Design

Health system challenge in India

Indians, on average, spend about INR 4,000 per capita, per annum, on healthcare. Of this, about one-fourth is public spending and the rest is by way of out-of-pocket expenses.

Even though the total spending on health care in India is over 4 percent of GDP, overall health outcomes are poor. Some statistics, by no means exhaustive, reflect this:

• Infant mortality rates even in high-performing states are high (Tamil Nadu – 21%, Himachal Pradesh – 35% and Kerala – 12%) in comparison to international standards (UK – 4%, China – 11%, Thailand – 11%, Brazil – 12%).
• Cervical cancer mortality rates among women are upwards of 20 (per 100,000 population); compared to 1.8 in UK, 9.7 in Thailand, and 7.3 in Brazil).
• More than 30% suffer from Stage-1 hypertension and about 10% from Stage-2 hypertension; and high blood sugar levels of about 17-18%.

A significant part of healthcare delivery and spending in India are in secondary and tertiary care. This tilt towards higher levels of care (as opposed to primary care) acts as barrier to early diagnosis and intervention. This is not only driving up costs, but is also leading to a sub-optimal urban-rural distribution of care availability. On the other hand, there is evidence that well-performing primary care systems improve overall health outcomes while bringing down costs. Thailand is an example where 80 percent of the total healthcare intervention is at primary care level. We at ICTPH believe that a widely available primary healthcare system, which can function reasonably well in low- and medium-resource settings, and well integrated with higher levels of care, should be the basis of Indian healthcare system.

ICTPH’s Primary care model

ICTPH seeks to design a health system – along with the development of key solution components that constitute the model – suitable for Indian conditions; and to demonstrate the effectiveness of the model (in partnership with its operations partner, SughaVazhvu Healthcare), for replication. Through its model, ICTPH aims to address some of the key challenges in low-resource settings: (a) the challenge of access to qualified physicians (b) the challenge of human resource capacity in the healthcare sector (medical and para-medical) (c) the challenge of healthcare delivery infrastructure; and (d) challenges in managing public / community health programs effectively.

The ICTPH model is conceptualized on four foundational pillars – human resource and capacity building strategy, adherence to evidence-based treatment protocols, robust technology support and a community-based approach:

• HR and capacity building strategy: In order to address the challenge of inadequate access to quality physicians, especially in rural areas, and to leverage the under-tapped section of physicians trained in alternative medical approaches, ICTPH has developed a bridge training program that equips medical practitioners, including licensed AYUSH physicians, with skills to diagnose and treat most common medical conditions at primary care level.

• Adherence to evidence-based care: A core aspect of the ICTPH model is rigorous adherence to evidence-based treatment guidelines and protocols to ensure quality and consistency of care. These protocols have been developed by ICTPH, in collaboration with University of Pennsylvania and adopted to Indian conditions by Indian MBBS doctors. These protocols have been in use in the SughaVazhvu network of clinics since their development. New protocols are continuously added and existing ones are regularly reviewed and refined.

• Robust technology support: the ICTPH model is designed on the strong belief that technology, particularly information and communication technologies (ICT), can play a crucial role in enhancing the effectiveness of our health systems. We believe that timely access to accurate health information of a patient to care providers, and clinical decision support to physicians at the time of providing consultation to the patients can significantly raise health outcomes of individuals and communities. IKP-TechPrima, ICTPH’s web-based health management information system (HMIS) has been designed and developed on these principles.

• Strong community-based approach: strong community / public health approach forms an important aspect of the ICTPH model of primary health, especially in chronic disease management and promotion of proactive, preventive healthcare and healthy life style practices. A community approach is reflected in all of ICTPH-SughaVazhvu’s programs as becomes evident from each of our current programs (described below).

Programs based on ICTPH’s health systems design

A key aspect of ICTPH’s work in health systems deign is demonstrating its model on the field and gleaning learnings from the field experience to further improve the model. The following are the two key programs presently in operation (being managed by ICTPH’s operations partner, SughaVazhvu Healthcare in Thanjavur district, Tamil Nadu):

• Project “Disease-free Village” (Comprehensive primary care centre in Alakkudi): SughaVazhvu operates a primary care centre in Alakkudi village in Thanjavur district with a goal to develop a model primary care clinic at a community level that could demonstrate the possibility of a “disease-free village”. This includes the enrolment of all residents of the village; identifying and offering managed care to those with chronic conditions (present focus on diabetes and cardio-vascular diseases); offering general physician consulting for most commonly encountered conditions at primary care level ; and in future, establishing linkages with hospitals for higher levels of care. The primary health centre in Alakkudi operates on the basis of the model and solutions developed by ICTPH. Once demonstrated, this could serve as a blueprint for a typical community health clinic to serve populations of around 5,000 in low-to-moderate-resource settings.

• Managed care solutions for Chronic diseases: chronic care burden in India is increasing and rapidly so, especially in case of diabetes and cardio-vascular diseases. Non-communicable, chronic diseases are estimated to account for 62 percent of deaths in low and medium income countries including India and approximately half of these are caused by CVD. Diseases such as diabetes, hyperlipidemia and hypertension are emerging not only as significant causes of death, but also as causes of debilitation in terms of health and wellness as well in economic terms. A 2010 World Bank study estimates that the loss of income due to impact of diabetes patients and their care givers is approximately INR 300 billion annually. The challenge can be exacerbated in rural areas owing to lack of awareness and lack of accessible and affordable care. While India is fast becoming the diabetes and hypertension capital of the world, there are no proven models to address this mounting challenge. ICTPH and SughaVazhvu are attempting to demonstrate a model to address this challenge by offering managed care to chronic diseases via pre-paid subscription packages. Subscribers receive necessary medicines, regular diagnostic tests and regular physician consultation and regular treatment-adherence follow-up to help manage their chronic conditions. These services are presently offered through a mobile clinic in order to enhance geographic coverage and to offer service at near-doorstep.

Health systems research

At ICTPH, we seek to demonstrate our model through our on-field activities at moderate scale and also are committed to draw evidence from our experiences that can help disseminate our leanings. We do this through our health systems research initiative that closely studies the effectiveness of the above model and its constituent components / solutions to glean insights that can inform health systems design and public policy.