Saturday 26 April 2008
It is important to differentiate between current visitors and target
audience. If your stats are able to, the important information is
return visitors and where they come from. There will always be random
visitors from all over the world, arriving via search engines. They
add to visitor numbers and page views, but what you need are visitors
that bookmark your site and use it as a resource. They are the
visitors who travel through many pages each visit, who read the
content, and who are in a better mood to notice relevant
advertisements. Many search engine visitors will only visit for a few
seconds then go somewhere else.
The advantage of Google Ads is that you get paid per click-through,
regardless of whether the visitor ends up buying anything. From this
point of view, it doesn't really matter where they come from - if they
can read English there's a 1-3% chance they'll click on an ad.
It is only an opinion, but aiming for an Indian audience, and treating
your site as a long-term proposition is what I suggest. This target
audience is going grow rapidly in the next decade. It is important to
be #1 at what you do. It is better to be the #1 Indian health portal
than the #37 international health portal.
I think each of Complementary Medicine, Conditions and Family Health
should be treated equally - the same amount of promotion from your
home page and the same amount of effort content-wise.
The final destination should be linked to form the body of the page people originally arrived at, and given a much better impresssion of the depth of information your site contains.
I suggest that the Support Group section be merged with Conditions section.
The visitor should be able to visit your home page, click on
Conditions, click on Epilepsy
(See Epilepsy Journals from The Lancet as well), and reach a page that links to all the
info your site has on the topic. When I get to the Epilepsy page, I
would like to see a menu prominently displayed in the center of the
page, that links to:
- Tips for living with Epilepsy
- Myths surrounding epilepsy
- Do's and Don'ts
- Epilepsy & Women
- Famous people with epilepsy
- VNS Therapy
- Support Groups
Fixing the Navigation
What needs to be done is this, for each ailment, remedy or general topic:
1. Find every page in your site that is related to it
2. Create an index page for it
3. Link to all the related pages, in a very clear manner. This means
in the main body of the page. Not in side menus, and not split into
4. When someone gets to the end of the chain, say a page of contact
details for epilepsy support groups, try to only have links in side
menus going to other epilepsy information. This is the reason they are
there, this is the topic that interests them. If they want anything
else, they can return to the home page and start again.
Then test it from a visitors point of view. Think of as many possible
types of information that your visitor is looking for, examples:
- What should I feed my baby?
- How can I relieve the pain of migraine headaches?
- Where is my nearest hospital?
- What is homeopathy?
For each possibility (there are hundreds), start at your home page,
pretend you have never been there before, and see how long it takes to
find information. From following links your ideal should be three
clicks, although for such a large site four is okay.
Compare the ease of navigation, and the quality/quantity of
information with your oppositon (links below).
Create a page like this one:
Doing so provides an extra way for your visitor to find the
information they want. It also provides you with an overview and
reminder of what your site contains.
Know your limitations
There are specialist sites that are better for health-related data
than your site is likely to achieve. For example, I have a
health-related webpage on one of my sites, and I link to the
Health on the Net
Drug Resource Center
Your visitors would appreciate getting information from the above
sites. If it is combined with the knowledge that for an Indian
perspective of things, visiting aarogya.com is their smart first step.
So, your drug database could contain the basic information, plus
anything specific to India (local brand names, suppliers, prices), and
a link to the full information at RxList.com. Alternatively you could
investigate licensing their drug data. An Indian user would, even
though they knew RxList has the most in-depth data, visit your site as
the first step.
Sites similar to yours include the following:
These sites have the advantage of being a sub-section of an
all-encompassing portal. They are more suited to the casual surfer.
They both use Google Ads for revenue, and general ads that appear
throughout the entire portal.
There is also:
There is always a temptation to make the site more dynamic, by using
.asp or .php and databases of information. The suggestion to do so
usually comes from the programming and web design staff, rather than
from users. I do not recommend this for site because:
- Most of the information you provide is static
- Dynamic sites are more prone to errors
- Search engines prefer static pages
If your site becomes popular and attains a PageRank of 8 or higher,
then the vast majority of your visitors will arrive via search
engines. For this reason alone, keep the pages as simple and static as
The best way of testing your site's speed using dial-up connections
would be from within India, as this is presumably where most of our
target audience resides.
Among the better known health care portals now up and running in India are:
- 3. goodhealthyou.com
- 4. webhealthcenter.com
- 5. mdspeak.com
- 6. indmedica.com
- 7. doctoranywhere.com
- 8. healthcarehouse.com
- 9. drgill.com
- 10. valcare.com
In this article the discussion is limited to content. A major discussion on revenue streams also needs to be taken up but it shall have to wait for a subsequent article.
BroadbandingIt is evident that there is a certain broad banding on content tried by a number of these sites. Even within the healthcare niche there seems to be an attempt to offer all the information that the healthcare consumer, be a doctor or a lay person, needs. Such an approach is full of possibilities. A health care website that offers all things to all men is one starting point when one has to begin somewhere and the first web portal off the block has tremendous advantages in this respect.
Its limitsHowever there are also drawbacks to this approach. The first is that even within the healthcare sector this approach calls for a site that offers immense amount of information in every direction at such a level as to make it the ultimate guide to the health care universe. This is clearly impossible. In the effort to offer too much to too many, a lot can get left out. Besides the knowledge base has to be re-engineered to fit the web format. Even if done successfully it can get out of hand after a certain critical size is reached. Also, ultimately a website is a place to which a consumer goes to get information and such other facilities that it offers. He is not interested in getting lost and worse, mired, in an ocean of information most of which is irrelevant to his immediate needs. It can be both irritating and off-putting. Therefore, in the healthcare sector, a horizontal portal can be both a bane and a boon. A boon because the information is likely to be available and a bane because a lot of effort may have to be expended trying to get to it.
VerticalisationIf, on the other hand, a website were to offer in-depth information to a very select audience, in other words try to be a vortal in a vertical business it runs the risk of painting itself into a corner, appealing to just those few whom it is aimed at. This limits the market and can result quite quickly in its becoming economically unviable. After all a website’s success is measured by its popularity in terms of hits and page views. No website is up on the net without an economic aim. A fine balance between breadth and the depth of content and consumer need has therefore to be cultivated with an assiduity bordering on the fanatical. This is a task that can call for juggling skills, far superior to anything seen in the best of
circuses.What is surprising is that so many succeed even partially at this. Not all deal with the same topics. Many ignore completely what some others lay emphasis on. Some make it clear which their primary target audience is and tailor the rest of the material around this main aim. On content much depends on your perspective and what you are looking for. It is useful therefore to look at content from different perspectives.
A perspectiveWhen websites are aimed at doctors, for doctors matters take a perspective that is by definition self-limiting but which concentrates with success on one task. It is therefore likely to be more thorough in its approach. For instance take the website called DoctorAnywhere. This site is meant for doctors who wish to take the opinion of experts by paying a fee. The site is one approach to offer doctors expert second opinions by specialists. Considering the shortage of specialists, particularly in the non-metro areas of the country, this site has a laudable aim that deserves credit. One hopes therefore that it will be able to make a success of its efforts in the long term.
There are possible hurdles, however. For one, no real expert offers a second opinion without personally examining a patient. Secondly, if he does he still hedges it with a lot of caveats. Which finally compels the patient to seek his own specialist instead of asking the GP to look for expertise on what is felt to be an anonymous source the internet. In India at least, patients look for medical treatment from doctors at a highly personalised level.
Therefore while the service offered by DoctorAnywhere has its good points— it offers GPs the ability get access to specialists from anywhere in the country and it enables information at an expert opinion is diluted, perhaps fatally by anonymity and distance.
