Tag Archives: India HealthCare

Considerations for #healthtech Startup

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We see that on an average, there are at least 10 new startup’s every month across the country trying to address Health Care IT Problems. Are we really solving or are we complicating things?

According to IMS Institute for Health Care Informatics and Health Care IT News, there are more than 165,000 Health-related apps available and a mere 36 of them have 50% or more downloads. Just 10% can connect to a device or sensor and 2% can sync into providers systems (US App’s).

In the Indian Health Care app scenario; there are around 100 Apps and Websites which are addressing the Health Care segment (My personal research) and quite a few are coming up. Out of these 100, around 40% are catering to search (Doctor, Hospital, Diagnostic Center etc.), 22% are in the Wellness segment, 10% in e-Commerce (Medicine delivery), and the others are distributed in Nutrition, EMR/EHR, Medical Devices, Personal Health Management, Chronic Disease Management, Doctors Networking, Analytics etc.

If you look at the big picture and identify sectors in Healthcare which startup’s are trying to solve, majority of the solutions are coming out in Doctor Search, Booking online appointments, Home Tests and Medicine Home Delivery etc. One concern I personally see is that these solutions are being focused on particular region and this poses challenges for scalability. In India, where we have diversified Health Care models it is very important to understand the scalability, adaptability and acceptability for the solutions which we design.

The other vulnerable area specifically in Medicine delivery is that the control, distinction and distribution of duplicate / fake medications.

There are certain key contributing factors for Startup’s and large organisations alike to bare in mind while defining the problem and designing the solutions.

The Big Picture – It is very important for aspiring entrepreneurs who are attempting to solve Healthcare problems to understand the big picture as to how the system is structured and how can we take this solution to the maximum consumers. Also, one should understand if the solution which is being designed will scale up to address the problem at the Nation’s level and will it contribute to uplift Healthcare delivery. Why is this important? Because scattered solutions do not help.

Workflow oriented – When we design Technology solutions for addressing Health Care IT, the most important aspect we should understand is to create solutions based on the Health Care delivery workflows. Even though you design the best solution, if it is not following the delivery workflow, you are loosing consumers.

Scalability – The next important consideration. Why? Health Care IT is not a problem for a specific city / district / state. It is the Nation’s need. Diversifying solutions for each geographical location is not a viable solution. If not today, at a later stage we will need to codify and bring solutions to a common platform.

Adaptability – How are consumers adapting to the solution? India is a culture rich economy where we trust more from family, friends and acquaintances while attempting to utilise HealthCare services. How are we as Entrepreneurs attempting to address this scenario in the tools we build? Today, everyone is using technology to get suggestions and help for their requirements, but do not completely go with the solution they find, but definitely ask others around if it is a viable approach. We need to understand the adaptability of the solutions we design and this comes with additional research on what key areas are people likely to gain deeper understanding before attempting to utilise the services.

Contextual – (Will this solution help better the situation) – This goes next to understanding the big picture. The solution we design should be contextual and if required work in tandem with existing solutions to address the scalability and adaptability.

Data Security – Very important aspect of building Health apps. We need to builds systems/applications following he Data security rules because Health data is very vulnerable and it is the responsibility of the Entrepreneur to ensure security.

To quantify, Entrepreneurs wanting to address HealthCare IT, should begin with the end in mind, understand the System and help develop workflow solutions which contribute to the Macro level.

Which HealthCare System should India follow? 

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India is a very interesting, unique economy in this world and there are many reasons for that. We are the country with the highest “working population”, we are a country with various traditional medical practices (which prove to work), we are a country with considerable number of people Below Poverty Line, we are a country, where in the last two decades have seen changes in our lives, livelihood, migrations and better quality of life.
With this, even the HealthCare landscape in India is changing. The model we follow is the “Out of Pocket Model”. Even though the Government has a very good spread for reaching each person in the Country, due to various factors, this does not work as expected. Private players are increasing and Technology is playing a bigger role in bridging the HealthCare needs to the common man.
Let us quickly examine the 4 HealthCare models on this Planet:
The Beveridge Model
This model is named after William Beveridge, the man who designed and developed the Britain’s NHS (National Health Services).
In this model, the complete Health Services are funded by the Government from the tax’s collected from public. The best example of complete Beveridge Model adoption is Cuba.
The Bismarck Model
This model is named after Prussian Chancellor Otto von Bismarck. This is an Insurance Model where employers and employees pay for Health Insurance through their payrolls. The Government holds a very strong control on the payout’s and hence the HealthCare costs are controlled. This is a pure “not-for-profit” model and this is the reason even though there are private Health Services, the costs do not go up.
This model is followed in Germany (where there are more than 200 funds which contribute to HealthCare services) and other European countries including Japan and Latin America.
The National Health Insurance Model
This is a combination of Beveridge and Bismarck models. This model uses private providers but funding comes from the Government’s Insurance Programs to which people contribute to. Since payments are controlled by Government, there are no denials/exploitations in the costs and services.
Best example for NHI Model is Canada.
 
