And more of it in us dwell
For this brain is such a wonderful box
It can digest quite a lot
- Dr. K. A. Hiranandani
Form poem ‘Memories’
In ‘Medical adventure’ (1942)
Antiseptic press, Madras (page. 69)
India has been on the path of globalization for more than a decade now. The successive governments at the center have continued the policy and with changing times, adapted its various laws, policies and systems of governance. Globalization is not the same as privatization. It is a mutually benefiting system of gradually cohabitating with other systems of management and governance of the world. Private sector plays a pivotal role in any globalized economy. They always work for their own profit and for ensuring the same they induce many changes, including technological ones in their respective fields.
Information technology and its current form seen in India is a blessing of globalization. It has affected day-to-day lives of millions of people all over the world and has created radical alterations in the way business is conducted, wars are fought and patients are treated. The advantages of growth of information technology are quite obvious: higher growth, improved living standards and newer opportunities. The central challenge, according to secretary general of the United Nations Kofi Annan, is to make sure that this much adored ‘blue revolution’ remains a positive force for Indian common man, instead of leaving millions of them in squalor, as has happened with other technological innovations[1].
The rear view mirror
It all started in 1991 with Dr. Manmohan Singh; the then finance minister of Government of India initiating loosening of government controls over many fields. That was an emergency imperative step for a nation in e queue for loans with other tin-pot nations at doorsteps of international funding agencies. Soviet Union was dead and there was no financial and technical help available from anywhere. Globalization induction acted as a dopamine drip in a nation under a financial shock. It was also the same time when IT revolution was breathing its birth-cry and setting government controls free acted as cutting umbilical cord of this neonate. New InfoTech firms were established and computers started appearing in offices. Enthusiastic private entrepreneurs started blasting off in mines of silicon and soon the found gold out of it. New opportunities for computer literate individuals arose and it was considered fashionable once upon a time to ‘study computers’ side-by-side with formal schooling. India adapted easily to the new thoughts, new process and new technology again, as it has kept doing for past five thousand years[2].
The mosaic that is IT
Applications of information technology began to appear an idea of formalizing them became stronger. The prefix ‘e’ began to be equated with efficiency, transparency and accountability[3]. Connectivity became mantra for success and number of telephone lines became one of the criteria of defining a country developing or developed[4]. Changing faces of IT soon gave it a new name – Information and Communication Technology (ICT). With expanded vision and unlimited market, ICT applications and IT-enabled services and products started their race towards the last in on the land. Possibly every machine in the world became computerize which augmented downfall of labor-intensive industries. The need to manage information flow on optical fibers networks and through satellite signals gave birth to new branches of education like Electronics and Communication, Information Systems Management etc.
ICT and Healthcare: ‘Just Married’
Healthcare information management and management of healthcare through information is relatively recent concept. It has become know with names like ‘bioinformatics’, ‘cybermedicine’, ‘internet medicine’, ‘emedicine’ ’ehealth’ and so on. Commonly divisible in ‘telehealth’ and ‘telemedicine’, they are defined as follows:
Telehealth – Broad concept including health services, education and research supported by information technology[5].
Telemedicine – Medical care and procedures offered across a geographical distance and involving two or more actors in collaboration often in interdisciplinary terms[5].
This change of face of Indian healthcare system runs at par with globalization. There is a telephone in every primary health center (PHC) now, the basic unit of the system. Some PHCs are now connected with secondary and tertiary care centres and are interconnected also, as is seen from examples of pilot projects in Pune district in Maharashtra[6] and Madurai district of Tamilnadu[7]. What is more important is that the doctors are also now turning to internet and other communication channels which are fast efficient and accurate in conveying the demanded information. Thoughts are also proposed that training of ICT should be imparted to medical students at undergraduate level only[8]. Apart from governments acting to change their way of functioning[3], non-governmental organizations and private corporations are also taking maximum benefit of the ICT revolution. Together these units form a healthcare information system.
India today: computers in dowry
‘Men may come and men may go, and governments and empires may lord it awhile and then disappear into the past; but the old tradition continues, and generation after generation bows down to it. Tradition has much good in it, but sometimes it becomes burden which makes it difficult for us to move forward.’
