Understanding Rural Healthcare System In India

Published Date: 02 Nov 2017

Public healthcare in rural areas is provided through a multi-tier network.  The layers are distributed as primary, secondary and tertiary centres at different levels. These are

Sub-Centres (SCs) - The Sub-Centre is the most peripheral and very important first contact point between the primary healthcare system and the community. There are sub health-centres for every population of 5,000 in the plains and 3,000 in hilly areas. 

A Sub-centre provides interface with the community at the grass-root level, providing all the primary healthcare services. The purpose of the Health Sub-Centre is largely preventive and promotive, but it also provides a basic level of curative care.

As part of National Rural Health Mission (NRHM), each Sub-Centre will have Accredited Social Health Activists (ASHAs). They are community health workers instituted by the Government of India's Ministry of Health and Family Welfare (MoHFW). ASHA in every village/large habitation are chosen by and accountable to the panchayat. ASHA act as the interface between the community and the public health system. She is an honorary volunteer, receiving performance-based compensation for promoting universal immunization, referral and escort services for RCH, construction of household toilets, and other healthcare delivery programmes.

Primary Health Centres (PHCs) - PHC is the first contact point between village community and the Medical Officer. There are PHCs for every population of 30,000 in the plains and 20,000 in the hills.  Generally, each PHC caters to a cluster of Gram Panchayats.  PHCs are required to have one medical officer and 14 other staff, including one Auxiliary Nurse Midwife (ANM). 

(Source: http://mla.prsindia.org/policy-guide/status-doctors-primary-health-centres )

ANM is a government paid health worker who provides free maternal and childcare services within a sub center area. The Mission seeks to provide minimum two ANMs at each Sub Health Centre to be fully supported by the Government of India.

Community Health Centres (CHCs) - There are Community Health Centres (CHCs) for every population of 1,20,000 in the plains and 80,000 in hilly areas.  These sub health centres, PHCs and CHCs are linked to district hospitals. 

(Source: http://mla.prsindia.org/policy-guide/status-doctors-primary-health-centres )

How health communication system works

Communication systems are combination of formal and informal guidelines defined by organizations to support their communication needs. In all the States there is an Information, Education and Communication (IEC) cell to support health communication programme. In some of the States like Rajastan and Madhya Pradesh, there is separate Health IEC Bureau. They have IEC officials at State, district, and block level, known with different designations. In communication system people exchange information using suitable technologies as per the organisational guidelines that define and constrain the conversations that are allowed to occur. Elements of communication systems are:

Communication channel: The channel is the ‘pipe’ along which a message is conveyed, and there are a wide variety of different communication channels available, from basic face-to-face conversation, through to telecommunication channels like the telephone or e-mail, and computational channels like the medical record. (Source : Enrico Coiera, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1579411/).

Every channel has certain attributes that determine their suitability for different tasks.

In today’s world, people communicate using various channels. Healthcare services use telephone, sms and email as channels to communicate with patients. These channels can be used for various activities ranging from setting up appointments with doctor, referrals, reminders, surveys, appointment confirmations, and even for consultations. Within the healthcare services, internally people use email, telephone and system based feeds to communicate. Healthcare services often use external communication to attract new patients within the community. Radio ads, newspaper ads and information videos are some of the channels used.

Cost effective options for mass communication include print ads in newspaper, informational pamphlet attached to the newspaper, bulletin boards, web site ads, web site testimonials, SMS, posters and hoardings. Expensive communication channel includes, satellite based TV broadcasting, radio adverts, commercial video ads and commercial billboards (static and mobile).

Types of message: Messages can be classified into two categories - informal and formal. Attribute of a message is to utilize available resources to suit the needs of the receiver. In day to day communication, people often use informal messages. These messages are not structured. For example: telephone conversation, SMS and email exchanges. In healthcare services, often formal messages are used to maintain consistency and standard. For example: hospital discharge summary slip, computer-generated email notification, reports and laboratory results.

Communication policies: In an organization, communication systems are bounded by formal procedures instead of technology. Each healthcare service provider may have many different policies that shape their communication system performance, independent of the specific technologies used by them.

Communication services: Communication system has evolved to provide number of different communication services using the same underlying channel. For example: a mobile phone can provide voice-mail (audio), MMS (audio+video) and SMS (text messaging) using the same channel.

Communication device: Communication services can run on different communication devices to provide a holistic experience. Innovation in communication devices has led to integrated solution. Now a tablet or smartphones or phablets are used for emails, SMS, MMS, video chat, online forums, banking and navigation apart from making a phone call.

Efforts in health communication

Government is making a lot of effort in communicating the importance of good health. Examples of polio, Nutritious diet, washing hand, safe sex, TB are well documented.

Private players do contribute in this field. They have their own channel and doctor is one of them. The doctors suggest their products to the patients. The use of regular TV and radio commercials by the private players are quite evident.

