across the country too.

Meanwhile, health statistics are terrifying. More than 40,000 people die every year of mosquito-borne diseases, which are easily preventable; a maternity death takes place every 10 minutes; every year, 1.8 million children (below 5 years of age) die of preventable diseases. “We are the only country in the world with such a huge percentage of privatised healthcare. Recent estimates suggest that approximately 39 million people are being pushed into poverty because of high out-of-pocket expenses on healthcare. In 1993-94, the figure was 26 million people,” says Dr Shakhtivel Selvaraj, a health economist.

So the state’s pretence of reaching out to the poor is really quite a farce. Consider what’s been happening between the Planning Commission and health ministry. In November, the battle between then health minister Ghulam Nabi Azad and the Planning Commission came to light: Azad had pressed for increased spending on the public sector while the commission was intent on increasing private participation. This was a telling comment on the priorities of the UPA government. But with the 2014 elections in view, the government would like to present “health reforms” as a political tool. A framework for “universal health for all” is expected by April this year.

According to the draft of the 12th Plan, the government will increase spending on health from 1.2 per cent of the GDP to 1.9 per cent, with greater emphasis on public-private partnership. While the expert group asked for scaling up public funding from the current 1.2 per cent of GDP to roughly 2.5 per cent by the 12th Plan-end (2017-18) and to roughly 3 per cent by the 13th Plan-end (2023-24), the government only relented a bit—enough to give it room to announce more populous aam admi schemes. D. Raja of the CPI believes that “through PPP (public-private-partnership), floated in the 12th Plan, the government is working as facilitator for private sector”, something that goes against the constitutional mandate of a welfare state. 

Former health secretary Sujata Rao says the state “cannot co-opt the private sector to provide healthcare for which government is paying money without framing stringent rules and norms.” More than 70 per cent of expenditure on health in the past five years has come from households. In its nine years in power, the UPA has overseen the shrinking of the public sector and the boom in the private. 

All the while, it has paid lip service to aam admi causes—even as it pushes people from the margins into the wilderness. In those five years, the well-to-do have obtained better healthcare than ever before. Both the Congress and the BJP have said in their party manifestos that they want to make India a “health tourism” destination. That has already happened. Would the UPA, champion of the aam admi’s interests, pat itself on the back for that? 

Meanwhile, most private facilities ignore a Supreme Court directive to reserve a certain percentage of their beds and treatment for the poor because they were given land at concessional rates.

Barely 100 km from the national capital, the Kosi Kalan district of Uttar Pradesh, near Mathura, presents a pathetic picture of community health care. Four months ago, the primary health centre, which caters to more than 50,000 patients with two trained nurses and two doctors, was upgraded into a community health centre with a new building. However, doctors haven’t been posted at the new centre. Says Rajkumar, a doctor at the primary health centre, “We got the new building about four months ago. We are waiting for administrative sanctions”.

It’s a familiar tale of rural India. But what is also significant is that in the post-liberalisation era, the government health sector has virtually vanished from Tier II and III urban centres. Subedar Gupta, 32-year-old commercial vehicle driver from Gurgaon, has discovered that the government sector is an empty shell. It’s the private sector that has fleeced him. His wife Chanda Devi has been complaining of severe bodyache, itching and weakness for the last five years and no one knows why. Gupta spent about Rs 30,000 last month at private hospitals. He is now broke. “They ask us for same tests—blood test, X-rays and ecg. She is continuously on medicines. They are sucking all the money out of us.”

Millions of Indians living in small towns go through the same agony--not knowing where to turn to in the absence of a good health system. Because of that, thousands travel to Delhi’s overburdened AIIMS and Safdarjung Hospital, which are staffed with excellent doctors. The rest just pay for a private system designed to extract the maximum from each patient. “Public health is a big question in small cities. They have government hospitals, which are not well-equipped—in terms of infrastructure or adequate numbers of doctors and other staff.  There is also a shortage of woman doctors,” says Dr Rajesh Shukla, a consultant who has evaluated icds programmes in rural areas and studied medical care in small towns.

