Abstract

Life expectancy in Indiahas been improving.[i] However, this has also thrown up challenges in dealing with geriatric population that is on the rise. Indiais yet to fully develop an end-to-end health care system for senior citizens. This, coupled with increasing structural changes in the societal matrix – from the conventional joint family to more urbanized nuclear family, migration and changes in economic activity – are all leaving the old people at the receiving end. Healthcare assumes one of the top most priorities for them.

With technology penetrating deep into the rural hinterland, it may now be possible to evolve a method for addressing the concerns of the senior citizens in a better manner, especially in the rural areas. Information and Communication Technology (ICT) can easily become an enabler for such schemes. The setting up of the common service centers (CSCs) promises a ray of hope as it will be able to provide surplus capacity to act as the last mile point of access to the rural citizens for elementary healthcare and support. This could also act as the last tier of a multi-tier health referral system. Once established, the system can also accommodate other related value added services meant for senior citizens such as health insurance and old age welfare schemes from the state.

Introduction

There have been several welcome developments in extending the welfare net to senior citizens, who for a long time remained as a neglected segment within the civil society. Starting with fare concessions on travel to better rate of returns on deposits with banks, the right noises have been made at the policy level in acknowledging the senior citizens. Yet much needs to be done in making public health care accessible to them, which logically speaking, should take precedence over other services. Based on the 2001 census, there are about 80 million senior citizens in the country and this will be over 120 million by 2020.

This papers attempts to identify ways in which Information and Communication Technologies (ICT) can act as enablers to provide senior citizens easy access to health care, which otherwise is a challenge for this segment. The paper tries to establish that ICT can act as the backbone for broad spectrum public health care for the aged with the Accessibility, Acceptability and Affordability principle.

The paper also tries to examine the challenges and possible conflicts involved when technology plays a central role in a domain like health care. It finally concludes by suggesting a loose architecture for the public health care for the aged and a business model that may be considered for ensuring sustainability and replicability. Furthermore, the paper tries to establish the possible linkages between robust geriatric health profiling and transparent health insurance schemes. It also envisages the possibility of linking existing senior citizen schemes such as old age pension, widow pension etc. to the senior citizen health record.

Background

India along with other WHO member Nations pledged to ensure ‘Health for All by the Year 2000’ at Alma-Ata in 1978; and in the same year signed the International Covenant for Economic, Social and Cultural Rights – Article 12, in which the State is obliged to achieve the highest attainable standard of health. However the health scenario in Indiais abysmal.  

The number of people over the age of 60 is expected to triple by 2050, according to a 2006 revision of ‘World Population Prospects’ by the UN Department of Economic and Social Affairs Population Division. And India, Nigeria, Pakistan, the Democratic Republic of Congo, Ethiopia, the US, Bangladesh and China will account for half of the world’s 2.5 billion extra people by 2050.  

The United Nations broadly classified societies into ‘young’ (4% or less of those aged 60+), ‘matured’ (4-7%) and ‘ageing’ (7% and above). India, which falls under the ‘matured’ society category, has moved further into the ‘ageing’ society.  

The age-wise segments within the growing population are increasing at different rates, the fastest growing segment being the 60-plus bracket. As a result the percentage of population of the elderly is likely to grow steadily. According to United Nation’s estimates there are 427 million aged persons in the world today, which constitute about 8.8 per cent of the total. However, by the year 2025, the population of the aged is likely to reach 1171 millions, which will constitute a staggering 21.9 per cent of the total population. It is estimated that by the year 2010 the elderly population of Indiamay be around 124 million, constituting over 10 per cent of the total population. 

Beyond the statistics, there are several socio psycho implications for the geriatric segment that need to be considered. In the Indian context, concepts of old age homes and Third Party Geriatric Care are yet to mature. Existing social system looks down at the proposition of sending ageing parents/relatives to “Homes.” However, the increasing pace of life among the younger generation has resulted in a widening gap between them and their seniors. Economic non-productivity, failing physical abilities all add to the complexities that already exist with the geriatrics. Partners in Development Initiatives, an NGO working on health has pointed fingers at “loneliness” as a debilitating factor among the senior citizens. A study on geriatrics in Kashmir speaks about depression as a serious ailment that often goes unnoticed.[ii] The paper also correlates the possibility of depression to family care and support. Adding up all the socio-economic factors, it becomes evident that this 10 per cent segment of ageing citizens requires equal or more attention than the new born and infants at the other end of the social spectrum. Needless to say, a significant part of such an intervention must happen from public spending.  

