March 2009

Role of telehealth in developing nations : Rajendra P Gupta, President & Director, Disease Management Association of India (DMAI)

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Economy and healthcare are two major thrust areas in every part of the world. If a country has a healthy population, it has a productive workforce that leads to a vibrant economy. Today, in a constantly changing multi-polar world, nations with younger population like China and India are driving the world markets with a high growth rate. As the economies grow, so do the healthcare concerns.

Out of the 195 countries according to the World Bank, 152 are developing countries. Ironically, developing countries have 84% of the world’s population, 93% of the burden of diseases and 11% of the global healthcare spending and it cannot get worse. If we see the geographical spread more than two billion people live in just South Africa and South East Asia. These are the countries with low income, high population growth, and low standard of living with no significant industrialisation. It is important to note that 80% of all deaths happening due to chronic diseases happen in developing countries. These countries have issues with regards to environmental sanitation, safe drinking water, undernourishment, and limited access to preventive and curative care. Approximately 80 % of the DALY’s (disability adjusted life years) are lost due to chronic diseases before the age of 60. Illness, ignorance, and poverty are a three-headed monster.  Adding to the already over-burdened, underfunded healthcare system is the rate at which these countries are growing old. These countries will become old before they become rich. It is estimated that by 2030, elderly population will grow to 22% of the population. There will be more people above the age of 60 than the children below 15 years.

The only way to address the current healthcare needs is to fuse basic healthcare with basic technology.

Developing countries have a poor doctor-patient ratio. For some countries in Africa, there is one doctor for every 50,000 people. South Africa has 1.3% of the health professionals but 25% of the global burden of diseases. No doubt that people in these countries spend a greater portion of their income on healthcare. Developing countries can be rightly classified as HPSA � Health Professional Shortage Areas.

Shift from infectious to chronic diseases

Over the last three decades there has been a shift from infectious diseases to chronic diseases. What is alarming is that countries like India are fast growing infamous by becoming the ‘Diabetic capital’and ‘CVD capital.’ Whereas, 60 % of all deaths in these countries are happening due to chronic diseases.  It is estimated that there are already one billion people who are overweight and this number is likely to cross 1.5 billion by 2015. The number of older people will grow from 249 million to 690 million from 2000-2030.

According to World Bank it is estimated that total deaths due to chronic diseases worldwide are 58 million. In 1990, the communicable diseases accounted for 49% of the illnesses and by 2020 non-communicable diseases will account for 43% of the illnesses.  Chronic diseases are now occurring at a much younger age than it was 20 years ago. World Bank estimates that approximately 60 million lives can be saved in low and middle-income countries if we are able to reduce deaths due to chronic diseases. In 2005, the chronic diseases accounted for 75% of all the deaths in low and middle-income countries.

The developing countries face the challenge of ageing population, shifts from infectious to chronic diseases and social changes, limited resources, lack of administrative capacity, high cost of reaching people and expensive delivery of care, huge population and geographical barriers, and limitations of the government in enhancing the GDP spend on healthcare.

The only way to address the current healthcare needs is to fuse basic healthcare with basic technology. Interestingly,  cellphone usage is growing and  Asia and Africa account for more than 42% of the worldwide Internet users.

Eighty per cent of the world population lives within cellular network range. If we see the growth of cellphones, 68% of the world’s new subscriptions in 2006 were in developing countries. Since the population of these countries is relatively younger, the adoption rates for the new technology is high. Cellphone usage in Africa itself is growing at 65%.

In all the current limitations of limited healthcare professionals, huge geographical barriers, rising healthcare costs, increasing burden of chronic diseases, and the availability of the modern technology presents a unique opportunity.  Technology is getting cheaper day by day. With organisations like Indian Space Research Organisation (ISRO) proving VSAT connectivity to almost all parts of the developing world on a very low set up cost, it is now possible to roll out not just primary care in remote places but also the advanced medical care in the remotest regions of the world.  While it might not be possible to set up a full-fledged healthcare facility everywhere as the cost is not just high, but maintenance is difficult. However, setting up the telemedicine network is possible with minimal infrastructure. The best part of telemedicine is that we do not always require trained doctors at the point of care. The remote monitoring can be done via a trained technician who would be literate. There are ‘Fool proof’ and ‘Idiot proof’ medical devices available that do not require much handling expertise. The results can be transmitted to a doctor at the center, and the investigation, diagnosis, and treatment can follow.

It is proven in different studies that if people don’t have a telephone access, 11% of the time people don’t go anywhere.

Telehealth can be via different mediums i.e. web-based or VSAT-based, Telephone/IVR-based, self-monitoring, and live consult. Today, telehealth includes eReminder, ePrescription, eConsultation, and eCounselling.

Telehealth is established in all branches of medicine i.e.  telemonitoring, telediagnostic, telecardiology, telepathology, teleradiology, teleneurology, telereferral, teleonchology, telesurgery, teleopthalmology, teleprenatal screening, teledermatalogy, etc.