The criterion of usefulnessOne of the ways GPS can get information on their everyday medical queries is about diseases and the drugs available to treat them, perhaps even the brands that are available. That would make prescribing that much more accurate and easier. Probably the best effort in this direction aimed at clinical physicians is from the web portal MDSPEAK.com. They have called it the Physicians’ Prescription Guide. The Guide extending more than 10,000 pages encompasses information on more than 4000 drug molecules.
A very uncomplicated and straight means adopted, which incidentally has made the site immensely popular, is that taken by HealthLibrary.com. All it does is to produce on the web issues of a magazine on healthcare issues on a bio-monthly basis. It also has archival material stretching back some four years which makes for a rarely seen continuity on the web. All one needs is to go through each issue to get to the article one is looking for. This approach is excellent for its simplicity but has
certain limitations. It is aimed at doctors who are expected to browse through whichever issue they think contains material on the subject they wish to read up.
DrGill.com by contrast aims at being as extensive as possible. Virtually every conceivable healthcare concern is addressed on this portal. It is inevitable that thoroughness is bound to suffer. And the lack of focus stands out like a sore thumb. Unfortunately also, the portal sometimes gets its lines mixed up. There was a Reuters picture report about gas bursts on comets in outer space shot by the Hubble Space Telescope on the portal. How it adds to the healthcare value of the portal is not clear. Another problem that one comes across is that each page view involves separate downloading of a page which makes for long delays in reaching across hot-links.
ExtensivenessIndmedica.com sports a certificate from the Britannica for being one of the best medical information sites on the web. It divides into 31 neat categories. Access to each of them is easy and at first glance it appears that each of those categories deals with the subject superficially. In fact under each of these categories there are hot-links to ten separate information sources including a link that offers access to some of the world’s best sources of information under that specific subject. For example, of the 31 categories if we take up just Cardiology, we get under Links the following sources: Annals of Internal Medicine, British Medical Journal, NAMA, Lancet, New England Journal of Medicine, and the American College of Cardiology. Apart from this just the reference to Cardiology has links to pages on Cyber Lectures, an Image Library, Conferences, Associations, a Doctors’ Directory, Case Discussions, a chat forum and a page for feedback. Each of these is tailored for just Cardiology. Each of the 30 other categories has similar information. A very good site meant primarily for doctors.
Webhealthcentre by contrast is aimed at the consumer. Sporting a Britannica award, it offers articles on various health conditions for consumers, on-line consultation, stores on-line medical records for those who want such a facility and it has an electronic health store that offers books, medicines, personal healthcare products and even has an emergency medical loan scheme tie up with Birla Global Finance. This therefore appears to be the first of the sites to strt addressing the problem of revenue streams in right earnest.
Likewise Goodhealthnyou is aimed primarily at the consumer. The site is said to be “educative (why not educational?), not prescriptive”. Good graphics, but the content is rather like reading a more sophisticated version of Women’s Era on the net. Take just these concerns: Our nitrition week special, Anger can break your heart, Silence is golden, right?, Exercise cycle, Alternative therapy (why not in plural), Managing anaemia, Shortness of breath and for good measure, Do you fall in love easily? An easy to read site, easy on the eye, modest tothe core, with much to be modest about.
Lost OpportunityOne would wish and in fact expect ApolloHealth@Satyamonline to live up to its incredibel pedigree. It has the support of the Apollo Hospital Group and all that implies and the site is up on the web courtesy Satyam, one of India’s best known IT companies. Unfortunately it appears that the site is a cursory attempt at trying to offer instant solutions in the shape of a medicyclopedia and a net clinic. Information wise it is bereft of the faintest attempt at offering anything of value. Apollo needs to take up this site in right earnest if it is to make a credible attempt at registering any kind of presence on the web.
Value Healthcare is another site that does not seem sure what it is aiming at or whom. For example it offers a “Practice Enhancer”. It is supposed to be a patient record with other things like a Scheduler, Networking, CME and Billing and e-mail thrown in. Fine as it goes. But it does not go. “This page cannot be displayed” - that is all you get to see. Apparently much of the content is yet to be uploaded. It should get better over time. There seems to be an attempt at making a database of surgical equipment manufacturers and suppliers with a sprinkle of articles aimed at nobody in particular. Even the News is not just Healthcare news. It is all things to all men. Clearly enough thought has not gone into the composition of content.
To a large extent Healthcarehouse which calls itself “Your complete online health guide” tries earnestly to fulfil what is sets out to do. It offers banks, and medical services and also medical advice for medical as well as medico-legal problems. There are no bells and whistles. It is low profile site with a lot of potential since it sets out to offer information as a one-stop shop to those looking for it.
One comes to the inescapable conclusion that, while offering informtion specifically for doctors is an arduous taks, it is not something that is difficult to grapple with. What needs to be offered is known. The knowledge base may be vast but it is documented. Therefore it is possible, perhaps with a lot of effort, but possible, to get together a compendium of information specifically to meet the needs of the medical fraternity. Many of the sites discussed seem to succeed, in varying degrees of course, but succeed nevertheless at offering what the doctor needs.
The problem arises with the lay consumer. For a lay person a healthcare portal is a source which he goes to only when he is in need of information. It is not a source for satisfying curiosity or a source of entertainment. Most portals are not clear what the lay consumer is looking for. This is understandable, since, often enough, the consumer is often not clear himself. It is therefore necessary for portals that aim their content at consumers to first try and find out how a lay person reats to the questionof healthcare. Going toa healthcare portal is something which a consumer does only because he is concerned and needs certain specific information. But this often applies to the health conscious consumer who knows the elements of healthcare and understands the significance of some of the better known medical terms. For such consumers articles written on various disease states in layman’s language are a useful aid-something he looks forward to. MDSPEAK.com for example offers this facility. It is an extensive facility which discusses disease states at some depth, all the time keeping in mind the non-expert nature of its target audience. It tries its best to impart to a lay person a level of knowledge that he is rarely able to garner from his normal sources of information.
However there is another kind of consuemr who is probably more often encountered. He is innocent of medical knowledge and knows at best only what he feels is happening to him. Such a consumer goes to a website in search of information armed with questions which are limited to the symptoms that he feels hehas. What, to him, would be of immense value would be a site that tells him, on the basis of his understanding of his symptoms, what they could conceivably be caused by and what treatment his doctor is likely to offer him to allevitate them. If websites that offer informtion to consumers could re-engineer their sources to come up with a compendium of symptomatology they woudl find they will be doing their consumers a great service and end up getting much more eyeball support.
Still, e-health is considered by many to be the most promising hope for the information- and service-driven healthcare industry. Due to its sheer size, even a small increase in efficiency can produce billions of dollars in savings.
Since the Internet has only existed in its current form for about 7 years, there is tremendous uncertainty about how to create a profitable Internet business. Popular trends wax and wane, and a company lucky enough to catch one can see tremendous, albeit temporary, success. What will support a start-up in the long term are its fundamentals.
We have identified 4 fundamental factors that seem to be the most important in predicting the success or failure of an Internet company.
These are: (1) a compelling value, (2) an unambiguous revenue model, (3) competitive barriers to entry, and (4) organizational structure for cost control.
A Compelling ValueSuccessful Internet companies need to offer many times more value than traditional alternatives. The entire Internet economy is in a constant state of flux, with products and services rapidly changing. This creates a tremendous uncertainty for consumers because of rapid vendor and service turnover. As a result, Internet consumers are very risk averse and often prefer to adopt a wait-and-see attitude before buying. This can be devastating for a young company because it slows sales and adds to sales overhead. To overcome this, start-ups must ensure that their product has clear, compelling, and undeniable value. A product that is merely an improvement isn't enough to overcome consumer skepticism. A successful product needs to be a quantum improvement above anything else available.