The Out of Pocket Model
About 25% of countries in this world have an established HealthCare Systems are the remaining are Out of Pocket Models.
This is a straight forward model where you pay for the services utilised (Minimal/free in Government Hospitals and completely paid for in Private Hospitals).
Is it time we follow a model / combination of models / Create a Model for ourselves? 

Indian HealthCare Education – How is it distributed?

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India ranks 112 in the World Health Organisation (WHO) Ranking of The World’s Health Systems. When it comes to per-capita spending on Health Care, India spends a little over 6% of GDP on HealthCare.

These are the common statistics which we see every day. What I wish to share are the other aspects of Indian HealthCare system which provide a strong support.

Imagine this, India is the World’s Second Largest Populated country and it is projected that we will overtake China by 2050 and the reality of data according to WHO is that India has about 0.49 Doctors and 0.80 Beds for every 1,000 Population in the country. When you hear/see these numbers, it does sound alarming! How are we going to put up with the Population Growth, provide basic HealthCare and create an Ecosystem for building robust Health Services across the country?

If the situation is bad when compared to other developed economies, then how is our Average Life Expectancy has been steadily increasing over the years? In 1947, when India got Independent, Life Expectancy was 47 Years and today, after 65 Years of Independence, we are at 65 Years. By 2025, it is projected that Life Expectancy would be 72 Years.

All the Health data which we see is primarily considering the English Medicine System or Allopathy. India and also other countries offer alternatives to the English Medicine. What we will look into here is how the HealthCare is structured and Health Education along with fundamental understanding on how Government spends its 6% on HealthCare along with what reaches the population living Below the Poverty Line (BPL).

HealthCare Systems in India

India has the most number of HealthCare systems when compared to any country in the world. Below are the five most known systems.

  • Allopathy (English Medicine)
  • Homeopathy
  • Ayurveda (Traditional Indian)
  • Unani
  • Naturopathy & Herbal Medicine

Formal Education for Doctors

India offers education in Allopathy, Homeopathy, Ayurveda, Unani and Naturopathy & Herbal Medicine. All education is recognised and Doctors who pass out of colleges are given license to practice any where in the country.

The below graph shows the admission trend to Graduate Allopathic Medicine Course over the last 20 Years. If we carefully observe, there has been a decline in admissions in the last two years when compared to earlier. Interesting.

MBBS Admissions

 

The Dental Education has quite picked up in the mean time. However, it is a poor state where the enrolments to Post Graduate Programs has been less than 10% of the actual Graduates. There are certain strong reasons as to why this happens and we will look at it later.

BDS/MDS Admissions 1991 – 2011

 

Now, let us have a look at how the Medical Education System is structured in India.

Medical College Distributions

 

Allopathy accounts to only 39%, which is around 314 Medical Colleges. in the remaining 71%, Ayurveda has 31% (249 Colleges), Homeopathy has 23% (186 Colleges) and Unani has 39 Colleges, Siddha has 8 Colleges and Naturopathy has 10 Colleges.

 

 

Issues with HealthCare IT in India

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Over the last few years, have been fortunate enough to be working with the HealthCare sector in India.

In the due course of time, I have been interacting with IT Departments of various Hospitals (Very Large and Large and to some extent at the Primary Health level too). What I have been trying to understand is the key reasons as to why the IT penetration has been at a distant in the Indian Hospitals. There are quite a few valid reasons and I also encountered one other not-too valid reason, but will have to give it a benefit of doubt.

Time factor – One of the key factor why Hospitals see resistance from Doctors to use IT systems is because of the number of clients (patients) they need to see. On an average, a Doctor in any Hospital in India see’s an average of one client every two minutes (the raw data might be even more). In these two minutes, the Doctor has to understand his client problem, establish a connection (Important in the Indian Context), provide guidelines for the analysis and prescribe. The complete process takes definitely more than two minutes, and if the Doctor tries to spend time on the computer taking notes, his/her client might not appreciate it and not return back to them. People in Cities understand the importance of technology, however, in India, as 80% of the population still lives outside Cities, it might not be practical for the Doctor/Hospital to make them understand the same.

