India has a vast public health system with 23,391 primary health centers (PHCs), 145,894 sub-centers, and 5335 community health centers (CHCs) providing healthcare services to ~70% of the population living in rural India. With the intent to deliver comprehensive primary health care services to the entire rural population, the government announced the Ayushman Bharat Program (ABP) in February 2018.
The ABP includes:
- Setting up~150,000 Health and Wellness Centers (HWCs)by upgrading the existing government primary healthcare facilities by December 2022.
- Pradhan Mantri Jan Arogya Yojana (PMJAY) for improving access to hospitalization services at secondary and tertiary level public/private health facilities for the bottom 40% of the population. This provides a floating health insurance cover of Rs 5 Lakhs per family for ~100 million economically disadvantaged families.
Currently, the primary healthcare system in India provides some basic services which include, outpatient care, family planning, pregnancy monitoring, childbirth, neonatal care, management of communicable diseases under the national health program, and referral to a higher-level hospital.
The HWC’s will extend these existing primary care services to include the screening and management of non-communicable diseases, mental health, ophthalmic and ENT problems, geriatric and palliative care, dental care, trauma, and emergency services.
For this ambitious and aggressive plan to be successful, several issues need to be addressed concerning accessibility, infrastructure, manpower, equipment, drugs, etc. at the primary care health centers.
Improve electricity supply, water supply, and other infrastructure
Around 3.2% of all rural PHCs and 24.7% of all rural sub-centers in India are still not electrified. Many of the centers that have electricity face intermittent power shutdowns, and voltage fluctuations. This can damage medical equipment, affect refrigeration infrastructure, and impact healthcare delivery. For the health centers to function efficiently, a reliable supply of electricity is required. Equipping the health centers with solar power to serve the energy needs of sub-centers (1.5-2 KW), PHCs (4-8 KW), and CHCs (9-10 KW) for 4-5 hours during peak loads during the day can help address the issue.
There is a lack of clean water supply at many of the health centers. This can be addressed partly by involving the local community to help tap existing water sources.
The government has created several dedicated COVID centers during the current pandemic. When the pandemic is behind us, the beds and other infrastructure from these COVID centers can be redeployed at PHCs where there is a shortage.
All health centers are required to have a computer and a telephone connection. However, only 75% of them have a computer, and 60% have a telephone connection. The health centers need to be equipped with a tablet, smartphone, and a reliable broadband connection (4G/5G),for voice and data communication.
Improve the quality of care by deploying Intelligent Telehealth solutions
There is a shortfall of specialists, doctors (6%), and health assistants (50%), at PHCs across the country. Several health centers (9%) do not have a doctor. Absenteeism is high. Many of the doctors do not have the required expertise to fulfill their role at the health centers.
The nurses and auxiliary nurses (ANMs) at PHCs usually come from the local communities and are more adept, committed, and responsive to the needs of the locals. Though they are generally more available compared to doctors, they are expected to perform a supportive role only, because of which their potential remains untapped.
HWCs will require additional doctors and ANM’s. This will increase the current shortfall of health workers. Increasing the number of health workers alone will not help address this issue.
Intelligent Telehealth based solutions can help provide quality care to rural India by leveraging the ANMs, ASHA workers and, the expertise of doctors remotely located at CHCs/district hospitals. This needs to be supported by an efficient ambulance service to transport patients to the nearest district hospital in case of an emergency.
- To enable this, the health centers, need to be equipped with video conferencing and connected medical devices (ECG, Pulse Oximeter, BP meter, Tablet, etc.).In hilly areas, the health centers are difficult to access. The ASHA worker equipped with a smartphone and connected monitoring devices can help extend care to these villages. Health workers need to be provided appropriate training in using telehealth applications.
- A secure regional cloud-based PHR/EHR will help store, share and track patient data being captured at the health centers and by the ASHA workers in the field. This data can be used by secondary and tertiary level hospitals, for treating patients referred to by the health centers.
- AI algorithms can analyze the PHR/EHR patient data in real-time to diagnose the health condition (pregnancy, cardiac health, diabetes, etc.)of the patient and notify ANM’s, ASHA workers, or doctors for appropriate action.
Improve access to care by leveraging Mobile Medical Units and Drones
The in-house laboratory testing facilities at PHCs are equipped to only perform basic tuberculosis and malaria tests. This is inadequate, and the results are sometimes delayed by several days. Nearly one-third do not have a lab technician. This results in patients choosing to travel to a private or a district hospital for even outpatient treatments.
Non-availability, wastage of medicines, and shortage of pharmacists (23%) are few other challenges faced by PHCs in India. There are several PHCs (1355) without an all-weather motorable approach road. Many of them do not have adequate public transport connectivity.
Deployment of additional and better equipped mobile medical units and drones can help address some of these issues.
- There are ~1700 mobile medical units across the country. This needs to be increased substantially. These mobile medical units need to be equipped with additional devices (Tablets, connected monitoring devices, etc.) to support telehealth, and devices to address the requirements of HWCs (ophthalmoscope, tools for a dental screening, etc.). The current mobile health units need to be augmented with an additional fleet of “larger mobile units” which carry imaging devices like x-ray, mammogram, and CT, supported with AI-based screening algorithms, for the effective management of chronic diseases.
- Drones capable of carrying payloads of around 10 Kgs positioned at strategic hubs can help alleviate several issues being faced by the public healthcare system. They provide an economical option for transporting essentials like medicines, vaccines, birth kits, surgical and medical equipment (lightweight), disposables, emergency supply of blood, etc. to the PHCs. This will help in reducing wastage of medicines and also in building an improved indent-supply system to ensure an adequate supply of essentials to the health centers. Drones can also be used to transport blood samples from the health centers to the labs located at district hospitals thereby reducing the turnaround time for tests.
The ongoing drone trials in the country can benefit from the learnings from the medical drone deployments in Rwanda. There is also an urgent need to review the current drone regulations in the country.
Steps need to be taken to bring in more accountability and in regaining the lost trust in the primary healthcare system.
Telehealth, artificial intelligence, connected devices, mobile health, solar power, and drones will have a pivotal role to play in this transformation journey of providing affordable quality care to people living in rural India. For this to be effective doctors, ANMs, and ASHA workers need to be trained in the use of these technologies. A holistic approach, leveraging technology is required to reinvent the primary healthcare system in India.
(Srinivas Prasad is Founder and CEO of Neusights and the views expressed in this article are his own)