The Government has attempted to give a boost to public health care by raising public health spending from the current 0.8 per cent to an estimated 3 per cent of the GDP (approximately INR 250 billion) by 2012 through a large program called the National Rural Health Mission (NRHM). NRHM is a comprehensive programme that seeks to improve rural health through decentralized planning and interventions. NRHM is being operationalized throughout the country with special focus on 18 states- Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, Uttaranchal, Orissa and Rajasthan, 8 North-EastStates, Himachal Pradesh and Jammu & Kashmir. NRHM, together with the states’ own health reform plans, is expected to push public spending in the health sector for better results.  

The main aim of NRHM is to provide accessible, affordable, accountable, effective and reliable primary health care facilities, especially, to the poor and vulnerable sections of the population. NRHM seeks to strengthen Public Health delivery services at all levels. The interventions/initiatives launched under the NRHM aim to reduce mortality and morbidity, and consequently improve life expectancy.  

While NRHM seeks to widen the coverage of healthcare through “innovation” and “public private partnerships”, role of technology is not expressed as forcefully as it could, however implicit it may be. Thus, a situation has arisen where there is a substantially large ageing population on the one side and there is an overarching “affordable, accountable, effective and reliable” health policy on the other side with a connecting link in between. Use of Information and Communication Technologies (ICT) can be an effective enabler in this context.  

Health is a state subject; however, it is under the overarching reach of the National Rural Health Mission (NRHM). There are several avenues in the NRHM that can be extended to benefit the senior citizen of the rural areas. Some of the measures that we propose are:  

• Mapping primary data of citizens

• Use of telecenters as collection points

• Convergence of data with the Village Health Plan, and making this data available to Rogi Kalyan Samitis (RKS)[iii]

• Use of sub centres (SCs) as the first level of data processing

• Use of Primary Health Centres (PHCs) as the repository for localized health information

• Develop two-way information flow from PHCs to Community Health Centres (CHCs), medical colleges and research institutions

• Develop public private partnership for research and evidence-based promotive, curative and preventive care at the state medical department/headquarters level  

Mapping Primary Data

Mapping and profiling of senior citizens at the local level is the single most important task in this exercise. Ageing and ageing-related ailments generally relate to disabilities affecting vision and locomotor movements, urogenital disorders and gastrointestinal disorders claiming the highest rate of prevalence.

The Department for Community Medicine at the All India Institute of Medical Sciences (AIIMS) has suggested the following set of parameters that can be applied to geriatrics. The entire matrix can be filled through a combination of efforts by the Accredited Social Health Activist (ASHA/ Multi Purpose Workers-MPWs)[iv] and the Gram Panchayat.

Source: Department of Community Diseases, All India Institute of MedicalSciences  

Use of Telecenters as Collection Points

Under the National e-Governance Plan (NeGP) of the Government of India, 100,000 rural telecenters and another 10,000 urban/semi urban telecenters running on broadband connectivity and offering government services will be established. The telecenters will presumably have surplus capacity to act as collection points for geriatric health profiles. ASHA/MPWs with sufficient training can use the centres (there will be a minimum of one telecenter for a cluster of six villages) to upload the non-GP data. Senior citizens can be identified with the help of census data or through physical verification by the health workers. The profile once recorded fully, will generate a reference number that will be retained by the citizen.  

Convergence of Data on to Village Health Plan

NRHM envisages the development of a village health plan that is aimed at capturing the salient health parameters of the region. The geriatric health mapping could be a component of the village health plan. Further, this data could be used for reference by the Rogi Kalyan Samiti, a participatory committee formed at the district level.  

Localisation of Data for Decentralized Administration

One of the unique features of the data capturing and retention at the local level is the reverse engineering impact it can have on health administration. As data at the grassroots level gets pushed upwards, it will also throw up region-wise demand for medical interventions and supply of drugs. A case in point is the decentralization of medical treatment for snake bites, effected by the Health Department of Goa. The Goa experiment shows how deaths from snake bites could be minimized through capacity building at the local level and decentralization of anti venom administration. Similarly, health care for senior citizens must be addressed by first mapping the generic needs of this segment, and then effecting it through a process-driven health support system.  

The Public Health Care System follows an elaborate process of reporting. However, in practice, these reports are erroneous, unreliable and far removed from truth. This apart, these monthly dispatches are executed with a lag at village, block and district levels resulting in a wasteful exercise. Thus, the present system defeats the very purpose of accurate and clean data collection. With the proposed health care revamp using ICT, the village level telecenters can act as points for the primary level data collection. Data that is digitally fed in can be sent to multiple recipients without any time lapse. MPWs, ASHAs and Anganwadi workers who normally get intimidated by the amount of file work for such reporting can pass on the information to telecenter operators who would be responsible for entering and updating data.

