In Venture Capital pitch rooms and mass media alike, there is growing buzz around health-tech. In India alone, health-tech startups raised over $500 million in 2018 (Source: Tracxn technologies). Care is getting smarter and better targeted. Artificial Intelligence (AI), Big Data, Blockchain, Machine Learning (ML), Internet of Things (IoT) - healthcare is seen as a massive opportunity for each of these new-age technologies.
I am often asked - will these emerging technologies transform public health? Over the next 3-4 months, I will attempt to answer this broad question by looking at how technology will impact different stakeholders in the public health ecosystem. Will set the foundation here with a simplified framework for thinking about the public health system.
Public health may be defined as the "art and science of preventing disease, prolonging life and promoting health through the organised efforts of society" (WHO). While in this article I try to introduce the various actors in the ecosystem, following articles will deep dive into how new age technologies can transform the way each actor works.
As per the Indian constitution, health is a state subject. While state Governments have primary responsibility, the Centre also sponsors important national programs including the National Health Mission (NHM), Ayushman Bharat and others. It has also emerged as a subject with important political ramifications. Central and State Governments make policies and own end-to-end implementation through programs, health facilities and frontline workers. They are also responsible for prevention of disease outbreaks, surveillance, disaster management and the health of the population.
New-age technology could help Governments better manage epidemics, allocate resources more effectively, design interventions offer more precise-targeted care, tackle human-resource issues, build capacity and more. India is already thinking actively in this direction with a National AI strategy in the works. The Government also actively uses dashboards to monitor real-time data and continuously improve effectiveness.
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Facilities and frontline workers:
India has a tiered network of public health facilities providing primary, secondary and tertiary care. The first point of contact for citizens in villages are the three frontline workers - a) ASHA, who mobilises the community, b) Anganwadi worker, responsible for nutrition needs of women and young children and c) Auxiliary Nurse Midwife, a nurse who carries out important services including antenatal care, immunisation and refers to higher facilities.
Frontline workers discharge important responsibilities in difficult conditions with little support. They collect copious amounts of data. Voluminous registers are slowly being supplemented by digital solutions. However, there are barely any attempts to make data work for them, to provide precise, targeted services. Can technology help? Sophisticated mapping techniques? Simple, hand-held diagnostic devices? The Government's ambitious proposal to upgrade ANM-run sub-centres to Health and Wellness Centres talks about taking advanced diagnostics closer to the people.
Frontline workers refer cases they're not equipped to handle, to public health facilities. Primary Health Centres (PHCs) are led by medical officers and serve populations of 20,000-30,000. For specialised care, patients are referred to Community Health Centres (CHCs) which serve populations of 80,000 - 120,000. Each CHC has 4 specialists - physician, paediatrician, surgeon and obstetrician - gynaecologist.
Cases requiring even more advanced care are referred to hospitals at the district and state level. Each of these facilities faces resource crunches - both in terms of equipment and personnel. Only 13% of PHCs meet the national public health standards. There is a shortfall of 82% in specialist positions at CHCs.
A similar structure is available in urban centres as well with Urban-Primary Health Centres (1 for every 50,000 people) and advanced secondary/tertiary facilities backed by community outreach services including systems like urban health kiosks, mohalla clinics and urban ASHAs. The private sector also plays an important role with over 82,000 private hospitals in India as of 2011 as per a study by the Institute for Studies in Industrial Development.
Big data can help improve diagnosis and early identification of diseases. Techniques like genome scanning and imaging can help improve the quality of care at facilities. Greater use of robots for surgical procedures, 3D bioprinting and use of augmented reality for greater surgical comfort are some other potential applications.
Management systems for the purpose of this article series would include the building blocks on which the health system is built such as health records, administration systems, centres of excellence, performance measurement and more. Collection, management and utilisation of health data in India still have much scope for improvement.
Electronic health records based on blockchain, in addition to improving data integrity and security could also provide actionable data to improve solutions and consistency of care to citizens, across public and private facilities. Research institutions could build on this rich data bank to develop innovative solutions. Health administration in India has acute human resource gaps - clinical and management roles - that can be alleviated by improved use of data and technology.
Drugs and medical devices:
The average lab-to-market cost for developing a drug has been estimated at $2.7 billion by the well-regarded Tufts Centre for the study of drug development. Prohibitively high costs result in companies passing on costs to consumers and sometimes even deciding not to produce a drug. Drug development costs are extremely high due to the low probability of successful development.
Solutions based on nano-medicine and AI-ML can help pharmaceutical companies achieve greater precision. Further, better data management can enable more adequate estimation of population health needs to develop tailored solutions. Technology also aids development of devices that can be used by individuals to monitor their own health and facilities/health workers for improved diagnosis and care as mentioned above.
Paying for health services is a daily challenge for the Indian poor. The Public Health Foundation of India (PHFI) estimated that out-of-pocket health expenses pushed 55 million Indians into poverty in 2017. The Government's Ayushman Bharat, billed to be the largest health insurance scheme in the world, proposes to fix that gap. Apps and wearables can change the health insurance game with incentive-based solutions.
New-age data-based solutions can also help insurers make more accurate assessments and informed decisions. This, in turn, will help them offer improved, customised solutions while better managing risk. Electronic health records and AI-based analytics can also enable more effective and efficient processing of claims.
Pharmaceutical supply chain system in India is complicated, because of the sheer size, large number of players, inadequacies in infrastructure and opacity. Highways constitute a mere 2% of India's road network and the cold chain system remains underdeveloped. A study conducted by Newcastle University, Lakshya society and Tata Consultancy Services showed that several Indians lack access to essential drugs.
In my experience, it is not uncommon to see expired drugs or imperfect management and storage practices. Supply of important drugs including vaccines and contraceptives is often intermittent or inadequate. Supply chain automation solutions, drones could enable drugs reach places and citizens who need it most, in a cost-effective manner. Blockchain also finds application in enhancing transparency within the supply chain.
'Community' in this context includes patients seeking care, people who need preventive solutions and others interested in remaining healthy. By impacting each of the above-mentioned factors, new-age technology could help improve health of communities. It further creates opportunities for citizens to take control of their own health and wellness.
Think customised diets, self-diagnosis, tracking treatment, post-treatment care and so on. IoT based wearable devices can analyse data real-time and provide better access to patient history using the cloud.
Technology is here to stay, and the public health system would be well-served to take advantage. As we dive deeper into the impact of new age technology on each of these actors in upcoming articles, I welcome your suggestions and thoughts on aspects that most interest you.
(The writer is the CEO, Antara Foundation. He has worked in management consulting with Arthur D Little and KPMG.)
(This article is the first in a multi-part series)