Cost – The second most important reason which needs serious consideration. 70% of HealthCare costs are “out of pocket”. Hence, when Hospitals/Doctor’s Clinic implement the use of technology, client tends to understand that cost of treatment is “higher” and hence avoid’s those kind of Hospitals/Doctors.

There is no support for Hospitals/Doctor’s to use Technology from the Government. Hence, the cost has to be shared by the client, which directly impacts their revenue.

Technology Education – There are no initiatives by the Government to spread awareness of the benefits of using Technology to end users. Even though there might not be immediate acceptance for this, on the long run, people would definitely see the benefit.

As an illustration, Government of India spend considerable time and money on the “Eradicate Polio” initiative and this has been a success. Even though initially the message was not taken seriously, now when a child is born even in the remotest place of the Country, parents immediately inquire of the Polio Drops schedule and ensure that their child gets them. The results speak for themselves – Today, India is “Polio Free”.

Variety of HealthCare Practices – India is a very large country and has variety of HealthCare Practices – Homeopathy, Allopathy, Unani etc. People change their practice depending on the kind of ailment. I have also seen and known people who follow a certain practice sticking to the treatment in serious conditions too, but very rare.

This does not have a direct impact on the HealthCare System/Process, however, this plays a vital role when people shift their accustomed practice.

More detailed information on various practices and Infrastructure in my earlier post.

Acceptance by all Stakeholders – Even though every Individual accepts that IT is an integral part of delivering Quality HealthCare, acceptance by all stakeholders also plays a very vital role in rolling out technology solutions.

As an Illustration, Government employees need to submit manual receipts and documentation for their medical reimbursement. Also, many Insurance providers do not completely follow the approval and reimbursement process online.

In summary, a Hospital/Doctor’s office is not encouraged in all aspects to implement Technology. There are many a times when they need manual documentation. To avoid multiple process flows, Hospitals keep their Technology inquisitiveness away.

However, things are changing. With a recent success story of how the Andhra Pradesh Government implemented Aarogyasri, many states have been trying to follow the same.

There are quite a few other concerns and problems for Hospitals to implement IT, however, if we have a humble beginning, success will definitely follow.

HealthCare Infrastructure in India

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There have been many articles, research papers and writeup on this topic available on the web. As part of a research project, I managed to gather some data points for understanding the State of HealthCare in India. Thorough this post, would like to share my findings and provide some references for a better understanding on this subject.Economically, India has been consistently growing at over 8% GDP every year for the last 3 years and if the Economists prediction goes right, we will continue to grow the same way for the next few years.

HealthCare is one of the key parameters in which a country’s Development and stature are measured. To begin this discussion, let us first understand the structure of HealthCare in the Indian Context.

Primary Health Care is essential health care; based on practical, scientifically sound, and socially acceptable method and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and self-determination (WHO & UNICEF, 1978).
The World Health Organization (WHO) has identified five key elements to achieving this objective:
  • Reducing exclusion and social disparities in health (universal coverage reforms)
  • Organizing health services around people’s needs and expectations (service delivery reforms)
  • Integrating health into all sectors (public policy reforms)
  • Pursuing collaborative models of policy dialogue (leadership reforms); and
  • Increasing stakeholder participation.

Primary HealthCare in India

In 1947, the year of India’s independence, average life expectancy was 29 years and today, in just 63 years, it has reached 65 years. According to estimates, it will reach 74 Years by 2025. There are many reasons for this impressive progress in life expectancy in India and one of the key reasons is the maturity of the Primary Health Care facilities and services in India.

PHC was conceptualized in 1946, three decades before the Alma Ata declaration, with the recommendations of the Bhore committee, that laid emphasis on social orientation of medical practice and high level of public participation. The government followed it up with setting the Community Development Plan in the 1st 5 year plan (1951-55) and Health Survey and Planning Committee in the 2nd 5 year plan.

Primary HealthCare as a key initiative has been an Objective only in the 9th 5 Year Plan (1997-2002).

  • Department of Women and Child Welfare (DoWCW) is responsible for the overall implementation of HealthCare schemes in India.
  • The Central Government is responsible for providing funds for HealthCare infrastructure across the country.
  • The State Government is responsible for allocation of funds to respective regions and building up the personnel and HealthCare facilities across the state.
  • At times of emergency, the Central Government is responsible for collecting and distributing Medicine’s and required support to the state/region.
  • The Government provides a three-tier (Primary, Tertiary and Secondary) support structure for addressing the HealthCare needs across the country.
Structure of Indian Public HealthCare System
The Indian HealthCare system is a three-tire structure which focus’s on delivering care at the individual level. This structure is designed according to the population norms.

