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.
By G Ananthakrishnan
In the absence of a robust state-funded health infrastructure providing free care, citizens have no option but to seek out private facilities. As a result, we have a burgeoning private healthcare sector, unregulated and often exploitative
A single episode of major illness is enough to eat away the life-savings of most individuals in India . In fact, there is data to suggest that such illnesses push several families below the poverty line. The World Bank reported in 2002 that irrespective of income class, one episode of hospitalisation is estimated to account for 58% of per capita annual expenditure, pushing 2.2% of the population below the poverty line. Even more disconcerting is the fact that 40% of those hospitalised had to borrow money or sell off assets. During 1986-96, the number of people who could not access healthcare because of financial reasons doubled over the baseline.
This obviously suggests a greater role for the public sector in healthcare. Yet, several studies have recorded the growing role of the private sector in the provision of healthcare in India . In a study of World Bank projects operating in India , Kamran Abbasi makes it clear that lack of funding in the public healthcare sector translates into inadequate quality of service, which forces "the poor to turn towards the private sector, which in turn exploits clients by using expensive inappropriate technologies and overprescribing".
Writing on the role of private practitioners in tuberculosis control, Mukund Uplekar et al note in The Lancet that 80% of households prefer to use private sector treatment in India for minor illnesses, and 75% of households prefer to go to the private sector for major illnesses. An examination of healthcare access patterns for the population leads to the startling revelation that the vast majority of people have been forced to rely on private facilities because there is an absence of state-funded alternatives.
According to figures from the National Sample Survey Organisation for 1998, quoted in a study by V R Muraleedharan and Sunil Nandraj, there was a 7% increase in the number of outpatients patronising rural private sector facilities, from 74% in 1986-87 to 81% in 1995-96. In urban areas, this rise was about 8%, from 72% to 80% during the same period. In the case of in-patients, the rise was sharper, from 40% to 56% in the case of rural and 40% to 57% in urban areas.
A snapshot of the private healthcare sector in India emerging from the study by Muraleedharan and Nandraj shows that in absolute terms, the size of the health infrastructure is significant, but its distribution is lopsided and urban-centric. There is one qualified doctor for 802 people and one hospital for 11,744 people, besides one bed for 693 people. But there are serious imbalances in the distribution of these facilities. In Tamil Nadu, at least 70% of 37,733 allopathic physicians are in the private sector while 10,000 are in government service. There are nearly 10,000 doctors in and around Chennai. Therefore, the ratio of doctors to population changes from 1:800 for Chennai to 1:1,590 for the state average.
The National Council for Applied Economic Research reported in 1992 that a study of household surveys showed over 55% of illness episodes being cared for by private facilities, and 33% to 39% by the public sector. PHCs and sub-centres catered to only 8.2% of cases in rural areas.
Why do so many patients seek private doctors?
In some settings, private practitioners are perceived as providing better care because they include injections as part of every treatment, and are willing to make house visits, which are convenient. In contrast, government services are not popular because of long waiting periods, the arrogant attitude of staff and non-availability of medicines.
In the absence of a robust state-funded health infrastructure providing free care, citizens must seek out private facilities. Based on a study of the weaknesses in the tuberculosis control programme, The Lancet reported that among 22 countries with the highest prevalence of TB, private health expenditure as a percentage of the total was among the highest in India , at 87%. The number of patients incurring 'out-of-pocket' expenditure as a percentage of total spending was also unconscionably high at 84.6%.
Acknowledging the rise in patronage of private healthcare in many poor nations, the British Medical Journal traced the phenomenon to greater flexibility of access, shorter waiting time, greater confidentiality, and sensitivity to user needs. However, there cannot be an unreserved commendation of any measure to expand the private sphere without an overarching concern for a state-funded care system. The debate on the debilitating impact of a policy that is guided by private care imperatives has dominated proposals to revamp the National Health Service (NHS) in the United Kingdom , with suggestions that the discourse on expansion is actually driven by a desire to pave the way for the entry of private care providers from the United States and elsewhere. Thus, tax funds would indirectly lead to an expansion of the private healthcare sector at the cost of the public system.
This issue is of particular concern to India , as the private sector has not met its obligations of providing free care to a particular percentage of poor patients as required by law. Citing this little-known and poorly-enforced provision, Members of Parliament Ram Kripal Yadav and Daroga Prasad Saroj wanted to know, in the Lok Sabha, the steps taken by the Centre to ensure that private hospitals provide 30% of their patients free treatment. Union Minister of State for Health and Family Welfare Panabaka Lakshmi replied on July 21, 2004 : "Health being a state subject, it is for the respective state governments to formulate conditions and norms for setting up of private hospitals... (and) with regard to the treatment of poor patients and also to ensure that the conditions and norms are followed by private hospitals."
