Portal de Periódicos da CAPES

Digital Health

2022; Medknow; Volume: 38; Issue: 2 Linguagem: Inglês

10.4103/ijsp.ijsp_119_22

2454-8316

Nagina Khan, Subodh Dave,

Healthcare Systems and Reforms

Introduction India is one of the fastest-growing economies in the world in terms of gross domestic product (GDP) and is expected to be the third-largest economy by 2050.[1] Yet, it is also impacted by the global shortage of 10.3 million health-care professionals. According to the World Health Organization (WHO), this is expected to rise to 12.9 million by 2035.[2] Many health systems in developing countries are still facing a care delivery crisis and a major contributor to this crisis, consistently is the shortage of staff.[3] On the contrary, immigrant health professionals have long been an important component of the workforce of developed countries, characterized by a flow of health professionals from low- and middle-income countries (LMICs). For decades the United Kingdom and other high-income countries (HICs), periodically have had government-led initiatives actively recruiting from abroad.[4] This global migration pattern has sparked a broad international debate about the consequences for health systems worldwide, including questions about sustainability, justice, and global social accountabilities.[5] In 2010, the WHO implemented a Global Code of Practice on the International Recruitment of Health Personnel to dissuade the enlistment of health-care personnel from LMICs.[6] The opportunities of health workers to seek employment abroad have led to a complex migration pattern.[5] The 2008 failure of the global economy witnessed a high number of skilled Indian labor laid off in many developed countries.[5] Rising unemployment rates in HICs and concurrent growth of the Indian economy inspired the migrant population to return to their homes. Such conditions resulted in a reverse flow of skilled workers who left India for opportunities in the West.[5] Remote working had previously been restricted to the technology sector, but now has been democratized to other employment sectors during the pandemic. Healthcare, driven by the need for reducing infection has rapidly adopted remote working. The coronavirus pandemic has shown that the worldwide use of digital health services has been effective in a range of health-care areas including monitoring technologies, telehealth, creative diagnostic, and therapeutic decision-making methods.[7] In psychiatry, its primary focus on communication in clinical consultations has boosted the pace and scale of interest in remote working raising the prospect of replacing "brain drain" with remote working across international borders. Improvements in workforce capacity increase the likelihood of realizing the principle of health as a fundamental human right. Clearly, evidence from across the world indicates that ill health disproportionately afflicts the poor.[8] The Sustainable Development Goals (SDGs) and targets and the United Nations Development Programme (UNDP) 2018[9] offer a framework for health systems aspiring to reducing inequities in access. Sustainable Development Goals and the United Nations Development Program The global indicator framework for SDGs was created by the Inter-Agency and Expert Group on SDGs Indicators. They were settled on during the 48th session of the United Nations Statistical Commission in 2017.[10] According to the resolution, the indicator framework was refined annually and reviewed comprehensively by the Statistical Commission at its 51st session in March 2020.[10] The COVID-19 pandemic has stalled global progress on many of the SDGs, including "Ending extreme poverty by 2030" – Goal 1, and pertaining to the discussion in this editorial, Goal 17 – "Strengthen the means of implementation and revitalize the Global Partnership for Sustainable Development"[11] [Table 1 and Table 2]. Linked to these goals above is the UNDP (2018)[9] by definition, pledged to "leave no one behind" - a commitment to end extreme poverty in all its forms and to act explicitly to ensure that those who have been left behind can catch up with those who have experienced greater progress.[9] This pledge was meant to drive all governments to outline a plan targeted explicitly at "reducing inequalities among people, groups, and places, improving remnants of discrimination and exclusion mutually among and in nations, highlighting and accelerating development between and in the remotest areas."[9] (p.8)Table 1: Goal 1 - End poverty in all its forms everywhereTable 2: Goal 17 - Strengthen the means of implementation and revitalize the Global Partnership for Sustainable Development[11]A major obstacle to realizing this pledge has been the shortage of health-care staff across the public and private sectors. India's staff ratio is 0.7 doctors and 1.5 nurses per 1000 people,[12] markedly lower than the WHO average of 2.5 doctors and 3.0 nurses per 1000 people. There is an additional need of 1.54 million doctors and 2.4 million nurses to match the global average.[13] The shortage of skilled workers in hospitals has led to suboptimal levels of patient care, increased mortality, and medical errors.[14] Approaches to retain personnel to deal with shortages have ranged from offering better pay, work autonomy, advanced educational proposals, fellowships abroad, work appreciation, and inclusion of domestic and social life issues.[15,16,17,18] No specific approaches have yet been successful.[19] Technology Can technology help address this challenge? It has become evident that digital health offers a valuable opportunity to handle epidemics where real-time data have helped inform rapid service and policy change[7] and telehealth became mainstream.[20] Different terminologies are used to refer to telemedicine or telehealth – for instance, digital health, electronic health, mHealth (Mobile Health), teleconsultation, and tele-triage.[21] In addition, there are some terms that refer to specialties, for example, tele-neurology, telecardiology, and telepsychiatry.[21] Telehealth has a broader scope of remote health-care services than telemedicine and digital and data science innovations including Artificial Intelligence and machine learning add another dimension to this advance.[21] India has a conducive ecosystem for health innovations. The use of technology as a means to an end has the potential to offer a socially innovative approach that can enhance both the access to and the range of services offered, thus allowing for a greater population to be served.[22] Digital health then becomes an attractive alternative for both health systems that are facing a crisis in recruitment of health-care personnel and for those that are facing a crisis in widening access to care.[20] In a country that leapfrogged landlines to offer widespread access to smartphones, the availability of mHealth (mobile health) applications[23] that enabled accessible remote communication between health-care professionals and their patients has the potential of transforming the health-care landscape.