Internet music-swapping service Napster is a good example of how compelling value drives growth. The service allowed users to download and listen to thousands of music files. The music files were of high quality, could be downloaded quickly, were available in great diversity, and were free. The alternative was a trip to the music store, which took more time, offered less selection, and was more expensive. For consumers, Napster was clearly superior. This compelling value accounted for the success of the service, which grew from 1.1 million to 6.7 million users in only 6 months.The service was later found to violate copyrights and was shut down by court order. Nonetheless, it is still a fine example of how compelling value can drive Internet growth.
Of the industry segments analyzed in this article, health information portals and comprehensive health sites did well at offering compelling value. These companies are providing patients and doctors with information and services that were unavailable before the advent of the Internet. During the recent anthrax scare, the Internet was the first place many people went for information about this formerly obscure bacterium.
By contrast, online drugstores failed at providing compelling value. They never gave consumers any reason to abandon their corner drugstore. For potential customers, breaking off a relationship with a pharmacist, having to wait days for delivery, and having to worry about online credit card security were sacrifices too great to justify the slight cost savings.
An Unambiguous Revenue ModelReliance upon unproven and risky revenue models contributed greatly to dot-com bankruptcies after 1999. Executives thought they could give away costly services for free and recoup losses with questionable revenue sources like banner ads. Not only did these companies fail, but they also conditioned a generation of Internet users to expect free services, making the business environment much more challenging. To succeed in this environment, tomorrow's executives must have a clear and unambiguous revenue model. They must diligently investigate their industry, know exactly where and how they intend to earn revenue, and understand the interests and incentives of their customers and competitors.
The online pharmacies and the health information portals failed here. The pharmacies did not understand that insurers are involved in 80% of prescription purchases and therefore viewed the start-ups as competition. The information portals revenue model was based on banner advertisements and depended on huge amounts of traffic and high banner rates. When rates dropped, the fates of these companies were sealed. The exception, of course, is MDConsult.com, which relies on subscriptions instead of ad revenue.
The strongest example of sound revenue models is the comprehensive e-health site WebMD, which has diversified revenue streams and thus protects itself from financial disaster should any one source of income disappear. The core revenue sources, physician practice management and transaction processing, are relatively stable once secured. Furthermore, revenue is based on licensing and/or service fees that are unlikely to change much with time.
Competitive Barriers to EntryAn enterprising entrepreneur can launch a Web-based company with a few thousand dollars and a good idea. With start-up requirements so modest, it is a virtual certainty that any successful Internet company will face hordes of copycats unless it can implement some form of lasting competitive advantage. Internet directory Yahoo is a fine example. Built by human beings, it differs from machine-generated directories and has a unique usefulness. Any would-be competitor must hire thousands of employees to surf the Web and build the directory manually. The longer Yahoo is in existence, the bigger its directory, and the larger the capital outlay for any new competitor. After nearly 6 years and millions of Web sites evaluated, such a task is nearly impossible.
Most of the companies discussed succeeded with this factor. The health information portals assembled a staff of knowledgeable medical writers who could produce high-quality articles. Competitors would need a large amount of start-up capital to hire a comparable staff. The comprehensive e-health site WebMD erected a formidable barrier to competitors by their sheer size and diverse set of assets. Smaller competitors would have to overcome its economies of scale.
The online pharmacies did not successfully create competitive barriers. Soon after their well-publicized launches, PlanetRx and Drugstore.com were besieged by both low- and high-end competitors. On the low end, discount brokers such as DestinationRx.com offered discount pharmaceuticals at lower prices than PlanetRx and Drugstore.com could. On the high end, CVS and Walgreens offered more complete service and local pickups. Squeezed between these 2 groups with no real differentiating factors, PlanetRx and Drugstore.com had nowhere to go.
Organizational Structure for Cost Control Internet leaders in the late 1990s thought that the most important predictor of future success was market share. Oftentimes, sound financial prudence was sacrificed to achieve greater market penetration. The promise of the Internet has always been to offer information and services to many customers at very low cost. Companies that succumbed to the temptation to spend lavishly soon found that they were short on cash and had to sell out or declare bankruptcy. Companies that had a rigorous organizational structure for cost control focused their spending on projects that were strategically important and offered solid returns. With cash in reserve, they were well equipped to survive economic disruptions and downturns.
Lack of an effective cost-control mechanism has been a critical problem in all of the industry sectors we have examined. Many of the companies adopted a "culture" of loose spending that was common at the time within the Internet industry. Extravagances such as fully equipped gyms, thousand-dollar Aeron chairs, and offices in the most expensive locales possible were seen as prerequisites to being a legitimate Internet company.
Many companies also succumbed to the rather erroneous notion that generous spending on advertising would automatically result in increased Web site traffic and hence increased revenue. Too often, marketing plans were approved that failed to offer adequate returns to justify their cost. Overspending on sales and marketing was a chronic problem for the online drugstores, health information portals, and WebMD.
Health info portal MDConsult is the one successful cost-control example. This is likely attributable to oversight of corporate owners which provided guidance and financial discipline.
Four Factors That Predict Future PerformanceWe have used our "4 factors" criteria to analyze 3 separate e-health market segments. This analysis is shown in Table 5. There is a definite trend for companies that achieved more of the factors to have performed better than those that achieved fewer.
A company that manages to secure all or most of these factors will have a lot behind it as it strives to build a profitable business. Physician reference site MDConsult.com is a wonderful example. With a unique and valuable product and disciplined spending, its future seems promising. This is the type of company that will grow itself and continue to grow, despite minor mistakes and setbacks that inevitably occur in a company's history.
Start-ups that have achieved only 3 of the factors face more challenges.
Success is possible, but there is little room for error. WebMD is a company that falls into this category. It has an impressive array of e-health properties that allow it to offer a bundle of services that nobody else can. It also has paying customers and an annual revenue stream of hundreds of millions of dollars per year. Its uncontrolled spending introduces a great deal of uncertainty into its future. This 1 missed factor turns a sure winner into a calculated gamble at best. Suddenly, success depends on whether its cash reserves will last. WebMD may very well overcome these issues with time, but its missing strategic factor has made success much more challenging to achieve.
E-health companies that have more than 1 missing factor are at a severe disadvantage. Their fundamentals are so flawed that even the most solid backing may not lead to success. The online drugstores come to mind. They had the best executives, the backing of leading venture capital firms, world-class strategic partnerships, and hundreds of millions in financing. In the end, none of this mattered and the companies still failed.
Future Opportunities Despite the widespread failure of e-health and other dot-com companies following the burst of the Internet bubble in 2000, the potential for e-health to streamline and improve medical care remains excellent. Even a small improvement in efficiency can produce tremendous savings for healthcare consumers and produce rich profits for enterprising start-ups.
The first generation e-health companies, like Internet companies in other industries, are mostly gone. These companies lost billions in value; thus, the lessons learned have been very costly ones. A new generation is emerging and can benefit from the mistakes of the earlier pioneers. Executives of these companies should study the past and take a hard look at their business plans. If their strategies offer compelling value and unambiguous revenue, create competitive barriers, and control costs then they are well on the way to building a successful Internet start-up and securing a promising future for their ventures and themselves.
- Provide interesting and meaningful content. The single most important element for an effective e-health portal is relevant and meaningful content. If the information on the site isn't interesting; if it doesn't encourage members or employees to visit a site, the employer or health plan sponsor will not be able to secure the benefits an e-health portal strategy can provide.
- Integrate the information with important benefit information. While people go to Internet sites to research healthcare information, as many e-health firms have discovered, content alone is not enough. The best sites today integrate meaningful educational content with pertinent health plan information and services involving claims, benefits, enrollment, provider directories, member services, and medical management programs.
- Provide a variety of information. A comprehensive and effective e-health portal allows health plan members to access the latest healthcare news and articles from consumer magazines and clinical journals. Award-winning e-health portals such as those offered by several Blues plans nationwide have gone a step further, providing original reporting, personalized newsletters, detailed website reviews, personal journals and more. The more varied and broad the information, the more apt the user is to stay at that site for all their healthcare information needs.