Population

Urban

Hilly/Tribal/Rural
Sub Center

5000

3000
Primary Health Center

30,000

20,000
Community Health Center

1,20,000

80,000
Sub Center
The Sub Center is the closest to the common man and becomes the first point of contact in the three tire system.
  • Each Sub Center is managed by an Auxiliary Nurse Midwife (ANM) and one Male Health Worker.
  • One Female Health Assistant and One Male Health Assistant manage 6 Sub Centers.
As of 2008,
  • There are 1,58,792 Sub Centers.
  • 53,390 ANM’s
  • 1,46,036 Male Health Workers
  • 23,458 Female Health Workers
  • 23,458 Male Health Workers.
Primary HealthCare Center (PHC)

Primary HealthCare Center’s form the second tire in the system (Secondary Care) and each PHC is a hub for 6 Sub-Center’s. A PHC typically has a 4-6 beds for addressing immediate and basic Health Care necessities.

Community Health Center (CHC)

CHC forms the third tier in the system.

  • A CHC has 1 Surgeon, 1 Physician, 1 Gynecologist and 1 Pediatrician along with 21 Paramedical Staff.
  • CHC is a 30 bed facility.
  • 1 CHC for 4 PHC’s.

Now, let us look at the core data of HealthCare Infrastructure in India.

Personnel Availability

Required In Position Shortfall
CHC 6491 4276 2337
PHC 26022 23458 4477
Sub-Center 158792 146036 20486
Doctors at PHC 23458 24380 3537
Multipurpose Worker (Female) at PHC & SC 169494 153537 21066
Nurse MidWife 53390 44940 18017
Only ANM 19385 21313 1841
Health Assistant (Female) 23458 17599 6481
Health Assistant (Male) 23458 17972 8827
Health Worker (Male) 146036 60247 79322
Laboratory Technician 27734 12885 14135
Obstetricians and Gynecologists (PHC) 4042 1029 2576
Obstetricians and Gynecologists (Other Location) 219 143 115
Peadiatrician (PHC) 4042 791 2814
Peadiatrician (Other Location) 219 73 146
Pharmacists 27734 20964 7017
Physicians (PHC) 4042 1043 2562
Physicians (Other Location) 219 81 138
Radiographers 4276 1695 2280
Surgeons 234 81 142
All Specialists at PHCs 17104 4279 11033
Total 739849 556822 209349

Infrastructure – (District Hospitals, Ayurvedic Dispensaries & Hospitals, Family Welfare Center and Referral Hospitals)

State District Hospitals Ayurvedic Dispensaries Ayuevedic Hospitals City Family Welface Center Referral Hospitals
Andhra Pradesh 16 557 9 0
Assam 22 380 1 0
Arunachal Pradesh 14 2 1 0
Bihar 25 311 11 12 70
Chhattisgarh 16 634 8 0
Goa 2 77 1 0
Gujarat 23 493 48 106 409
Haryana 21 472 8 0
Himachal Pradesh 12 1109 25 0
Jammu & Kashmir 14 273 2 0
Jharkhand 24 122 1 0
Karnataka 27 589 122 2 57
Kerala 14 740 124 0
Madhya Pradesh 50 1427 34 0
Maharastra 23 469 55 0
Manipur 7 0 0 4 8
Meghalaya 5 12 1 0
Mizoram 8 0 0 0
Nagaland 11 85 0 0
Orissa 32 624 8 0
Punjab 20 507 15 0
Rajasthan 33 3539 100 0
Sikkim 4 1 1 0
Tamil Nadu 27 35 7 104 100
Tripura 2 55 1 0
Uttar Pradesh 71 340 1771 0
Uttaranchal 18 467 7 0
West Bengal 16 295 4 0
Andaman & Nicobar 3 5 1 0
Chandigarh 1 6 1 0
Dadra and Nagar Haveli 1 3 0 0 1
Daman and Diu 2 1 0 0
Lakshadweep 1 2 0 0
New Delhi 9 148 10 0
Pondicherry 4 16 1 0
Total 578 13796 2378 228 645

Infrastructure – Homeopathic Dispensary & Hospitals, Medical Colleges, Unani Dispensaries/Hospitals