A large number of swanky hospitals and clinics have come up in urban India. But that does not ensure good care. There is also the issue of all this being loaded in favour of a profit-seeking system. Take the Rashtriya Swastha Bima Yojna, a government-supported health insurance scheme that rides on the private sector to provide medical care and surgical procedures at predetermined rates. Experts point to the dangers of induced demand and the prescription of unnecessary procedures to claim insurance benefits. Besides, the technology at private centres is often used to fleece patients rather than help them.

Dr Subhash Salunke, former director-general of health services, Goa, and currently director of the Public Health Federation of India, says the private sector is very scattered and unregulated, leading to lot of malpractices. This could have been checked to some extent had rules of the Clinical Establishment Act, 2010, been framed and implemented. Two years after the legislation was passed by Parliament, it hasn’t been implemented. The problem lies with the “stiff resistance from the private sector to the laying down of guidelines”.

The health sector is also crippled by a shortage of doctors and nurses (see graphic). So when the government says it is serious about training more doctors and nurses, by setting up six new AIIMSes, it makes for sound planning. But politics quickly shows up: one of the AIIMSes is planned in Sonia Gandhi’s constituency, Rae Bareli. Many doctors trained in excellent government medical colleges swiftly move to the private sector; they are even reluctant to take up rural jobs or postings. 

“Of the 1,400 doctors appointed after a proper selection process, only 900 joined the service,” disclosed a spokesman of the Uttar Pradesh health directorate. Because of the shortage of doctors in government hospitals, the National Rural Health Mission (NRHM) had started to recruit those trained in the Ayurvedic, Unani, Siddha and homoeopathic streams, but the process was stalled by a Rs 5,000 crore scam.

So the poor continue to suffer. In a general ward of Krishnanagar Hospital in Nandia District, West Bengal, members of a patient’s family say that not a single doctor checked their ward for 24 hours after he was admitted with a cerebral condition. The doctor assigned to the hospital, who was in his chambers some 10 km away, had this to say when tracked down by Outlook, “I’m the only doctor for close to 500 patients. Is it possible for me to visit each and every patient? You have to understand my constraints. There is very little monetary incentive for doctors working in the rural areas. These are punishment postings. No one wants to come here. They want to work with rich patients and earn big money.”

As he spoke, there were close to 100 patients waiting in the visiting room to see him. They were all from the villages and small towns in Nandia district. Krishnanagar Hospital is the main district hospital and patients from all over Nadia are referred to this hospital. In Uttar Pradesh, modern private health services have yet to reach beyond a dozen key cities. The rest of the state has to depend on these 12 cities, a handful of which have facilities for tertiary care. 

Some facilities are available only in Lucknow, where the government has concentrated all the healthcare while the rest of the sprawling state—75 districts—goes without even secondary care. According to the NRHM’s fourth common review mission report, of the 515 community health centres in Uttar Pradesh, 308 were below norms laid down in the Indian Public Health Standards.

Even in states that are economically better off, such as Andhra Pradesh, it is an abject tale. Right from Seetampeta in north Srikakulam district to Utnoor in Adilabad, the public healthcare system is in a shambles. Adivasis simply have no access to potable drinking water and succumb easily to totally preventable diseases. If it’s gastroenteritis in Adilabad, it’s malaria in Paderu Agency of Visakhapatnam district. 

Anti-larval spraying operations are late and haphazard. Community health workers are badly trained. Human rights teams which visit these areas say the medicines provided are sometimes past the expiry date. “Deaths due to malaria are sought to be passed off as due to other diseases like cancer, heart stroke, old age or TB,” says V.S. Krishna of the Human Rights Foundation. 