The issue becomes clearer in the answer of Health Minister A R Antulay to a question in the Rajya Sabha in 1995. The minister said: "The 4th Joint Conference of Council of Health and Family Welfare held in October 1995 also recommended that the private sector which benefits from concessions should provide a minimum of 30% beds and 40% outpatient/diagnostic services free for treatment of the poor. In the past, private hospitals/nursing homes were allowed to import medical equipment at concessional rates of duty subject to the condition that a certain percentage of free treatment would be provided in OPD/IPD to poor patients. The state governments are required to check whether these conditions are being met by private hospitals/nursing homes."
Regulation and the lack of it
There is a complex set of factors that have rendered regulation of medical care practically meaningless in India . Muraleedharan and Nandraj report that the major problems include lack of monitoring by statutory bodies, outdated and inadequate legislation, and inability of the government to enforce even the available regulatory laws.
One of the earliest laws in force is the Delhi Nursing Homes Registration Act 1953, which requires that all private nursing homes satisfy a set of criteria and register themselves. However, a survey reported in 1994 found that there were 1,600 unregistered nursing homes functioning in the national capital, despite the law, indicating that it was not being enforced even in the city where national laws are made.
On the question of costs associated with private care, V R Muraleedharan points out that there is inadequate information on in-patient care to come up with a sound analysis on whether the costs are justified. The lack of sustained data collection was confirmed by the then minister of state for health and family welfare, in answer to a question in Parliament: "Health being a state subject, the details of hospitals run by state governments in the country are not maintained centrally."
There is thus considerable evidence to conclude that the poor are unable to access quality healthcare in India due to inequities prevailing in the system. Health insurance, either taken individually or provided as group cover, is helping some sections, though this remains a minority phenomenon in the overall scheme. The imperatives for policy therefore are to bring about greater budgetary expenditure on public health, institute monitoring mechanisms involving transparent and professionally audited procedures both in the public and private sectors, and ensure that the private sector, which has a legal commitment to share its facilities with the poor, is compelled to do so.
India's attempts to make a foray into the world of telemedicine has not made much headway, especially due to foreign data processing laws and difficulties in certification of qualifications of Indian telemedicine providers, the Planning Commission has said.
Rising costs and dearth of medical personnel have created pressures for public health care providers in developed countries to explore the possibility of electronic delivery of services across the borders and they looking for opportunities to outsource diagnostic services to private healthcare providers.
What is relevant is the emergence of opportunities for Indian service providers to supply telemedicine services to developed countries in such segments as diagnostics, dermatology, opthalmology and psychiatry, a high-level group of the Commission observed in a report.
The group notes that a number of telemedicine centres are already operating in the country.
In 2001, the Indian Space Research Organisation launched a pilot project that connects 78 hospitals in remote areas to super speciality hospitals in the cities.
In a recent study it has been reported that supply of telemedicine services from India has not taken off in a big way, except to the United States and Singapore.
The client base of telemedicine business in the US has increased in recent years to scores of hospitals and the National Healthcare Group of the Singapore has tied up with Indian telemedicine institutes for providing teleradiology services to designated hospitals in Singapore, the study said.
The potential with respect to the European Union has not been translated into actual business as yet on account of a number of factors such as data protection laws of EU members states and difficulties in certification of qualifications and accreditation of Indian telemedicine providers by the authorities in EU member states.
There are issues as well that come in the way such as malpractice policies, liability insurance and jurisdiction issues for settling disputes that might arise.
One of the main problems impeding growth of supply of telemedicine services by Indian service providers is the large variation in the quality of medical professionals with graduate and post-graduate qualifications produced by institutions across the country, which is a major constraint in receiving recognition from oversees medical authorities, the report said.
However, with the government's decision to recognise degrees from foreign universities of English speaking countries, the problem would be addressed to a large extent.
Telemedicine has also opened up possibilities of professionals providing expert healthcare services in remote rural areas from their locations in cities, the report said.
Surrogate mothers being outsourced to India add one more chapter to the saga of cheaper "jobs" being transferred to low-cost economies such as India. For now, "hiring" a womb appears to be a win-win situation, both from the cost and quality of medical service.
California-based Thomas and Karen, in their 30s and originally from South Korea, were married two years ago, but due to medical complications were forced to look for a surrogate mother. Research on the Internet led them to Anand in Gujarat, which has
become known for such in-vitro fertilization (IVF) procedures.
Pictures of their son, Brady, looking very much like his genetic parents, were splashed across television screens this week.