State Homeopathic Dispensary Homeopathic Hospitals Medical Colleage Rural Dispensaries Unani Dispensaries Unani Hospitals
Andhra Pradesh 286 6 32 196 6
Assam 75 3 3 1 –
Arunachal Pradesh 44 2 – –
Bihar 179 11 8 366 144 4
Chhattisgarh 52 3 3 6 1
Goa 59 1 1 – –
Gujarat 216 14 13 8347 – –
Haryana 20 1 3 19 1
Himachal Pradesh 14 1 2 3 –
Jammu & Kashmir 0 0 4 235 2
Jharkhand 54 2 3 30 –
Karnataka 42 20 36 176 51 13
Kerala 580 33 18 1 –
Madhya Pradesh 146 22 8 50 2
Maharastra 0 45 39 25 5
Manipur 9 1 1 42 – –
Meghalaya 10 7 – –
Mizoram 1 0 – –
Nagaland 115 1 – –
Orissa 603 6 4 9 –
Punjab 107 5 7 35 –
Rajasthan 178 9 8 102 3
Sikkim 1 0 1 – –
Tamil Nadu 46 9 25 1421 21 1
Tripura 93 1 2 – –
Uttar Pradesh 1482 8 16 49 210
Uttaranchal 60 1 3 3 2
West Bengal 1220 12 9 3 1
Andaman & Nicobar 15 1 – 1
Chandigarh 5 1 1 – –
Dadra and Nagar Haveli 1 0 3 – –
Daman and Diu 0 0 – –
Lakshadweep 1 0 – –
New Delhi 98 2 5 25 2
Pondicherry 7 0 8 – –
Total 5819 228 263 10355 1008 254

State wise Population to Infrastructure availability

State Population Sub Center PHC CHC Doctor
Andaman & Nicobar Islands* 356,265 3,125 18,751 89,066 4,880
Andhra Pradesh 75,727,541 6,048 48,234 453,458 34,204
Arunachal Pradesh 1,091,117 1,843 9,406 24,798 12,542
Assam 26,638,407 5,801 31,562 258,625 65,290
Bihar 82,878,796 9,356 50,505 1,183,983 52,958
Chandigarh* 900,914 64,351 450,457
Chhatisgarh 20,795,956 4,386 28,843 152,911 24,125
Dadra & Nagar Haveli* 220,451 5,801 36,742 220,451 36,742
Daman & Diu* 158,059 7,185 52,686 158,059 26,343
Delhi* 13,782,976 336,170 1,722,872 599,260
Goa 1,343,998 7,814 70,737 268,800 30,545
Gujarat 50,596,992 6,956 47,155 185,337 49,654
Haryana 21,082,989 8,665 50,198 245,151 60,237
Himachal Pradesh 6,077,248 2,934 13,535 83,250 14,932
Jammu & Kashmir 10,069,917 5,281 26,853 118,470 22,328
Jharkhand 26,909,428 6,799 81,544 138,708 81,544
Karnataka 52,733,958 6,476 24,025 163,263 18,562
Kerala 31,838,619 6,250 35,026 297,557 18,383
Lakshadweep* 60,595 4,328 15,149 20,198 10,099
Madhya Pradesh 60,385,118 6,836 52,554 223,649 57,951
Maharashtra 96,752,247 9,146 53,278 237,721 81,236
Manipur 2,388,634 5,687 33,175 149,290 20,771
Meghalaya 2,306,069 5,751 22,389 88,695 21,755
Mizoram 891,058 2,435 15,633 99,006 17,136
Nagaland 1,988,636 5,009 23,124 94,697 25,173
Orissa 36,706,920 5,488 28,700 158,904 27,130
Pondicherry* 973,829 12,647 24,970 243,457 14,321
Punjab 24,289,296 8,499 50,184 192,772 120,842
Rajasthan 56,473,122 5,257 37,574 161,814 36,623
Sikkim 540,493 3,677 22,521 135,123 12,869
Tamil Nadu 62,110,839 7,134 51,120 301,509 27,483
Tripura 3,191,168 5,512 41,989 290,106 12,514
Uttar Pradesh 166,052,859 8,092 45,001 322,433 82,985
Uttaranchal 8,479,562 4,804 35,479 154,174 9,792
West Bengal 80,221,171 7,746 86,819 229,860 99,038
Total 1,027,015,247 7,033 2,988,332 7,595,753 1,830,246

I will append more information as I get to learn more.

Most of the data was taken from Ministry of Family and Child Welfare (http://www.mohfw.nic.in) and also from search, papers and other websites. I ensured that I do not violate any copyright information.