Once touted as a model state for implementation of health insurance, Andhra Pradesh today faces a problem where the scheme is being misused by the rich. A qualified doctor himself, the late YSR, former chief minister of Andhra Pradesh, launched the Rajiv Aarogyasri Scheme in 2006, providing medical cover of up to Rs 2 lakh for bpl families. Since corporate hospitals handle a bulk of the procedures, the scheme is misused. Says a cardiac surgeon at a leading Hyderabad hospital, “The rich come and seek heart procedures under Aarogyasri, casually whipping out white cards meant for bpl families. There are no checks.”

The ailments of the poor often have nothing to do with the agendas of rich and powerful pharma companies. Are there lessons India can learn from the world? Experts say that the US has one of the worst public healthcare systems in the developed world. But in most countries, in Latin America or Europe, universal healthcare been achieved through governments. 

In Asia, Sri Lanka and Thailand can teach India some lessons on the health front. So India may be a powerful nation simply by dint of its size and market. But it is also a ‘sick’ nation, where there’s no help for the poor when they fall sick. It’s a country where a poor man can die on the pavement outside a gleaming state-of-the-art hospital with the best medical technology in the world.

Why Indians Need Separate, Specific Medical Insurance For Mental Illness?

Insurance providers are reluctant to cover mental illnesses because of the duration and costs of treatment as well as stigma attached to mental disorders.

A doctor at Kashmir's psychiatry hospital in Srinagar, checks the hands of a Kashmiri youth during a counseling session.

Product Review: 'Health Companion' Plans By Max Bupa

SPONSORED: Let’s accept the fact that buying a health insurance policy isn’t on the priority list of many, and till 2013 I belonged to this cadre of visionaries. I woke up from this deep sleep quite recently when I was admitted in the ICU, and had to pay huge bills (almost 70 thousand for 7 days in ICU) before the discharge. This made me realise the importance of owning a health insurance policy, albeit in a much harsher way.

While finally picking up a health insurance policy I also realised that this task wasn’t easy, especially with a market full of options.

Can Telemedicine Alleviate India's Health Care Problems?

Chakrajmal village, in the Bijnor district in the North Indian state of Uttar Pradesh, got its first doctor in 2008. He was not based in the village, though. The villagers had access to the doctor via a telemedicine project launched by World Health Partners (WHP) to provide health care services to 1,000 villages in Uttar Pradesh's Bijnor, Meerut and Muzaffarnagar districts.

Set up in 2008, WHP, a U.S.-headquartered international nonprofit, provides basic health care and reproductive health services by harnessing local market forces to work for the poor. According to Gopi Gopalakrishnan, founder-president of WHP, the organization's model is to draw on private sector capacity through social franchising, innovations in labor management, and low-cost technologies to develop a scalable and sustainable health care service delivery model.

WHP's Uttar Pradesh telemedicine network now comprises around 1,200 local individuals called Sky Care Providers and 120 entrepreneur-run centers branded as Sky Health Centers. The Sky Care Providers are given training and low-cost mobile solutions by WHP to perform diagnostics, symptom based treatments, tele-consultations and, wherever needed, referrals to the Sky Health Centers.

These centers use remote diagnostic devices for measurement of basic parameters such as blood pressure, heart rate, electrical activity of the heart and pulse rate. The patients are connected to doctors at WHP's central medical facility in New Delhi via computers and webcams. The entrepreneurs have the option of leasing the equipment from WHP. For the patients, consultation charges vary from 20 U.S. cents for below poverty line households to US$1 (at the exchange rate of Rs. 50 to a U.S. dollar).

Patients who require surgery, inpatient care or specialized procedures that cannot be delivered via telemedicine are referred to the nearest WHP franchised health care clinic. Currently WHP has 16 such clinics in Uttar Pradesh. Since 2008, WHP has provided villagers in Uttar Pradesh with around 35,000 tele-consultations for common ailments such as fever, indigestion and gynecological problems.