Role of ICT in development and especially health

Information and Communication Technology (ICT) enabled solutions offer new and exciting opportunities to individuals. Use of ICT in health significantly enhances the quality of the delivery of healthcare, and addresses inequalities in people’s access to health information and services. In order to achieve results, these technologies must be managed and directed appropriately and technological tools must be made equitably available.

In the last decade (2000-2010), ICT have clearly made an impact in development sector, especially in health. This translated into savings in lives and resources, and direct improvements in people’s health. Use of ICT resulted in:

Improved awareness about health and associated challenges. In India, out of many public health initiatives, polio eradication and HIV had considerable impact. In both cases, a host of agencies worked together to develop a multi-pronged strategy led by communication professionals. This helped in creating multiple strategies that were used to engage diverse audiences. Awareness messages were everywhere — from print, TV, radio, Internet, SMS for the more urban and semi-urban audiences and on roadsides, on the back of buses, transport vehicles and in small village fairs.

Quick access to health information - Doctors can now access patients’ medical records more easily, get immediate access to test results from the laboratory, and deliver prescriptions directly to pharmacists. ICT can help patients become more involved in their own care, which is especially important in managing chronic conditions like diabetes, asthma, or heart disease. Patients with blood pressure, heart problems can carry monitors which alert their doctor if their condition changes, yet allow them to continue with their daily routine. Using telemedicine, primary healthcare costs can be reduced and helping people in remote areas not to skip a day’s work and wages in trying to get to a doctor for minor ailments. In urban India, lab pathology reports are now available online. SMS is sent to patient with username and password along with instructions to view the report.

Monitoring and tracking - Mobile phones, tablets, palmtops and computers are now used for data collection in various health and development programs. Collected information (in digital form) can easily be collated and analyzed. With the rapid spread of mobile phones and network coverage, Global Positioning Systems (GPS) and smart phones that include GPS functions, the mapping, are now being used to check public health threats. With targeted information, authorities can now respond in a timelier and effective manner. In SAARC countries, global satellite technology is used to track outbreaks of epidemics. Real time information ensures that effective prevention and treatment methods can reach people in time. In India, under the NRHM project, Mother and Child Tracking System are keeping track of each pregnant woman from registration to post natal care.

Improved collaboration and engagements – Resources are now just a click away. People today have more modes of communications and are more connected to one another than ever before in human history. The choices, accessibility and affordability of communication technology have naturally changed social habits and styles. Doctors now use WebEx or online video conferencing software’s to interact with colleagues in different part of the world. Latest case studies and research articles are immediately available to the world wide audience. People now can learn anywhere, anytime through online modules. Use of e-learning is pivotal in quickly creating an army of knowledgeable work force for any situation.

Improved efficiency – ICT helps in streamlining the process and helps in reducing the administrative bottlenecks. ICT helps in resolve complex decision making, communication and decision implementation. It helps in automating tedious tasks done by humans, and support new tasks and processes that did not exist before. When ICTs are properly aligned with governance goals, they can help to create gains in both efficiency and effectiveness.

The gap at different levels

There are numerous factors that can affect the introduction and successful application of ICTs in the health sector. Satellife (2005) identified three main factors: connectivity, content and capacity. Madanmohan Rao (2005) adds five more factors for analysis: community, commerce, culture, cooperation, and capital.

Connectivity – Internet speed is the biggest bottleneck in implementing ICT solutions in healthcare. As ICT progresses throughout the decades, one of the biggest challenges is the high-speed internet access. Dependable connectivity is needed for reliable transactions. In developing countries reliable broadband connectivity is still limited, and usually only dial-up access is available. While in urban India people have excellent 3G coverage for high speed internet, rural and outlaying areas struggle with connectivity issues. Because most ICT technologies rely on the internet and cloud based storage – connectivity is the defining issue for ICT today.

Content – Whenever there is a new program or health intervention, the content is created in either English or one of the local languages. In a country like India, where there are 18 official regional languages, lack of local content creation is a limiting factor. It is often observed that the content is generalized and not customized based on the language used and the relevance of content to the local situation. Appropriate language, based on the target audience, is frequently neglected in ICT programs and little content is available in local languages for health programs. The greatest challenge facing any information/knowledge dissemination activity is the need to customize information differently for various audiences. These skills are critical, yet scarce. Moreover, to customize information availability of relevant resources are limited. Content experts or a team of experts are required to identify content or information that needs customization. Lack of proper training, poor coordination and inconsistent approaches used by technical content experts and information and communication specialists’ results in poorly customized material. There is a strong need for coordination to build a strong evidence base and to make the information more accessible to policymakers, health workers, and the public.

Quality and reliability of health information is another major content issue. The Internet, if used properly, can provide access to timely, accurate, diverse, and detailed health information. However, its decentralized IT setup structures, global reach, level of access to publication tools, immediacy of response, and ability to facilitate free information interchange makes the Internet a channel for potential misinformation and concealed bias. There are no regulations or government policies to regulate such information. In such scenario, it is a challenge to ascertain and recommend the credibility of information. Many times, unregulated websites are sponsored; others promote dangerous forms of health solution/recommendations or products. Not always the intention to share information is wrong but they contain misleading or false information.