- Ensure the information provided is accurate and timely. With so much healthcare information available today, it is easy for consumers to become confused and misled. In addition, the rapid pace of healthcare could mean that what may have been an accepted standard yesterday is no longer the best treatment available. Clinicians who specialize, or who are board-certified in the area corresponding to a specific content area to ensure the information provided is medically accurate and timely, should review all information on an e-health portal.
- Personalize the portal. Another critical element for an effective e-health portal that can help to drive users to a site is personalization. For example, more than 80% of Internet users want a healthcare site that provides personalized disease management, according to a recent survey conducted by Cyber Dialogue. Personalized newsletters on pregnancy, diabetes or other conditions are a good start. To take the strategy a step further, the site can also provide more specific information such as a daily pollen count for members with asthma and discounts on related products.
- Give users the opportunity to interact. Realizing they have the opportunity to move beyond "generic" content, health plans are embracing the Internet for interactive communications that build more positive and personalized relationships with members. Features should include personal reminder systems, a drug database and herbal index, as well as health tools such as calculators and quizzes, ask-the-expert bulletin boards, member-to-member chat capabilities, and professionally moderated support group links. As this component becomes more familiar, site sponsors may want to consider adding additional features such as e-mailing physicians and communication with other healthcare providers such as case managers.
- Make the site easy to navigate. Despite its popularity, not everyone is at ease with the Web. An e-health portal must make it easy for all members to find their way around the website, which means the overall design, color schemes, templates and task bars should be both appealing to the eye and user-friendlY.
- Offer the latest in security and confidentiality. From a technical standpoint, there's no issue more important than protecting the identity of end users and confidentiality of personal information. Be sure that the website's technology partner provides state-of-the-art encryption and firewall security, as well as policies that guard against selling end-user data. Members will not use a site if they fear that administrators or others will be able to access personal information. Data should be gathered and communicated in the aggregate only. In addition, the program must be an opt-in allowing those who want greater personalization to access that feature but still giving those who want simply to access information that option as well.
- Provide opportunities for safe and secure online shopping. The original e-commerce model - consumer information sites driven by advertising - is not proving to be viable as the healthcare industry matures. The new approach involving private label and co-branded e-health portals allows health plans to preserve and own the channel for online communications to their members instead of giving away this piece of the value chain to a third party. The cost of customization can be subsidized by sharing a portion of e-commerce revenues, with the percentage of revenue sharing linked to the level of traffic a plan drives to the site.
- Select partners to develop the e-health portal carefully. Developing an e-health portal is a difficult proposition that often requires outside expertise and direction. Customized healthcare websites are only as good as the partnerships from which they are born. The federal Office of Disease Prevention and Health Promotion urges consumers to pay close attention to who's sponsoring and managing these sites, as well as their credentials and level of medical expertise. Working with a credible developer can help an organization ensure that their members will have the comfort level needed to feel secure using a site.
Friday 25 April 2008
One of the Web's most well-known health sites -- DrKoop.com, founded in 1997 by former U.S. Surgeon General C. Everett Koop -- set a bad example when it had a much-publicized heart attack. The site went public in 2000 and at one point had a market value of more than $1 billion. But the company foundered and was delisted by Nasdaq only a year later. The site name was purchased for $186,000 by Vitacost and the brand is now operated by a group called MDchoice.
The good news for health consumers -- which ultimately includes all of us -- is that reliable health-care information is becoming more widely available than ever. The upshot of this may be of great significance to you or your company.
New Entrants Offer Expanded Health Info
Three sites typify the new wave of health portals that are changing the way people get information about diseases, medications and treatments:
• PatientInform.org has just gone live as a pilot project to unearth health research that might otherwise remain buried behind fee-based subscription services. The site is a joint effort of the American Cancer Society, the American Diabetes Association, and the American Heart Association.
• MammaHealth.com launched just yesterday as a specialized offshoot of Mamma.com, a Web search engine. The new health site "has harnessed the power of the Deep Web by hand-picking the most relevant medical sources for credible health information and crawling deep into the content these sites provide," according to Nicole Festa, a company p.r. representative. "You can simply type in the word diabetes and instantly get back credible information, not disorganized results leading you to sites trying to sell you pharmaceuticals or information from dubious sources."
• Answers.com launched in January as a serious attempt to respond to search queries with informative articles rather than unrelated lists of links, à la Google. Although the site isn't limited to health concerns, it does quite a credible job on medical topics, providing a series of articles from established reference sources.
Of these three efforts, PatientInform.org is the most interesting. That's because it represents a ground-breaking attempt to wrest medical research studies from publications that otherwise charge hefty subscriber fees to read them.
Information Wants To Be Free
Ironically, you can't go to PatientInform.org and type diabetes or any other keyword. Instead, PatientInform is more like a code name for the information-liberating campaign of the three health groups sponsoring it. These nonprofit associations are determined to make research studies available to the people who need them, free of charge, no matter who may own the original, copyrighted material.
"What PatientInform is adding is one important part," says David Sampson, a media relations representative for the American Cancer Society. "We link to the actual study, which is normally blocked off behind a subscription barrier."
Some medical publishers won't allow any cost-free links to the studies they publish. But because of the prestige of the nonprofits sponsoring PatientInform, many publishers have decided to allow the groups to link without cost to material that otherwise requires a paid subscription.
To get access to these studies, a consumer should first go to the sponsoring nonprofit that's related to a particular disease or medication. For example, if you're looking for the latest information on multiple myeloma, go to ACS News Center of the American Cancer Society's site. Clicking the link regarding the disease reveals a summary of a report published in the New England Journal of Medicine, with a link to the full article. The PatientInform logo on that page indicates that the information is an outcome of the nonprofit groups' efforts to make such information available for free.
The Challenge Of Providing A Simple User Interface
As important as the groups' goal may be, the PatientInform.org site unfortunately doesn't yet have a user interface that's convenient for consumers to use. Far from providing a simple search box for visitors, the site makes you drill down just to find links to the three participating organizations where the useful information is actually located.
Sampson says this is because the combined site is still a pilot program. He promises that the site's search functions will become easier in the future.
Even at this early stage, however, the PatientInform campaign is unearthing information that was previously difficult or expensive for lay persons to find. "A patient already has access to some of these [reports], but you'd have to be very savvy," Sampson says. For example, some medical studies can be found in printed form in university libraries -- but this is hardly as convenient as looking them up on the Web.
PatientInform's philosophy of converting fee-based information to free is one that could apply to many other fields, not just health. It's a model that profit-making corporations as well as nonprofit organizations should look into.
Even though the Indian health insurance market grew by 38% in 2006-07, only 1.08% of India’s billion plus population has medical insurance. The general perception is that the prospects for growth in this sector of the insurance market are good.
Health insurance policies were first introduced in 1986 at a time when the Indian insurance industry was nationalised. The policies on offer were complicated to read and offered limited cover. There were no third party administrators operating in India, and there was no direct settlement of claims between health Insurer and hospital. There were therefore issues concerning claims servicing, which involved an Insured following cumbersome procedures to get claims authenticated and paid. The business was not profitable for the nationalised Insurers, and not popular with the public at large.
The original ‘Mediclaim Policy’, however, developed and in many cases has provided the base model for the health care insurance policies that were introduced immediately after liberalisation of the general insurance sector at the turn of the millennium.
Health insurance, however, saw no specialist players until relatively recently with the entry into the market of companies such as Star Heath & Allied Insurance and Apollo DKV Insurance. This is because there was a general expectation that the insurance industry regulator, the IRDA, would set a smaller capitalisation requirement for health insurers and/or amend the rules for foreign equity ownership in Indian Insurers in recognition of the fact that health insurance loss ratios were not good, and therefore finding an Indian partner to invest 76% in a health insurer would be a difficult task.