- Jawaharlal Nehru
In ‘Glimpses of World History’
What the first prime minister of independent India wrote to his much-famed daughter of January 14, 1931 from Nainy Central Prison is an eternal truth and an inbuilt characteristic of an Indian’s mindset. Having a long past which has its own highs and lows, India today is walking with a shipload of traditions, customs, rituals, beliefs, superstitions and taboos on her head. India has the highest number of cases tuberculosis, leprosy, malaria, preventable blindness and neonatal tetanus in the world[9]. More than 50% of all deliveries are conducted by untrained persons which results in more than 100000 maternal deaths every year: 1 maternal death every minute[10]! 33% of all children born are with below than normal weight[11]. There have been successive changes in governments at the center but allocations to the field of health from union budgets have always been poor. The great Indian mindset has refused to change at the speed the external world has been changing. Sam Pitroda, often regarded as the telecom man of India, recently expressed his anguish against this attitude:
‘The knowledge industry has arrived in India, but we still like to hold on to the Brahminical and Shudra based structure of work. It is time we give up this kind of mindset.’ [12]
‘Often we try to impose our thoughts on our children, building them like us. But we fail to realize that we need different mindsets to build a nation.’[12]
Community use of information and ICT has developed in a piecemeal fashion as a series of rather unconnected initiatives. Extremely high rate of growth of ICT has surpassed any other technological innovations in India, at the same time it has posed a formidable challenge in front of institutions in adaptation to it and co-coordinating and controlling complex health services and in training healthcare professionals for it. This has led to lack of availability of competent healthcare professionals to manage telecommunication networks and information flow in healthcare management. Increased demand and limited supply of trained professionals in medical informatics naturally increase their market value and many institutes have come into being claiming of teaching bioinformatics, including a college degree in the field. So far, they have been working without clear uniform guidelines about education or without a proven scientific theory of how informatics can improve healthcare[13]. Moreover, existing information available on the World Wide Web is largely due to efforts of western medical experts and therefore is based on the data generated from western population and on issues more concerning to their health needs. Such information is not a tool of substantial strength, which can deal with grass-root healthcare adversities observed in rural India, comprising 70% of Indian population.
Primary health care in India
Concept of primary health care has its roots deep in Indian health system. Dating back to around 1400 BC (circa) Manu prescribed his codes of personal hygiene, dietetics and rituals of hygiene at the time of birth and death. Ruins of Mohen-jo-dero, Harappa (both in Punjab) and Lothal (Gujarat) show some of the systems of roads, buildings and drainage that are even today seldom available in Indian towns and villages. Old Indian treaties mention, ‘Sarve santu niramaya,’ meaning ‘may all be free of disease.’
Gradually with time, changes came into population and concept of positive health and hygiene disappeared from the people’s psych. British invasion of India helped in formalizing laws and rules, many of them observed even after 100 years. A look on the chronology of primary health care development in the country[14]:
1864 – Sanitary commissioners appointed
1873 – Birth and death registration act
1880 – Vaccination act
1881 – First all India census
1897 – Epidemic disease act
1909 – Central Malaria Beauro at Kasauli
1930 – All India Institute of Hygiene and Public Health established at Calcutta
1943 – Health Survey and Development Committee formed under Sir Joseph
Bhore
1946 – Report of Bhore Committee
The Bhore committee report was a major step towards achieving goal of basic health care for all in a huge nation with limited resources. It had a certain kind of futuristic vision, which still today is continuously guiding health planning and implementation in India. This report had not only proposed the idea of primary health care but also given a road map to achieve that goal. Subsequent reports by other committees and individuals only strengthened importance of bhore committee report.
Primary health care gained a major thrust in 1977 when at Alma Ata conference, World Health Organization (WHO) accepted and advocated this concept. It has defined primary health care as:
”essential healthcare base on practical, scientifically sound and socially acceptable methods and technologies made universally accessible to individuals and families in the communities through their full participation and at a cost the country and community can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.”[15]
Currently India has a vast network of primary health centers (PHCs) and associate staff[16]. (Table 1)
How ICT can help in primary health care?
There are 8 components of primary health care described in the Alma Ata conference, also known sometimes as ELEMENTS of primary health care. Those components can be integrated with ICT applications. A brief summery of possible examples can be:
(1) Use of ICT as a tool of education about commonly prevalent diseases, their prevention and treatment.