Gopalakrishnan is now replicating this model in Bihar. Currently there are 104 telemedicine centers up and running in 13 districts of the state. He hopes to expand to 400 centers across 25 districts (covering a population of 70 million) by end of 2012 and 1,250 centers over the next three years. Apart from treating basic ailments, Gopalakrishnan now also wants to focus on detection and treatment of tuberculosis, visceral leishmaniasis, childhood pneumonia and diarrhea.

"There's a huge, unmet health care need in our rural hinterlands. The challenge is to make health care affordable for the masses and attractive to the providers at the same time," says Gopalakrishnan. "Telemedicine is a good strategy to strengthen the existing human resources available in health care. The scale, however, will come only through effective government intervention."

According to Rana Mehta, executive director and leader of health care practiceat PricewaterhouseCoopers (PwC), access to health care in India "gets limited by the affordability factor and hence telemedicine -- or the remote diagnosis, monitoring and treatment of patients via videoconferencing or the Internet -- has a very important role to play. It is at a fairly nascent stage right now having started only about a decade back, but it is undoubtedly a fast-emerging trend, led by growth in the country's information and communications technology sector."

K. Ganapathy, president of the Apollo Telemedicine Networking Foundation, past president of the Telemedicine Society of India and adjunct professor at the Indian Institute of Technology, Chennai, is categorical that telemedicine is the way ahead. "We can't go far with conventional brick-and-mortal hospitals,' he says.

Vijay Govindarajan, professor of international business at the Tuck School of Business at Dartmouth College, not only sees India as one of the early adopters of telemedicine, he also notes that the country has the potential to develop innovations that can be adopted in other parts of the world, including developed nations like the U.S. "In the United States, we are thinking of IT [information technology] as just electronic medical records," Govindarajan says. "This shortchanges IT's full potential. Driven by extreme need, India is inventing new ways to use information technology to improve health care."

Govindarajan lists the reasons why telemedicine will take off first in India: A severe shortage of doctors, especially in rural areas; very high patient volumes; widespread availability of mobile networks; rapid growth in the availability of low-power, hand-held medical monitoring devices, and the shift away from the proprietary, local area network-based medical image archiving and communications systems to a networked tele-enabled system. "Innovations in telemedicine will accelerate in India, where access and cost are critical issues. These telemedicine innovations will be adopted in the U.S., where cost and access are becoming increasingly talked about. This is a classic reverse innovation story," he adds.

Potential for Growth

A January 2012 report titled, "Global Telemedicine Market Analysis," by RNCOS Industry Research Solutions, an India-based market research and information analysis company, projects that the global telemedicine market will grow at a compound annual growth rate (CAGR) of around 19% from 2010 to 2015. An earlier report in 2009, titled "Global Telemedicine Market: 2008-2012" published by Infiniti Research, a London-based market intelligence firm, pegged the size of the global telemedicine market in 2008 at US$9 billion. According to this report, Asia is the fastest growing region for the telemedicine market with India and China leading the growth.

There are no clear numbers, though, on the current size of the telemedicine market in India. Murali Rao, associate vice president for health care at the New Delhi–based research and consultancy firm Technopak Advisors, estimates the current size of the Indian telemedicine market to be around US$7.5 million. "This is expected to grow at a [compound annual growth rate] of 20% over the next five years," he says. That would take it to around US$18.7 million by 2017. Mehta of PwC on the other hand notes: "Studies indicate that the size of India's telemedicine market is expected to be US$500 million by 2015." (This is a nascent area and estimates vary widely.)

Ganapathy of Apollo points out that 80% of India's population has no direct, physical access to specialist health care and gives some back-of-the-envelope calculations: "Estimates suggest that the telemedicine market is at least for 800 million Indians. Even if half of these 800 million need to consult a specialist once a year, [that still amounts to] 400 million specialist consultations per year. Even if 10% of these are enabled through telemedicine we are talking about 40 million consultations per year from rural India alone…. The market potential for telemedicine is obviously enormous."