The IRDA did not, however, relax either the capitalisation requirements or foreign investments caps. Initially, therefore, the health insurance market did not grow as quickly as may have been expected.
The generally optimistic perception for the growth of health insurance is certainly supported by the growth in the number of policyholders, but the profitability of this line of business remains an issue. The health insurance sector had a loss ratio of about 78% in 2003, which deteriorated to 98% in 2004-05. Currently, available figures suggest that the claims ratio stands at 110% - 120%.
Growth in policyholder numbers, more effective third party administration and an effective network of hospitals is expected to see the numbers improve. Other changes have been effected to encourage growth in this sector. For example:
Life insurers have been allowed to sell health insurance. Initially, life insurers were only allowed to sell certain types of health covers as a supplement to a life policy. However, the (IRDA) has allowed life insurers to sell pure health insurance products subject to product specific approvals.
The standard mediclaim policy has undergone several revisions and modifications. In recent years, private health insurers, such as Apollo DKV, have been offering fresh products with increased covers and sums insured.
The growing expense of health care in India. Private hospital rates are still low compared to the rates charged in more developed countries, but high when compared to average Indian earnings. It is no longer uncommon for Indian employees to now expect that health care will be part of an employment package.
With the opening up of the market to private competition, the claims process has become much less cumbersome.
Support for a health insurance market has also come from some less obvious sources. Indian states have started relying on insurance policies to meet some of their legal obligations to provide health care to their citizens. The central government has also proposed the introduction of free health care insurance for the poor. This plan is meant to cover every poor family for INR30,000 (c. US$750) per annum. The central government will pay 75% of the premium, leaving the remaining 25% to be covered by state governments.
The IRDA has also encouraged Micro-insurance as a means of extending the availability of health insurance to areas of the market that, geographically and economically, may not have been at the forefront of Insurers’ business plans.
The Legal Playing Field
At the same time as the market grows, the IRDA and the Courts are stepping in to create a more consumer friendly playing field, particularly as regards the treatment of senior citizens; the operation of the pre-existing diseases exclusion, and the reluctance of insurers to renew policies where the claims experience has been bad.
Senior citizens had been complaining about the reluctance of Insurers to issue policies to them, and the inclusion of disadvantageous terms when policies were offered – such as hefty increases in premium rates, added exclusions and conditions, etc. In May 2007, the IRDA set up a Committee on Health Insurance for Senior Citizens to make recommendations. Its members included representatives from the General Insurance Corporation of India, Oriental and Apollo DKV as well as others. The Committee reported in November 2007 and made the following main recommendations:
Senior Citizens should have some assurance that their policies will be renewed.
The Industry should adopt standard terms and conditions, such as for the definition of pre-existing diseases.
The Committee also said that policy wordings should be simpler for the lay person to follow, suggesting that uniform terminology be used by all Insurers to lessen confusion in the public mind.
The IRDA is still in the process of evaluating the Committee recommendations and none of them have been formally adopted, but there are indications of an indirect reliance on part of the Committee’s recommendations during the File & Use procedure. This is the process whereby a non-tariffed product is brought to market. It must first be filed with the IRDA, and only thereafter can it be sold. During the filing stage, the IRDA has been paying particularly close attention to exclusion clauses in general, and the pre-existing disease exclusion in particular.
The Courts have taken a similar interest. The Judgment in New India Assurance v Akshoy Kumar Paul was handed down by the Delhi High Court in November 2007 and has only recently been reported. The Court had to consider whether, on renewal, a state owned Insurer could refuse to renew or insert an exclusion clause if it did renew. The Insured had held the policy for 5 years, renewing it on 4 occasions. In the preceding year, he had suffered a heart attack. It was held that New India must renew, and the ‘renewal of an insurance policy means repetition of the original in a manner that the old policy gets revived on the same terms and conditions as were incorporated in the original policy’. The exclusion clause was not permitted.
Although it interferes with principles of privity of contract, the judgment can be justified by reference to earlier decisions to the effect that state owned Insurers have special obligations to act fairly because they are state owned and therefore an extension of the state. It remains to be seen whether the obligation to renew on the same terms will be extended to private Insurers.
Nevertheless, there is a clear pro-consumer trend in the Courts and at the regulatory level when it comes to health insurance.
Article by Neeraj Tuli
The Smart Card Alliance has formed a Healthcare Council to bring together payers, providers and technologists to promote the adoption of smart cards in U.S. healthcare organizations. Smart card technology is increasingly being used in healthcare applications to enable secure access to patient information to improve both care-giving and administration.
"Smart card technology holds great promise for the healthcare industry," said Randy Vanderhoof, executive director of the Smart Card Alliance. "The Healthcare Council provides a forum where all the stakeholders can collaborate to educate the market on how the smart cards can be used and to work on issues inhibiting the industry."
Dr. Paul Davis, Council co-chair and CEO of Uniliance Health, outlined the priorities for the Council. "There are numerous initiatives around the world using smart cards for a variety of secure healthcare applications. One of the group's initial projects will be to examine current implementations and describe the benefits and best practices for smart card deployment in various healthcare environments."
"Smart cards can play an important role in the implementation of privacy- sensitive access to secure personal health information, support safer patient care and help reduce the overall costs associated with the delivery of that care," said Frank Avignone, Council co-chair and business development manager for Healthmeans.
The Council will also seek partnerships with standards-setting groups such as HL7 and other organizations whose mission it is to achieve common standards for electronic medical records.
A new white paper from the Smart Card Alliance details how smart card technology is slowly making its way into the healthcare industry and the benefits of transitioning to a system that provides better security while meeting patient privacy regulations.
In an era of managed care, specialized medicine, mile-high paperwork, high costs, identity fraud and government demand for secure, portable and confidential patient information, the competitiveness of healthcare providers depends on the proper use of information technology. As a result, the healthcare industry is on the cusp of a move away from error-prone paper and ink toward a more secure electronic world.
A new white paper, Smart Card Applications in the U.S. Healthcare Industry, examines how smart card technology is being incorporated into new healthcare systems to protect and enable convenient access to patient data and support new applications that deliver clinical and administrative benefits.
"The use of smart cards in healthcare is gaining momentum. This white paper explains how its feature-rich, flexible platform provides a practical and portable way to enhance the security and confidentiality of patient information," said Randy Vanderhoof, executive director of the Alliance. "In the long run, the data carried by smart health cards can not only save lives, but can also save the healthcare industry billions of dollars."
The white paper describes the following benefits that smart cards provide in healthcare applications:
-- Support privacy and security requirements mandated by HIPAA
-- Provide the secure carrier for portable medical records
-- Support new processes that can reduce administrative costs
-- Reduce healthcare fraud
-- Provide secure access to emergency medical information
-- Provide support for patient loyalty programs
-- Enable compliance with government initiatives and mandates
The white paper concludes with profiles of a number of organizations who are implementing smart cards, including the Queens Health Network, University of Pittsburgh Medical Center, St. Luke's Episcopal Health System, Florida eLife-Card, Texas Medicaid, and the French and German health cards. The paper explains how these implementations illustrate the diversity of applications that are enabled by smart card technology and the business benefits that the technology delivers to healthcare organizations.
Individuals from 24 organizations in the Smart Card Alliance Healthcare Council collaborated on this white paper. Lead contributors included representatives from: ACI Worldwide, Axalto, Competech Smart Card Solutions, EMIDASI, Healthmeans, Hitachi America Ltd., Lockheed Martin, Oberthur Card Systems, OTI America, PrivaMed, Inc., Sharp, TecSec, Uniliance Health, U.S. Dept. of Defense, VeriFone, and Visa USA.
The white paper, written for executives and managers, is available at no charge from the Smart Card Alliance web site at www.smartcardalliance.org.