Today, the data received from the field is kept with scant respect at the state headquarters. Often such files are looked at only when questions about a particular disease or a pandemic outbreak are raised in the legislative assembly or in Parliament. However, digital data updated at the village level can be converted into a wealth of primary information with respect to the general health profile of each and every region. The data can be used by not only the Directorate of Health Services in the state but also Institutes of Nutrition, Virology, Immunology, Communicable Diseases etc. to analyse and study commonly occurring deficiencies and the diet pattern of the people in a particular region; and to work on the possibility of supplementary nutrition etc.  

The Tripura Experience

In Tripura, the government is experimenting with the use of ICT in healthcare on a large scale. The government has embarked upon a plan to link major government hospitals in the state with PHCs with CSCs. This model is replicable as well as scalable in the rest of the country too. A work flow chart of the program is given below.  

Telemedicine Model, Tripura

Earlier, the people of Tripura had to travel long distances to access health care services. Now, this is no longer required– at least in the case of eye sight related problems. The Vision Centre project, initiated by the Department of Health, provides quality eye care services to rural patients in an integrated manner whereby every case is accounted for, classified and closed with a solution.

41 vision centres for providing tele-ophthalmic services are being rolled out across the state. The vision centres in rural villages are connected to the mini data centre at IGM Hospitalin the city for maintaining electronic medical records and connectivity with an ICT enabled real time consulting facility at the ophthalmology-OPD counter at IGM.

The project is being deployed in phases and caters to a population of about 3.4 million people spread across 38 blocks of four districts in Tripura. The first and second phases have been successfully completed with more than 5,000 patients having been screened in 11 locations. The third phase is currently on for the remaining locations in the state.

The Tripura model proves that a reliable network of primary data collection centres (telecenters) could be put to good use to link up with a multi-tiered health referral system finally terminating at the speciality and super speciality hospitals in possible far off areas. This hub-and-spokes model has the potential to include other services related to health care, such as health insurance and old age pension.

Data Synthesis and Way Forward

Some states have taken the step of connecting the front and back ends of the hospital administration. Since health is a state subject, the progress of interlinking medical establishments within and outside the states varies. However, concepts like Electronic Health Records (EHR) and Hospital Management Information Systems (HMIS) are being implemented at several places. Similarly, back-end supply chain management programmes are also being embarked upon. The proposed health profiling for the senior citizens can compliment the ongoing reforms and modernization in the public healthcare sphere.

The senior citizens’ health mapping needs to be backed by a regular institutional support system which may be fee-based. The operational success of the scheme relies heavily on post-data support. The mapping done at the telecenters will be rendered useless soon enough unless it is regularly updated and followed up with through an institutional backing. The proposed plan is to widen the net of healthcare support through home visits by ASHA/MPWs and if required, the village postman.

Thus, the designated telecenter in the region acts as a data entry point for the entire catchment area surrounding it. The (non-clinical) data is captured into a designated template by the ASHA/MPW and sent to the SC or PHC. Citizens, who are in receipt of the reference number from the telecenter, can present themselves at the Sub Centre or PHC for examination by the general physician (GP). The GP can access the template of the patient by feeding in the reference number and complete the clinical parameters of the patient. This completes the health profile of the rural citizen.

Using the health profile as a reference, the GP can flag areas of concern and send the template back to the telecenter. The telecenter manager acts as the coordinator for the region and uses the network of ASHAs/MPWs or even village postmen to track patients who require medication, care and support. Health profile card holders, in turn, pay a pre-designated amount for the service.

Enhancing Value Delivered to Stakeholders

The data collected at the grassroots level pertaining to this segment of the society is priceless. Research institutions such as the National Institute of Immunology or Institute for Tropical Medicine may find data updated at regular intervals to be extremely important. On the commercial front, health insurance companies stand to gain significantly as they could get authentic information regarding citizen’s health. This information is also very useful to pharmaceutical companies and manufacturers of personal hygiene products wishing to target this segment.

From the welfare point of view, there are already several schemes running in the country that use chip-embedded plastic cards for data storage. NREGA scheme inBihar , Women Economic Empowerment Scheme in Rajasthan, Employees State Insurance Scheme by the Ministry of Labour, Government of India are all examples where personal information is stored and distributed on plastic cards for easy mobility, transferability and authenticity. Therefore, it should not come as a surprise if a willing state introduces SMART health cards for its rural citizens that can be read at the Sub Centre level and upwards.