(2) Developing monitoring systems on supply chains of various health related goods including:
- Family planning products
- Vaccines
- Food supply under present system of distribution.
- Monitoring the water supply lines/ canals by establishing electronic monitoring points in the line.
(3) Early transmission of patients’ data to the tertiary care center upon referral of the patient, which can save valuable time.
However any application of the ICT should take into account the basic guiding principles of the primary health care systems, viz. community participation and equitable distribution[17]. As of now, doubts are being raised over the efficiency of developing nations in utilizing the available resources through various mediums[18]. There have been usual allegations and counter allegations which mar the scenario of Indian health system. The media repeatedly points out the glaring dissimilarity in healthcare between the poor and the rich[19]. It is tie now for the governments to stop investing in marriage beauros[20] and work in a constructive manner[21].
TABLE 1
VHG 3.26 LACS
Trained dai 660996
Subcentres 137027
PHC 23266
CHC 2962
Training of FHW 133618
Training of MHW 73266
Training of LHW 19475
REFERENCES
[1] Annan K. Making globalization work for the poor. The Hindu. Undated
[2] Nehru J. Discovery of India. Oxford university press. New Delhi, 1980; 34
[3] Ajaykumar. E-government & efficiency, accountability & transparency. Electronic J Info systems in developing countries. 2003. 12(2) 1-5
[4] Sèror A. The Internet, global Healthcare management systems and sustainable development: future scenarios. Electronic J Info Systems in developing countries. 2003: 5 (1); 1-18
[5] McClelland S. ‘The economics of need.’ Telecommunications: Americas Edition, 1998: 32(5); 10
[6] Radhika V. Telemedicine service in Pune primary health centers. Asia Pacific Network Information Centre. (URL: http://www.apnic.net/mailing-lists/s-asia-it/archive/2001/05/msg00006.html) (Cited November 1, 2003)
[7] Anon. Sustainable Access in Rural India (SARI) Voice and Internet services in Madurai district. Indian Institute of Technology, Madras (URL: http://www.tenet.res.in/rural/sari.html) (Cited November 1, 2003)
[8] Park K. Textbook of Preventive and Social Medicine. (17th Ed.) 2003: 265 Banarasidas Bhanot Publishers. Jabalpur. India
[9] Annual Report (1999-2000) Ministry of Health and Family Welfare, Government of India. New Delhi. (URL:http://www.mohfw.nic.in) (Cited on November 1, 2003)
[10] Anon. ‘Telehealth industry: Overview & prospects. Industry Canada: Health Industries Branch. 2001. (URL:http://strategies.ic.gc.ca/SSG/hs01321e.html) (Cited on November 1, 2003)
[11] Baxi MV. Update Medical Education in India. (Submitted for publication)
[12] For globalized outlook, we must loose boundaries: Pitroda. The Indian Express (Vadodara Newsline) January 18, 2003
[13] Anon. ‘Telehealth industry: Overview & prospects. Industry Canada: Health Industries Branch. 2001. (URL:http://strategies.ic.gc.ca/SSG/hs01321e.html) (Cited on November 1, 2003)
[14] Park K. Textbook of Preventive and Social Medicine. (17th Ed.) 2003: 265 Banarasidas Bhanot Publishers. Jabalpur. India
[15] Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR. World Health Organization. Geneva. (1978) (URL: www.who.int/hpr/NPH/docs/declaration_almaata.pdf) (Cited November 1, 2003)
[16] Park K. Textbook of Preventive and Social Medicine. (17th Ed.) 2003: 637 Banarasidas Bhanot Publishers. Jabalpur. India
[17] Bridging the Gap: World Health Report. Report of the Director General. (1995) World Health Organization. Geneva
[18] Garner P. Is aid to developing countries hitting the spot? Brit Med J. 1995: 311; 72-73
[19] Anon. Docs, rallies blamed for child’s death. The Indian Express. October 16, 2003. Pg.5
[20] Anon. Naidu to click mouse to play match-maker. The Indian Express. Jan 19, 2003
[21] Odutola BA. Developing Countries Must Invest in Access to Information for Health Improvements. J Med Internet Res 2003, March, 31; 5(1): e5
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