Capacity – While there are challenges in adapting information to ensure that it is culturally appropriate and relevant, it is also a challenge to use ICTs effectively, and to service and maintain them. Skilled ICT ready resources are essential for the effective use of ICTs in health. It is difficult to find ICT professionals, technology products and services providers and health project management experts with high skill levels and experience working in the health sector.

Capacity also refers to the digital divide in societies and the sharing of resources within the community. For example, due to poverty and lower literacy rates, village people are not given equal access to the benefits of ICTs. These facilities are mostly clustered within cities.

Community – Currently, ICT is primarily used by affluent and educated class. People in rural areas have limited exposure to ICT services. Implementations of ICT and health program are executed without studying the ground realities. Often community perspectives and concerns to empower people within the community, mobilize skills, expertise, and resources are ignored.

Commerce – In this category also, affluent and educated class are the primary users. Lack of connectivity, education and government policies on promoting online mobile transactional capabilities that will be beneficial for consumers, businesses and public health interests hinders the growth path.

Culture – ICT programs often run in isolation with taking into account the ground realities. Lack of understanding the cultural inhibitions and social-barriers within society and institutions prevent effective use of ICTs.

There is little or no transparency in Government run or funded projects. Lack of political will to ensure that government projects are more transparent and that information-sharing cultures are encouraged, results in failure.

Cooperation - The use of ICTs for health and development is a complex issue and it should involve local, regional, and international participants as stakeholders. Active group members should be invited at the beginning of an intervention when discussing efforts for ICTs and health; otherwise there is a risk of developing technical solutions looking for a problem to solve. However, in majority of decision making situations, only few relevant and qualified people are involved. Outcomes are often based on their priorities and not based on health needs and the views of the communities to be served by ICTs.

Lack of knowledge and skills training to the health workers and not engaging them throughout the project life cycle often results in disintegrated solution.

Capital – In most developing countries, there is little investment in ICTs for health. Very few government-run health services have properly functioning integrated ICTs within them, and there is lack of reliable infrastructure to enable information transfer between organizations. Invariably, there is no national health information and IT infrastructure to underpin the healthcare delivery.

As noted by Hagland "The lesson to be learned for the use of ICTs in health is that technology can be justified economically only if organizations deploy it in a real practice environment and closely track how managers and direct care professionals are using it. This requires the stepwise development and implementation of processes and metrics to monitor productivity and impact" (Hagland, 2001; Yaffe, 2001).

Today, in rural India, patients are dependent on either ANMs or ASHAs. I service sector including healthcare, manpower themselves become bottleneck in information interchange. If ANMs or ASHAs or health representatives don’t come and interact with the community, getting timely help would be big question mark.

ACHIEVEMENTS in health communication AND THE TASK AHEAD

Some Info here

Future trends in ICT

Technology is changing and reshaping our lives every day.

Cloud Computing – Cloud computing allows users to carry out tasks remotely. Information, applications and even entire platforms and infrastructure are stored in a remote location, and accessed via an Internet connection. There is no need to have the required hardware and software to be present locally.

File:Cloud computing.svg

(Source: http://en.wikipedia.org/wiki/File:Cloud_computing.svg)

In major cities across India, there are some of the best hospitals in the world which provide high quality of healthcare services using latest technology. However, in rural hospitals even basic infrastructure is missing. Having high end technological infrastructure is a distant dream. Doctors, nurses, administrators, and other healthcare personnel working in the rural hospitals have no or limited exposure to technology. Government and private sector players are now working closely on a cloud solution to create uniformity in healthcare technology adoption. Healthcare applications will be available to hospitals and healthcare providers to use on a ‘pay per use’ model. There will be tremendous cost saving by not purchasing and deploying expensive technology.

The rapid adoption of electronic health records are creating a critical need for more data storage, resulting in increased IT related spending. Cloud technology can provide access to the data and applications they need on demand and from any location.

New advancements in cloud technology are now rapidly changing the way healthcare providers operate their technological infrastructure. Healthcare providers are now realizing the benefits of cloud technology, instead of owning and maintaining centers with huge investments in technology and human resources.

Mobile Based Applications – In India, by the end of 2016 the number of mobile connections will cross 900 million (source - http://www.gartner.com/newsroom/id/1963915). Till last decade, ‘going mobile’ was limited to select few. However, with the dropping prices of laptops and mobile phones, the mobile movement gained momentum. The evolution of mobile Internet aided the expansion of the mobile device’s role in consumers’ lives. Mobile has now become a part of our lives. With tablets, phablets and smart phones more and more powerful technologies are available for communication and computing.

In future, mobile devices will be used to perform multiple diagnostic tests. These test application will be available to downloaded and used on "pay-per-use" basis. The test reports will be directly shared with your family physician.

One thing is clear; ICT will have significant influence in achieving holistic health of individuals and society.