While the numbers may vary, what is undisputed is the potential that telemedicine holds. A major driver of telemedicine in India is the dismal state of health care in the country. India's government spending on health as a proportion of the GDP – currently at around 1% of the GDP - is among the lowest in the world. Even in other Asian countries, it is higher. The corresponding amount is 1.8% in Sri Lanka, 2.3% in China and 3.3% in Thailand. Despite the launch of the National Rural Health Mission in 2005, India continues to grapple with a 33% shortage of rural hospitals, which are called Community Health Centers (CHCs). Even in the ones present, there is an acute shortage of staff. According to the Ministry of Health and Family Welfare, there is a shortage of 50-70% of physicians, specialists, lab technicians and radiographers at the CHCs. And around 10-15% of them lack even basic amenities such as water supply and electricity.

Experts have time and again suggested that if the vision of "Health for All" is to be achieved by 2020, India will have to pump in 6% of its GDP in the health care sector. At the same time, technology-enabled health care networks can play a huge role by bridging the distance between doctors and patients through Internet and other telecommunication technologies.

Ground Realities

Some of the major players in telemedicine in India at present include Narayana Hrudayalaya, Apollo Telemedicine Enterprises, Asia Heart Foundation, Escorts Heart Institute and Aravind Eye Care. Devi Prasad Shetty, a leading cardiac surgeon based in Bangalore and founder of Narayana Hrudayalaya Hospitals, predicts that it is only a matter of time before we see a huge spurt in the use of telemedicine. "In the early days, satellite was the only means of managing the telemedicine program and keeping satellite connectivity was not very easy," he notes."However, now with Skype and other ways of videoconferencing there are many options available. With the stabilizing of technology platforms, technical problems are extremely rare."

Shetty is at the helm of one of India's earliest and largest telemedicine programs. Launched around 10 years ago, the initiative is managed through satellite connectivity provided free of cost by the Indian Space Research Organization (ISRO). Presently, the Narayana Hrudayalaya telemedicine network is connected with about 100 telemedicine centers across India. Outside India, as part of the PAN African satellite network, it is connected to 55 cities in Africa. The connectivity also extends to some other places like Iraq, Malaysia and Mauritius. Since its launch, it has conducted around 53,000 tele-consultations in the areas of cardiology, neurology, urology and cancer. Narayana Hrudayalaya also has an electrocardiogram (ECG) network wherein general practitioners in remote locations are given a trans-telephonic ECG machine that helps transmit ECGs. Narayana Hrudayalaya gets about 200-300 ECGs daily. These are interpreted by its doctors and then communicated to the local doctors at the remote locations.

Shetty points out that telemedicine is not just about connecting remote locations. Six years ago, when Narayana Hrudayalaya started performing liver transplants on babies, its cardiac anesthetists did not have adequate experience for this procedure. So Shetty turned to telemedicine. Narayana Hrudayalaya's operating room in Bangalore was connected to the Children's Hospital of Philadelphia and the anesthetists there. "After hand-holding for about five to seven liver transplants, our anesthetists acquired the knowledge," says Shetty. He goes on to add: "In the coming years, most of the medical treatment will be through telemedicine either in the same city or in other countries. There will be enough gadgets available at home to check blood pressure, blood sugar, ECG, oxygen saturation, even ultrasound. Patients will consult the doctors through mobile phones or videoconference through cellphones."

Some of this is already happening. Recently, leading telecom player Airtel tied-up with Healthfore (a division of Religare Technologies) and Fortis Healthcare (a Religare group company) as the knowledge partner to offer Mediphone services to its customers. This service allows subscribers to access basic medical guidance on non-emergency health problems over the phone. The service is available around-the-clock at less than US$1 for each consultation.

Other telecom players like Aircel and Idea have launched similar services in collaboration with HealthNet Global, a Hyderabad-based emergency and health care management services firm. The subscribers who call to seek health advice are visited by paramedics who come with a laptop and medical diagnostic equipment and conduct consultations via video conferencing. This is also gaining traction among insurance companies. "We have already conducted 1,000 sessions since our launch in September 2011. We are currently present in Chennai, Mumbai, Delhi and Hyderabad. We plan to expand our services to all the metros," notes Rahul Thapan, global head of marketing & sales for HealthNet Global.

