Editor’s note: “Healthcare providers in developing markets need to scale up adoption of IT applications to have a robust, accessible and affordable healthcare system available for all,” says Dr. Lalit Singh, Elsevier’s Director of Clinical Solutions and Product Strategy. Here, he writes about the problems of development, access and cost, and the need to regulate, develop and deploy digital health across the continuum of care.
I recently attended the 7th Healthcare Leaders Forum in New Delhi, where Elsevier was recognized with a leadership award for its outstanding contribution in the field of advancing science, technology and health. The event brought healthcare providers and policymakers together – including key decision makers from both public and private sectors – to discuss healthcare reforms in India and the role digital technology plays in solving complex issues.
It got me thinking: while the needed interventions would be specific to India and would possibly vary for different regions within the country, the foundational realities which would drive these reforms in India are similar to those in other developing countries throughout the world, namely accessibility, affordability and availability of healthcare.
While there are many factors impacting how each country deals with these fundamental issues and their digital health strategies, in my view, there is a crucial need to develop, deploy and regulate digital health across the continuum of care. Healthcare providers need to scale up on IT applications to have a robust, accessible and affordable healthcare system available for all.
1. Accessibility of healthcare
Access to healthcare is a complex issue with unique problems for each country, and these problems need to be addressed in their entirety.
In the context of India, the first major issue is an inadequate and poorly maintained physical infrastructure and insufficient allocation of funds for properly running the existing healthcare infrastructure in the public sector. The second major issue affecting access to healthcare is an over-reliance on the private sector to provide healthcare. Private sector healthcare is profit-driven and has thrived largely in large cities and only in tertiary care segments.
These two factors combined have left a big gap in the area of primary and preventive care, especially in non-urban and remote areas. Technology has a big role to play to improve accessibility of care. For example, telemedicine, if deployed systematically and holistically, is an excellent way to take healthcare to virtually anywhere, rather than patients having to visit a clinic or hospital.
Telemedicine, in different forms, has existed in India for over a decade now. It has been reasonably successful in private institutions as an outreach medium, but not so successful at a population level. The reasons telemedicine has not achieved the desired results include disjointed implementations in the public sector, poor mapping of the clinical workflows in telemedicine systems, and lack of training and empowerment of the care providers. Policy makers need to look at telemedicine in a fresh perspective by:
- Identifying the real opportunities where remotely delivered care would make an impact
- Educating, enabling and empowering the healthcare workers with the right kind of resources
- Connecting the ad hoc telemedicine implementations with the rest of the public health delivery system for continuum of care
- Driving the required regulatory changes to give telemedicine its due space and recognition
- Building a workforce of clinicians and technologists to reinforce the culture of telemedicine
One of the most important elements is to ensure that the care delivery system is clinically relevant and aligned to the standard clinical workflows. This should further be augmented with the right kind of clinical decision support (CDS) tools to enable care providers deliver high quality, evidence-based and standardized care.
2. Affordability of healthcare
According to India’s National Health Policy, 2017, more than 63 million people are pushed to poverty every year due to healthcare costs. It is important to understand that the cost of healthcare in a system dominated by for-profit organizations is not just the price one pays for the services delivered inside the healthcare setup and buying medicines. There are many associated costs such as travel, hiring a full-time caregiver, and follow up visits, which eventually add up to a large sum of money. To top that off, lack of longitudinal health records often necessitates duplication of diagnostics, thus creating a huge burden on the healthcare systems and further increasing the cost of care for patients, often driving not so fortunate families below the poverty line.
While India spends a relatively small percentage of its GDP on health compared to other developing nations, we need to also think about where the country should spend the money allocated to healthcare in order to derive the greatest return on investment. Fortunately, the basic economics of healthcare is opposite that of other industries because, unlike with other things we spend our money on, it is actually possible to reduce the cost of care by improving its quality.
For example in a fee-for-service world, if a patient undergoes an operation and the surgeon does a poor job, and the patient has to undergo two more operations and spend two weeks the ICU followed by four weeks in a normal ward for four weeks, that costs a lot of money. However, if the operation is done well and the patient is discharged in a week, it costs a lot less money.
Investing in digital technology that gives healthcare professionals access to current, credible, evidence-based information not only elevates healthcare but helps reduce variability, which in turn will reduce the cost of healthcare while improving patient outcomes. As such, an early major investment should be in a combination of push and pull CDS solutions, which deliver current, credible evidence-based information to doctors, nurses, other traditional providers and patients.
3. Availability of healthcare
It is unrealistic for developing countries such as India to rely solely on their limited number of trained physicians to drive impactful healthcare reform. The shortage of healthcare manpower and resources has two dimensions – quantity as well as quality. In my opinion, the greatest impact to improving the quality of healthcare can be made by empowering two critical non-physician provider groups: nurses and patients.
For example, the quality of education and clinical training for nurses in the Indian education system varies widely. Also, nursing is not a very highly sought career option in a hierarchical healthcare set-up like India’s because the role of nurses in delivering care is often not fully acknowledged and appreciated by healthcare professionals and the public at large. However, it’s a given that care will eventually always be delivered by the nursing staff, especially in a peripheral setting where nurses are typically the first point of contact for patients. They therefore play a very crucial role in driving the impact of any population health measures.
With proper practice training and empowerment and appropriate incentive schemes, nurses can play a crucial role in providing safe, high-quality, cost-efficient basic care to patients in peripheral areas. This redistribution of clinical workload to nurses would also help the physicians by allowing them to focus more on patients who actually need their interventions.
Digital learning and training tools have a definite role to play in India’s ambitious “digital heath” program, as these will allow the country to not just train more nurses in nursing colleges, but also allow nurses in the workforce to upskill themselves to take up greater responsibilities in managing care at the community level. Similarly, the nurse-specific CDS solutions, when implemented in an integrated fashion, would allow enable nurses in hospitals to deliver superior care.
To truly reform, India, like all other developing countries, must commit to an even more challenging “people investment”: empowering patients themselves with knowledge and credible scientific information about health and diseases. Until patients truly own and take responsibility for their health, any healthcare reform cannot realize its full potential. It is therefore critical to immediately start the long process of radically altering the entire population’s view (including that of physicians and governmental health authorities) as to who truly owns health and healthcare – which in my view is undoubtedly the patients themselves.
Such a monumental change in perspective requires investments in public education and easy-to –use, people-friendly CDS solutions, possibly in local languages, geared to engage and educate patients and their families about preventative and maintenance healthcare.
In conclusion, while the challenges posed by radical healthcare reform in a vast and diverse country like India are great, the reality is that the danger of waiting to initiate and invest in digital interventions in healthcare is far greater. Technology has emerged as a real driving force in transforming India, and interventions using technology have transformed several industries, including banking, public distribution systems, transportation and taxation. It’s time we use technology as a force to drive major improvements in healthcare for achieving the 3 As: accessibility, affordability and availability.