About the Healthcare Council
The Healthcare Council is one of several Smart Card Alliance Technology and Industry Councils, a new type of focused group within the overall structure of the Alliance. These councils have been created to foster increased industry collaboration within a particular industry or market segment and produce tangible results, speeding smart card adoption and industry growth.
The Smart Card Alliance Healthcare Council brings together payers, providers, and technologists to promote the adoption of smart cards in U.S. healthcare organizations. The Healthcare Council provides a forum where all stakeholders can collaborate to educate the market on the how smart cards can be used and to work on issues inhibiting the industry.
Healthcare Council participation is open to any Smart Card Alliance member who wishes to contribute to the Council projects.
About the Smart Card Alliance
The Smart Card Alliance is a not-for-profit, multi-industry association working to accelerate the acceptance of smart card technology.
Between 1987 and 1996, there was a shocking 30% decline in the use of public healthcare facilities in both rural and urban areas. Over this decade, utilisation of private health services, especially in the hospital sector, increased substantially, out-of pocket spending on healthcare galloped, and indebtedness due to healthcare affected nearly half the users of healthcare facilities. A comparison of utilisation and health expenditure data across the 42nd (1987) and 52nd (1996) Rounds of the NSS showed up these alarming trends. As a consequence of the declining use of public healthcare facilities, the 52nd Round showed higher levels of untreated morbidity, especially amongst poorer groups. The 2002 National Health Policy unashamedly acknowledges that the public healthcare system is grossly short of its defined requirements, that functioning is far from satisfactory, that morbidity and mortality due to easily curable diseases continue to be unacceptably high, and resource allocations generally insufficient.
Why did this happen? The inadequate commitment of public resources to healthcare was mainly responsible for poor health outcomes in India.
The cost of seeking treatment even at public hospitals had increased five-fold (simultaneously, the cost of treatment in private hospitals increased nearly seven-fold), though the purchasing power of the poorer classes had not changed in any substantial way.
These trends are closely linked to a wide spectrum of changes in the economy since the mid-1980s, which have led to the privatisation of services, deregulation of drug prices, increased reliance on market mechanisms to address welfare needs, and a weakening of public health systems.
As a result of structural adjustment programmes, investment and expenditure in the public health sector has been declining. This privatisation policy, which mandates the introduction and/or increase of user charges at public health facilities, has taken the public health system to the brink of collapse. With greater dependence on the market for healthcare, access had become more difficult for an increasing number of people.
Public financing is critical
Public financing of healthcare is critical in both developed and developing economies. A political economy based largely on private health financing can create adversities for health not only for poorer sections of society but also the middle classes. In most developed countries, where healthcare access is near-universal, public financing, which accounts for around 80% of all health expenditure, whether through state revenues and/or social insurance, has been the critical component in realising universal access with equity., In contrast, in most developing countries the reverse is true -- 70-80% of health expenditure is met by individuals from their private resources.
India lost the opportunity to implement a national healthcare system immediately after Independence through the Bhore Committee recommendations. The country made very poor investments in the public health sector over the years. But the mid-1970s saw major investment, especially in rural India , via the Minimum Needs Programme. The Fifth to Seventh Plan period was the 'golden era' of public health sector performance in India, when public investment and expenditure in healthcare peaked and health outcomes witnessed substantial improvement, first in the developed states and then in the underdeveloped ones.
But the economic crisis of 1991 and the economic reforms posited by the Structural Adjustment Programme (SAP) pushed by the World Bank upset the achievements of the public health sector in this golden era. Resource commitments to public health declined in the 1990s, especially in the developed states. Improvements in health outcomes slowed down, and the rural-urban gap widened. Public healthcare facilities were incapacitated because of insufficient inputs. This has been caused by the compression of public spending in the health sector as well as allocative inefficiencies caused by unprecedented increases in salaries as a consequence of the implementation of the Fifth Pay Commission (1996-1998). Non-salary components have shrunk considerably as budget increases do not factor in allocative efficiencies for the effective running of the public health system. This coupled with privatisation policies, including the introduction and/or increase in user charges, has taken the public health system to the brink of collapse. With greater dependence on the market for healthcare, access becomes more difficult for an increasing number of people.
In fact, when we relate health outcomes with expenditure we see that in comparison to similarly developed countries India 's performance is the worst despite the fact that we have one of the highest total health expenditures amongst these countries. See the table below.
Health outcomes in relation to health expenditure patterns
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Total health expenditure as % of GDP
Public health expenditure as % of total
Source: Changing the Indian Health System -- Draft Report, ICRIER, 2001
This poor performance is largely because, in India , spending is mostly out-of-pocket as the public resources committed are very low. In a scenario of poverty, such a mechanism of financing will never show up good health outcomes because when the poor and not-so-poor have to pay their health expenses they forego other basic needs or, worse still, get indebted. National surveys show that loans for healthcare is the number one reason why families, especially the poor, are trapped into indebtedness . This is clear evidence that public financing is critical for good healthcare and health outcomes.
Only 15% of the Rs 1,500 billion healthcare sector is publicly financed
The total value of the health sector in India today is over Rs 1,500 billion, or US$ 34 billion. This works out to about Rs 1,500 per capita, which is 6% of GDP. Of this, 15% is publicly financed, 4% is from social insurance, 1% from private insurance (Mediclaim policies, 85% to public sector insurance companies) and the remaining 80% from the pockets of patients as user fees (85% of which goes to the private sector). See table below. Two-thirds of users are purely out-of-pocket users and 70% of them are poor. The tragedy is that in India , as elsewhere, those who have the capacity to buy healthcare from the market most often get healthcare without having to pay for it directly, and those who are below the poverty line or living at subsistence levels are forced to make direct payments, often with a heavy burden of debt. National data reveals that 50% of the bottom quintile sold assets or took loans to access hospital care. Thus, loans and sale of assets are estimated to contribute substantially towards financing healthcare. This further underlines the need for insurance and social security.
Financing healthcare in India (2003)
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Estimated users in millions
Expenditure (Rs in billions)
Of which social insurance
Of which social insurance
About 80% of public financing of healthcare comes from state government budgets, 12% from the Union government and 8% from local governments. Of the total public health budget today, about 10% is externally financed in contrast to around 1% prior to the structural adjustment loan from the World Bank and loans from other agencies. Private financing is mostly out-of-pocket, with a large proportion, especially for hospitalisation, coming not from current incomes but from savings, debt and sale of assets. Insurance contributions, whether for social insurance schemes or as private insurance premiums, constitute a very small proportion.
Trends in public health expenditure
Public investment in the social sector in India has been a cause for concern. The attempt at a mixed economy that marries socialism and capitalism has not worked for either system. In retrospect, the large public sector economy failed to realise both economic and social goals. On the contrary, it helped the accumulation of private capital. The Indian bourgeoisie and the state did not have the vision to promote a welfare state. From the First Plan onwards the health sector has received inadequate resources and these resources largely benefited the small urban-industrial economy. Table 1 in the Factfiles section at the end of this journal profiles the investment and expenditures in the health sector since the First Plan period. It is evident that the state has, over the years, committed a mere 3% of public resources for the health sector and this has invariably been less than 1% of GDP. As a consequence, healthcare has been an out-of-pocket burden on households. Of the total health expenditure in India , the public sector contributes around one-fifth and this has remained more or less constant over the years, with a declining trend in the last decade. This level of state investment in health is not adequate to ensure universal and equitable healthcare access.
The post-SAP period saw a declining trend in public resources being committed to the health sector, and the stagnation in health outcomes is largely a consequence of this. Graph 1 and Table 2 in Factfiles show the trends in public health spending from 1976 to 2001 and it is evident from this that in the 1980s public health expenditure as a percentage of GDP as well as a proportion of total government spending peaked and then began to decline. Worse, the proportion of capital expenditure was halved during the '90s as compared to the '80s; this meant that new investment in public health had almost ceased. This was the period of private sector expansion in the health sector (post-SAP, even private health expenditure showed a decline, but in the latter half of the '90s it began climbing again and rapidly). (See Table 1 and Table 6 at the end of the article.)