[24] There remain significant concerns – digital poverty, poor or unstable network access, data security, and privacy raising both ethical and practical considerations.[25] Moreover, robust safety and effectiveness data are not yet available for all digital health applications.[26] However, the impetus to resolve these challenges is particularly pressing for economies such as India with a historic underfunding of health services. Clearly, if India is to achieve its SDH and UNDP goals, she will need to balance technological progress with patient rights to confidentiality and privacy.[27] India: Can digital health improve access and affordability of healthcare? India, the second-most populous nation in the world, will soon overtake China. Health needs of the population are growing at a rapid rate with the health sector estimated to increase by $280 billion.[28] Access, affordability, availability of human resource, and accountability of health-care providers remain key challenges and despite being a colossus leader in IT-enabled services, digitalization of health has been restricted in the country.[29] August 15, 2021, saw India's Prime Minister Narendra Modi launch the National Digital Health Mission (NDHM), which will provide every Indian citizen with a unique digital health ID.[30] NDHM should allow patients to effortlessly shift from one health service provider to another, allowing access to patients' health data and enabling insurance providers to quickly verify and process claims.[30] Concerns have been raised about privacy and lack of investment enabling universal access to healthcare. Differential access to healthcare has been highlighted with the finding that per capita expenditure on public health has been reported to be lower in rural areas compared with spending for urban areas. India, like many other LMICs, and in contrast to several HICs, spends a smaller percentage of its of GDP on healthcare, leaving a much larger share of the burden of the expense on individuals.[31] Digital health offers the promise of widening access to healthcare addressing systemic inequities, a vital goal in the Indian context? An Australian scoping review identified four key areas of gains with digital health-productivity gains, reductions in secondary care, alternate funding models, and telementoring.[32] The authors concluded that in the Australian activity-based funding models, digital health was unlikely to provide any efficiency savings. However, in the Indian context, benefits of digital health such as better awareness and improved self-care, reductions in unnecessary investigations, and treatment reductions in travel costs are likely to deliver both cost-effectiveness and cost-efficiency. Digital health and virtual health can improve the physician: patient ratio through efficiencies delivered by better utilization of scarce skilled workforce.[33] Moreover, efficiencies achieved through the transfer of some of the care responsibilities from humans to technology (technology-enabled care) have not been realized in HICs where the cost of digital systems and telemonitoring has been prohibitive. India could leverage its digital and technological prowess to optimize the impact of digital innovations. Several examples of such innovations are coming on board and offer promise. The Electronic Urban Health Centre model in Andhra Pradesh ensures specialist care and patient satisfaction at the urban health center level.[34] Boat clinics in Assam are mobile clinics on water bodies which provide health services to the residents residing in remote islands across the state.[35] These examples strengthen the idea that a Digital India – envisaging transformation of India into a digitally empowered society – could retain health-care personnel, enhance the quality of care, and improve access for hard-to-reach populations while retaining the affordable care advantage that India enjoys compared to its HIC peers.[36,37] Critical caveats remain, for example, smartphone numbers in India are estimated to be about 750 million, these are likely to be distributed inequitably and enhanced rollout of digital health initiatives may worsen the polarization in access to care rather than ameliorate it. Initiatives that increase awareness also tend to increase need and this may overwhelm the already stretched workforce. Finally, digital initiatives such as NDHM are likely to change the health insurance landscape. Clearly, the pricing of health insurance benefits from a better assessment of risk and protective factors. Although, a focus on individual risk factors can take the focus away from wider public health factors that modulate health risks for individuals. These public health factors usually require sustained governmental-level investment and more importantly a long-term strategy. Delivering the health goals of UNDP and SDG will need adequate resources – both financial and human resources. While digital health may deliver efficiencies, it will not obviate the need for increased investment in healthcare. Digital India: Leading the way? India is uniquely placed to match needs with an innovative solutions. Decades of underfunding of healthcare have created a wide health-care gap. Workforce shortages have been exacerbated by the emigration of skilled health-care personnel to HICs. At the same time, the rise of India as a digital superpower enables the use of its technically proficient workforce to design and deliver solutions at scale,[33] where other health economies have floundered in making such innovations sustainable. It is evident that if these digital innovations are: (a) backed with adequate and proportionate investment in healthcare; (b) innovations in healthcare education to embed digital literacy in training and service delivery; (c) creating and enforcing a robust regulatory framework to protect patient privacy and data security enabling cross-border digital healthcare, then the solutions are more than likely to transform the health-care landscape not merely for India but for the world at large. The global health community watches with abated breath. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. About the Authors Professor Subodh Dave is the Dean of The Royal College of Psychiatrists, United Kingdom. He has various interests in social and community psychiatry, with a particular interest in maximizing the impact that teaching should have on clinical practice and patient outcomes and has been involved in re-designing the psychiatric curriculum nationally (UK) and internationally (Zambia). Dr Nagina Khan is a senior researcher, (North America) and she collaborates with the Dean on Medical Education research. She is also an Editorial Board Member of the BioMed Central Medical Education Journal, UK.