The cost of renting a womb is under US$5,000, compared to more than $50,000 in the West. The entire procedure in India costs in the range of $10,000, and the quality of treatment and technology and the expertise of the country's doctors compares with the best in the world.
What is more, the surrogate mother in the case above desperately needed the money. She lives in an impoverished district of West Bengal and needs to pay for treatment for her own very ill child who is suffering from a heart ailment.
The income she has earned is huge given her probable subsistence at less than a dollar a day. There are over 200 million Indians in this income category, in a country with annual per capita income around $500.
It seems that while one life has been created, another has been saved, though there has been criticism regarding the "commoditization of motherhood", risk to health and exploitation of the poor by the rich. However, the "plight" of a smiling surrogate mother with a big bank balance still looks like a better option than being one of the thousands of destitute women who are pushed into prostitution and treated mercilessly.
"It is difficult, but it is all right. They did not have a child so I am happy that they can be parents now, and I have found a friend in her," said the surrogate mother whose name has been withheld. "She's like my family. We just don't share parentage of the child. It's more emotional. She is like my sister," said Karen.
Infertility expert Dr Nayna Patel, who conducted the procedure, said: "I have found surrogate mothers for more than 50 couples, nearly 35% of which are foreigners, so far. This case is a good example of how technology can help solve crucial social problems. For me, the smile on Karen's face when Brady was born was satisfying enough."
According to Indian medical practitioners, 100 to 150 of the 500 to 600 surrogate babies born across the world every year are born in India. Many more are trying without success.
However, doctors say that given the fact that many women work and contribute significantly to household welfare, some may not want to take the time out to bear children and will choose the IVF option.
Many couples who adopt kids could also exercise this option. The Indian Council for Medical Research has estimated that the reproductive sector could soon be worth $6 billion a year.
As things stand, surrogate motherhood is illegal in Italy and banned for commercial purposes in Australia, Spain and China, and permitted with restrictions in the US, France and Germany.
Though new laws are being drafted, Indian medical statutes permit doctors to implant five embryos into a surrogate mother. In Britain the maximum is two, while many European countries are looking at a single embryo. India's existing laws permit the surrogate mother to sign away her rights to the baby, immediately after birth.
Reuters quotes C P Puri, director of India's National Institute for Research in Reproductive Health, as saying: "Every pregnancy and birth is associated with some health risk. We must not promote surrogacy as a trade. In addition, many surrogate mothers in India face issues associated with "traditional attitudes to sex and procreation".
A report by India Brand Equity Foundation and Ernst and Young says that outsourced healthcare will employ nearly 200,000 people in India by 2008, up from about 20,000 people in the medical, healthcare and pharmaceutical business process outsourcing space now.
According to estimates, the industry is expected to generate about $3 billion per year by 2010. Medical outsourcing has four clients - provider (hospitals and physicians), payer (health insurance companies), pharmaceutical companies and healthcare information technology companies.
Today, the Indian medical tourism market (foreigners seeking medical treatment in India) is worth $700 million and the projection is that it will swell to $1 billion in the next couple of years. More than 150,000 patients, the majority from the US and the UK, have undergone treatment in India.
The price differential can be quite significant, especially for patients from the US. For example, a liver transplant in the US costs around $450,000, while in India it is $40,000; low-cost cardiac surgery in India costs $4,000 to $9,000, while in the US it can be in the $30,000 to $50,000 range; orthopedic surgery costs as little as $4,500 in India, while in the US it is about $18,000. A comprehensive health check-up for a US patient in India is around $80, substantially less than the $600 it would cost stateside.
It is estimated that 50 million US citizens do not have health insurance policies due to high premiums.
Traditional outsourced services have been medical insurance claims processing and digitizing patient health records (medical transcription). Now, several high-end services such as clinical data analytics, biometric services and medical engineering are being sourced from India.
Newer services being outsourced include research, analyses and reports on emerging technologies for major US healthcare foundations and organizations, and for industry publications.
The US-based First Consulting Group, an IT services firm, recently set up a healthcare outsourcing facility in Bangalore.
Karvy, a financial services company, has now moved into providing services to the healthcare industry. Outsourcing major Firstsource Solutions, formerly ICICI OneSource, recently acquired BPM, a Delaware-based healthcare claims outsourcing company in the US.
Last year, Indian pharmaceutical firms acquired international firms. Dr Reddy took over German company Betapharm for about $570 million, and Ranbaxy bought out Terapia for about $324 million. Various Indian pharmaceutical firms have also started to expand their businesses in countries such as the US and the UK.
Several foreign pharmaceutical firms are targeting India's growing market and also looking at outsourcing research at half the cost.
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