While overall public health investment and expenditure have been low and inadequate to meet the healthcare needs of the population at large, there are hierarchies within this health spending. The most obvious hierarchy is the rural-urban dichotomy in public health investment and expenditure. Rural areas across the country have public health services that largely focus on preventive and promotive aspects. Thus, immunisation for children and pregnant women, antenatal care, surveillance of selected diseases and family planning services constitute the key focus of the primary healthcare system provided for rural India . The component for ambulatory curative services is grossly inadequate under the primary healthcare system. In contrast, the focus in urban healthcare is largely curative, with dispensaries and hospitals taking away most of the health resources. Since India lacks a national health accounting system, disaggregation of public spending across rural and urban areas, for the country as a whole, is difficult to compile. However, we have done this exercise for Maharashtra state to estimate rural-urban differentials in the allocation of resources (Table 3/Graph 2 at the end of the article).
The rural-urban distribution of resources at one level favours urban health facilities with over 60% of allocations for urban areas where 40% of the population resides. But, more important, at another level the service mix of healthcare in the two regions differs significantly. Rural areas get only half the resources urban areas get on a per capita basis, and within this low allocation only 4% is for medical care and a little over 1% for capital expenditure (Table 3). The rest is on the preventive and promotive programmes referred to earlier.
In contrast, in urban areas, resource distribution shows a good mix of curative, preventive and promotive services, with curative services comprising nearly half the urban health budget. While this data is from Maharashtra , in other states the rural-urban disparity should not be very different; in fact the allocation of resources to rural areas in the under-developed states is likely to be worse.
While rural-urban differential health expenditures are not available in the national health accounts, we do have data on expenditures across major health programmes. Table 4 shows that until the beginning of the 1990s the proportion across programmes maintained an astonishing consistency. What we see since then is a decline in the proportion of expenditure on hospitals and dispensaries, capital expenditure and disease programmes. One programme that has gained substantially is Mother and Child Health (MCH) now called Reproductive and Child Health (RCH) together with the family planning programme, because of an increased focus on antenatal care and child immunisation. Capital expenditures have taken a real beating (see Table 2) and as a result there have been virtually no new investments in the public domain during the 1990s and subsequently. However, the decline under the budget head 'hospital and dispensaries' and 'disease programmes' may not be actually so. In the finance accounts there have been changes in reporting in which external budgetary support is shown under a separate head, and since such resources have come largely to the hospital sector (health sector reform projects of the World Bank, European Union, etc) and to disease programmes like AIDS and tuberculosis, there is perhaps no real decline under these two heads. So the astonishing consistency seems to continue, perhaps reflecting that there is very little drive for change in the method of public health spending.
Further, when we look across states the declining trend in public health expenditure during the 1990s is almost universal (Table 5). The collapse is taking place across the length and breadth of the country and this is a very serious concern. Yet, one sees increased proportions being allocated in the central government's budget: this is also a matter of concern because most of this increase is due to external funding for vertical health projects like the health sector reform projects of the World Bank and EU, RCH projects of various bilateral and multilateral donors, HIV/AIDS funding, etc.
Another concern vis-à-vis public health budgets is that of allocative efficiency of resources. In the 1990s, budgets shrank, yet salaries (post-1996) increased substantially and this upset the availability of resources for non-salary components in most states and added salt to the wounds of the ailing public health system. It is only in the last few years that the ratio of salary to non-salary is returning to the pre-1996 period.
To sum up then, it seems clear that the collapse of the public health system during the last decade is linked to falling levels of public health investment and declining public health expenditure. In a situation of continuing poverty, this can only lead to increased adversities in health outcomes.
Source: Performance budgets, ministry of health and family welfare, government of Maharashtra 2002-03, Mumbai, 2003
|Table 1:||Pattern of investment and expenditure on health and family welfare (Rs in billions) and selected health outcomes (Click here)|
|Table 2:|| |
Total public health expenditure (revenue + capital) trends 1975-2003 and selected ratios (Click here)
|Table 3:|| |
Maharashtra 2000-01 public health expenditures (Rs in millions )
|Table 4:|| |
Disaggregation of national public health expenditure by major programmes (Click here)
|Table 5:|| |
Revenue expenditure on health: Union government and states (Click here)
Private health expenditure trends (Click here)
(This is an abridged version of a paper titled 'Public Health Expenditures, Investment and Financing Under the Shadow of a Growing Private Sector')
By Soumitra Pathare
Mental health disorders account for nearly a sixth of all health-related disorders. Yet we have just 0.4 psychiatrists and 0.02 psychologists per 100,000 people, and 0.25 mental health beds per 10,000 population. If access to mental healthcare is to be improved, mental healthcare must be provided at the community and primary level
Mental disorders are grossly underestimated by the community and health system in India and across the world. It is estimated that in 2000, mental disorders accounted for 12.3% of disability adjusted life years (DALY) and 31% of years lived with disability. Projections suggest that the health burden due to mental disorders will increase to 15% of DALY by 2020 (Murray and Lopez 1996). Thus mental disorders account for nearly a sixth of all health-related disability.
Despite this, most countries devote 1% or less of their health budgets to mental health services. India spends just 0.83% of its total health budget on mental health (WHO 2001a).
India has a high rate of suicides -- 89,000 persons committed suicide in 1995, increasing to 96,000 in 1997 and 104,000 in 1998, which is a 25% increase over the previous year (WHO 2001b). Hidden in the data on mental health morbidity are two points of particular importance for India:
- The burden of mental disorders is highest among young adults aged 15-44 years, which is the most economically productive section of the community.
- It is projected that developing countries such as India will see the most substantial increases in the burden of mental disorders in the next two decades.
Many people are still unaware that there are effective treatments for many mental disorders. For example, nearly 50-60% of persons with depression will recover with treatment in three to eight months; with schizophrenia, a combination of regular medication, family education and support can reduce the relapse rate from 50% to 10%. There is also sufficient evidence to show that adequate prevention and treatment of mental disorders can reduce suicide rates whether such interventions are directed at individuals, families, schools or other sections of the general community (WHO 2001c).
In spite of the high burden of mental disorders and the fact that a significant portion of this burden can be reduced by primary and secondary prevention, most people in India do not have access to mental healthcare due to inadequate facilities and lack of human resources. India has 0.25 mental health beds per 10,000 population. Of these, the vast majority (0.20) are in mental hospitals and occupied by long-stay patients and therefore not really accessible to the general population. There is also a paucity of mental health professionals. India has 0.4 psychiatrists, 0.04 psychiatric nurses, 0.02 psychologists and 0.02 social workers per 100,000 population. To illustrate the level of under-provision, Indonesia , a low-income-group country from the Asian region, has 0.4 beds per 10,000 population and 0.21 psychiatrists, 0.9 psychiatric nurses, 0.3 psychologists and 1.5 social workers per 100,000 population (WHO 2001a).
India has a community mental health programme that consists of integrating basic mental healthcare into general healthcare services by training primary healthcare personnel in mental healthcare, providing adequate neuropsychiatric drugs in primary care settings, supervising primary healthcare staff and establishing a psychiatric unit at the district level. The programme is being implemented in 22 districts in the country and covers around 40 million people, which is approximately 5% of the population. This programme will be extended to 100 districts over the next five years but will still only cover 150 million people, or approximately 15% of the country's population.
Thus, the key priority for mental health in India is addressing the accessibility issue. Policy interventions are needed to increase the level of access of the entire population to appropriate and quality mental health services.
How can access be improved?
First it must be acknowledged that improving access requires additional financial resources. There is an absolute as well as relative (to other health sectors) under-provision of financial resources for mental health that needs to be urgently corrected. Within the health budget it is imperative that allocation to mental health be increased, taking into account the burden of mental health problems. As noted above, India spends only 0.83% of its total health budget on mental health.