In December of last year, microfinance firm Equitas also launched tele-health care delivery centers in association with HealthNet Global. The project is funded by Fem Sustainable Social Solutions (FemS3), a nonprofit company operating in the social business space. Equitas' Consult 4 Health and Call 4 Health products, developed exclusively for the firm by the Centre for Insurance and Risk Management at the Chennai-based Institute for Financial Management and Research, allow its members to consult physicians from Apollo Hospital over video for a charge of US$1 a consultation. The patient's data is also stored for any further diagnosis and treatment in the future. 

"It is our endeavor to improve the quality of lives of our members and their families," says P.N. Vasudevan, managing director of Equitas. "Health care is a source of significant financial stress for this segment. The initiative with HealthNet Global using physicians from Apollo Hospital will bring a revolution by providing health care to the doorstep of our members and the best medical care anytime, anywhere. We will roll out our services from Chennai and gradually go pan-India." Currently, Equitas has three tele-health care centers operational in Chennai.

Other new models are also emerging. Take Mumbai-based MeraDoctor (My Doctor) founded in 2010 by Gautam Ivatury, who was earlier working in the area of mobile phone-based services, and Ajay Nair, a medical doctor with a master's degree in public health management from Harvard. A phone-based medical advice service, MeraDoctor works on a membership model. The company offers family membership plans for three months and six months; during this period, members are entitled to unlimited phone consultations with MeraDoctor's team of doctors. Members can also avail of discounts at select diagnostic centers that MeraDoctor has tied up with.

There are new products, too. Dartmouth's Govindarajan points to General Electric's innovative low-cost ECG machines, which were developed in India and can take digital images that can be emailed to cardiologists in the U.S. "[This gives] poor patients in remote rural areas access to world-class care," he says.

Another example is 3nethra from Bangalore-based Forus Health. Developed with the aim of enabling mass pre-screening outside the hospital environment, 3nethra is a portable, non-invasive device that helps in early detection of eye diseases like cataract, diabetic retina, glaucoma and cornea related issues. The digital information taken by 3nethra can be easily transmitted electronically. The device won the Samsung Innovation Quotient award in 2011. "At 3nethra, we wanted to work with the system and its limitations," notes K. Chandrasekhar, founder and CEO of Forus Health. "Even a minimally trained technician can operate it. The idea was to develop a solution that was cost effective. The device that we have developed is available for one-sixth the cost of present diagnostic devices. Also, it uses only 10 watts of power. It can run for four hours on a UPS, making it ideal for rural areas [which face enormous shortage of power]."

Challenges Remain

But even as the telemedicine scenario in India is seeing significant developments, challenges still remain. According to Narayana Hrudayalaya's Shetty: "The greatest challenge is getting enough medical specialists to see patients in remote locations and also to get the patients to trust the opinion by the doctors, virtually."

Healthnet Global's Thapan points out that India will soon have a billion phone connections and the network will not be a problem. "It's now about finding the right linkages," he says. Thapan notes that ASHA (Accredited Social Health Activists) workers, for instance, can be trained to aid the doctors. "It will help spread the network," he adds.

Apollo's Ganapathy suggests that the potential of telemedicine in India is still under-realized because of lack of awareness among the masses and lack of a business model that caters to all the stakeholders. "Telemedicine will never reach the critical mass for take-off until doctors are excited about it and unless people clamor for it as a cost-effective method. We need public-private-partnerships to drive telemedicine [in India]."

Mehta of PwC says the entire ecosystem needs to be strengthened. "Ten years ago, there was the technological barrier," he notes. "That has gone away. However, the economic barrier stays. The ecosystem, in terms of incentives for the hospitals, the broadband service providers and the patients, needs to be defined. That is the tipping point of the telemedicine market in India."