Benefits of Telehealth

  • Outpatient visits are about seven times more expensive than electronic consultation
  • Rural population doesn’t need to travel to difficult terrains
  • Telemonitoring can avoid white coat hypertension
  • CVD is the cause of death for 65 % of diabetic patients. If telehealth is introduced the death rate can reduce to 58.5%. With telehealth 10% of the pre-diabetic patients will not develop diabetes.
  • Telemonitoring can reduce emergency room visits
  • Telemonitoring can get timely interventions thus saving lives
  • Telehealth can deliver direct to patient service � educational, preventive, and administrative
  • Telehealth has been known for fewer human interventions, thus reducing the chances of human errors
  • Fewer missed appointments
  • Increased compliance and adherence to treatments
  • Improved coordination
  • Universal access to EMR and specialist advice
  • Telehealth empowers the chronic patients for self & managed care. Allows home-based health
  • Telephone/eConsult lasts approximately 10 minutes compared to 3-6 minutes for consultation with a doctor
  • Privacy is protected
  • Patient-centric care
  • Equivalent outcomes at lower costs.

Different controlled studies have shown that telehealth in chronic patients leads to 40% reduction in emergency room visits, 63% reduction in re-hospitalisations, 22% reductions in total bed days, and cost of care is 27% less in telemonitoring groups.

It is stated in a few reports that disease management saves USD 4.8 for every dollar spent and telehealth saves USD 5.6 for every dollar spent.

Help to the medical fraternity

It is a fact that for each patient that exists in the developing world, there are nine who are still undiagnosed. Telemonitoring can bring such patients to the doctor for treatment.

Further, many a time due to frivolous problems patients rush to the doctor and end up wasting their time and money. This can be judiciously used if a pre-screening could be done using telemedicine.

A lot of old doctors especially female doctors with children prefer to continue practising from home or at their convenience. Telehealth is one option that lets them practice at their convenience.

Telemonitoring can do a 12 lead ECG, ultrasound- X-ray, sugar check, cholesterol check, blood pressure, lung function test- Spirometry, Pulse oxymetry, etc.

Indian healthcare – need gap

India has a healthcare system where the number of doctors are 0.60 per 1000 population, beds at 0.70 per 1000 population, nurses 0.80 per 1000 population, dentist 0.06 per 1000 population, and pharmacist at 0.56 per 1000 population. If we check on some of the specialities like psychiatry and take the rural and urban divide into account, doctor to population ratio is 1:1 million. We have just about 7,00,000 doctors and we churn out about 22,000 doctors per year. Current healthcare system is accessible to just 30-35 % of the population.

There was a shortage of 4,833 Primary healthcare centers (PHCs) across India and over 800 rural hospitals were functioning without a single doctor.  “A total of 807 PHCs are working without a single doctor,” said Health Minister Anbumani Ramadoss in a written reply to the Lok Sabha.

“There are a total of 22,370 primary health centres functioning across the country, and the shortfall is of 4,833 PHCs. And, there are only 15,546 female health assistants against a requirement of 22,370,” he said.

PHCs function as the first contact point between villagers and medical officers. They render curative, preventive, promotive, and family welfare services to rural Indians.

Giving details about the status of community health centres, the minister said there was a shortage of 2,525 CHCs across the country and of the total 4045 CHCs 26 were running in rented buildings, 306 in panchayat buildings.

He said 449 buildings were under construction and 199 buildings needed to be constructed, and there were only 5,117 specialised doctors working in these CHCs but the requirement was of 16,180. Against a demand for 4,045 radiographers only 1,740 were working in such centres.

In both PHCs and CHCs there is a requirement of 50,685 nurses and midwives but only 29,776 are in position.

CHCs are established and maintained by the state governments. A CHC has at least 30 indoor beds and provides facilities for emergency obstraetrics care and specialist consultations.

Adding to this deficiency,  absenteeism in PHC is around 40%. There is an average of one urban primary health facility for about 150000 urban population with only 2-4 health workers.

India according to WHO is short by 2.4 million physicians, nurses, and mid wives. A recent planning commission document said  that India was short of six lac doctors, 10 lac nurses and two lac dental surgeons.

Major private groups are shying away from foraying into healthcare in a big way due to high real estate costs, lack of trained manpower and high gestation periods. A few years ago  two of the biggest business houses announced investments into healthcare aiming to capture 20% of the healthcare, but gave up quickly seeing the cash burnout without quick financial returns. Most of the privately run healthcare entities are run for charity. Adding to the woes is low penetration of health insurance that is 1.08% of the total population .

Knowing well that currently two thirds of the Indian population is under 35 years of age, India will become older before it becomes rich. The healthcare issue is like a ticking time bomb.

The way forward for Telehealth

Despite countries like the US that spend over USD 7000 per capita the healthcare issues remain unaddressed. So there is a lesson to be learnt that  just spending more on healthcare does not solve the problem. We don’t need just healthcare delivery, but pro-activeness and innovation in healthcare delivery to address the issue. We will have to reduce healthcare cost, avoid chronic disease burden  and increase positive outcomes.

Telehealth should be used as the de facto POC (point of care) tool for preventive care and follow up care in chronic disease management.

The channels of delivery must not just be confined to doctors and hospitals but must also reach pharmacies and other channels nearer to the POC.

Seeing the situation in developing countries telehealth is the only economically viable way to address the elderly population, rural areas, preventive care, chronic diseases, and increasing healthcare costs within current limitations.

(The writer is  on the board of several companies across retail, hospital chains, disease management , pharma R&D, diagnostics, biotechnology, genomics  amongst others.)

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