It is difficult to know the exact break-up of spending, as India does not have a separate mental health budget. However, details of mental health spending are available for one Indian state, Gujarat . In Gujarat , the total allocation towards mental health works out to Rs 82 million out of a total health budget of Rs 8,562 million. Of this Rs 82 million, Rs 37 million is spent on mental hospitals, Rs 34 million on medical colleges (presumably departments of psychiatry in medical colleges) and Rs 5 million on district hospitals (Mission Report, 2003). It appears that Rs 2.15 million under 'central sponsored schemes' is the only outlay on a community programme. About 67% of the total expenditure is on salaries and 20% on medicines and supplies.
Many countries spend much more on mental healthcare as a percentage of total health spending. For example, Malaysia spends 1.5% of its total health budget, China 2.35%, South Africa 2.7%, Australia 6.5% and New Zealand 11% (WHO 2001a).
Integrating mental health with primary care
Integrating mental health services into primary care is the only viable strategy for quickly increasing access to mental healthcare. Services provided through primary care also have higher acceptability within the community. There is less stigma associated with seeking help from primary healthcare services because these services provide both physical and mental healthcare. Community-based primary care services are also less likely to result in human rights violations for persons with mental disorders. Most such violations have occurred in institutions.
For integration to succeed it is important that primary care staff have the appropriate training and skills in providing mental healthcare. Primary care staff are already overburdened with multiple healthcare programmes. If they are to take on additional mental health work, the number of primary healthcare staff will have to be increased. Adequate support and supervision of primary care staff by mental health professionals is essential if integration is to succeed.
Availability of psychotropic drugs at the primary level
Psychotropic drugs provide an essential first line of treatment for mental disorders as they can reduce symptoms, shorten the course of mental disorders and prevent relapses. Psychotropic drugs should be included in the essential drugs lists so as to improve their availability at the primary care level. Legislative and policy changes may be necessary because only psychiatrists are authorised to prescribe many psychotropic drugs. If primary care integration has to work, primary care health professionals should be allowed to prescribe and have access to psychotropic drugs.
The indicative costs of drug treatment for mental illness is quite low compared to many other chronic medical conditions. For example, the indicative drug cost of treatment for schizophrenia is Rs 1,380 for three years; for bipolar disorder it is Rs 6,000 for three years and for depression it is Rs 1,300 for one year. These costs are based on retail pricing of drugs -- bulk purchases by organisations are likely to cost at least 30% less. There are also many low-cost providers of psychotropic medications who can provide these medicines still cheaper.
There is unlikely to be a significant impact of WTO patent protections coming into play in 2005 in the short-term as most of the drugs are already available in the Indian market. In the long-term, as new drugs are discovered, there may be a cost impact or non-availability in the Indian market. At the moment it is difficult to estimate this cost impact.
Increasing the number of mental health professionals
Increasing the number of mental health professionals is another area that needs urgent attention. Along with an absolute increase in the number of mental health professionals, the ratios of various mental health professionals should be balanced. India has a top-heavy and skewed distribution of mental health professionals, with nearly 10 times as many psychiatrists as psychiatric nurses, and nearly 20 times as many psychiatrists as psychologists and social workers. In most countries the ratios are the reverse, with 10-15 times as many psychologists, psychiatric nurses and social workers as psychiatrists. Unfortunately, there is no professional body that has overall training responsibility for mental health professionals. Professional psychiatric training is controlled by agencies dealing with medical education and training such as the Medical Council of India, National Academy of Medical Sciences and the like, while nursing education and training is the responsibility of the Nursing Council, and psychology and social work training the responsibility of university departments of psychology and social work. Many psychologists and social workers do not get any hands-on clinical training, as their courses are almost entirely classroom-based. There is a need for closer collaboration and co-operation between the various agencies involved in training different mental health professionals. For example, psychologists and social workers need clinical training in working with patients with mental illness -- this can only be done in medical departments of psychiatry, which historically have only been involved in training medical professionals. It is important that university departments of clinical psychology and departments of psychiatry work together to train all mental health professionals.
Inter-sectoral collaboration provides another opportunity for improving access to mental healthcare. Inter-sectoral collaboration includes collaboration within the health sector and outside the health sector, as well as collaboration between the private sector, NGO sector and public sector. For example, there are many general practitioners in the private sector who can provide community-based care, with adequate training and supervision. Psychiatry departments in public sector medical schools could collaborate with these general practitioners to provide training and supervision and thus exponentially increase access to mental healthcare.
Within the health sector, collaboration with other health programmes such as those addressing HIV/AIDS and maternal and child health provides the opportunity to improve access, especially to vulnerable sections of society. Many NGOs have community-based programmes, and effective collaboration between the mental health sector and the NGO sector could help improve access to mental healthcare. For example women's mental health issues, including depression, could become part of a wider programme addressing domestic violence. Masum, an NGO working with rural women in Maharashtra , has decided to integrate mental health issues in all its programmes. Its staff (120 of them) will be trained to detect clinical depression in the community and in basic listening and communication skills. All staff will be trained to assess the risk of suicide. A smaller proportion of the staff (approximately 20) will be trained in specific psychotherapeutic methods and a basic understanding of psychotropic drugs. This is backed by a general physician prescribing medicines if necessary. They also have access to a psychiatrist who is mainly involved in training and supervision and will see only the most seriously ill persons. This way, most of the clinical work is done by community-based staff within the community and the medical professionals are only utilised for serious problems where medication or admission to hospital may be necessary.
Community participation and awareness
It is essential to involve communities, families and users in developing and delivering mental health services. This leads to the development of services that address people's perceived needs and are therefore better utilised by them. Community participation also has the added advantage of tackling the stigma and discrimination associated with mental disorders.
Increasing public awareness about the burden of mental disorders and the availability of quality treatment is essential to reduce barriers to treatment due to inadequate knowledge about mental health services. The media can play a role in highlighting the availability of effective and safe treatments for mental illness. It can stop using negative language when referring to people with mental illness (for example the use of words such as "crazy, mad, lunatic") and also spread information on the symptoms of common mental disorders. Public health departments also have a responsibility to disseminate information on the identification of common mental disorders and the availability of help at the primary care level. Many people who are aware of their own mental illness will not seek help because they fear they will have to approach a mental hospital and also fear the stigma of having a mental illness. It is important to assure them confidentiality and availability of mental healthcare at the primary level.
Mental health policies
Finally, it is important that we develop mental health policies, programmes and legislation to increase access to mental healthcare and promote respect for the human rights of persons with mental disorders. India 's mental health law is very inadequate and in many instances acts as a barrier to accessing mental health services. We need a modern mental health law that gives priority to protecting the rights of persons with mental disorders, promotes development of community-based care and improves access to mental healthcare. The legislation in India does not promote community-based mental healthcare and widespread access to mental health services. There is no specific law requiring the creation of community-based services in the Mental Health Act, or incorporating mental healthcare into primary healthcare. There is no explicit legislation requiring the informed consent -- oral or written -- of a patient for medical treatment upon admission under voluntary or involuntary circumstances. There are no safeguards or review mechanisms for involuntary treatment of patients, regardless of how they were admitted into a psychiatric facility. And, lastly, Indian penal laws still regard attempted suicide as a criminal act. Thus patients who have attempted suicide are liable for prosecution. In reality, no one has yet been prosecuted for attempted suicide but this provision gives the police an opportunity to harass people who actually need help and treatment. There is enough anecdotal evidence that the police extract money from patients and their relatives, threatening them with prosecution and publicising the fact that they attempted suicide. Thus we have a peculiar situation here -- the state will not provide medical help for what is clearly an act arising out mental illness, but is eager to prosecute vulnerable people who need help.