In the remote and sparsely populated hills of chapad village in Champawat district, Revati Devi was carrying out her daily chores in hilly terrain when she suddenly began getting headache and in sometime she fainted on the ground. Her companions immediately came to her rescue and took her to shade. She was offered water and gained consciousness. After some time, instead of showing any panic sign or seeking a medical consultation, she started working again in the fields as if nothing happened. I was dumbstruck and ask her why?
With a pale smile she says “hm aurato ki jindagi aisi hain. yeh to hota rehta hain, phr khud thik ho jata hain”. “bal yaha se doctor bhi bahut dur hain, ana jane main hi bahut paise lg jata hain aur uska upar dawai ka kharcha aur private doctor to hm jaiso k liye hain hi nahi”. Ignoring illness is her way of living while she has to look after her three children in absence of her husband who earns a modest income working in a petrol pump in Delhi. After few years, one day Revati didi (as I fondly called her) I got to know that she lost her long battle to illness and died in local hospital. She was very weak and was suffering from extreme pain. She was diagnosed with anemia and her lungs were also very weak. Nothing doctors could do to save her. It was too late. I keep mulling a question “If only she had consulted doctor in the first place?”
Health in Doldrums: Uttarakhand Dismal Healthcare
Revati Devi was not the first victim of her ignorance nor she will be last. Local newspapers are filled with such numerous deaths and critical cases on daily basis. Unfortunately, the government is more ignorant and the system have displayed apathy towards her people. The poorly equipped local primary health infrastructure have wiped away people’s confidence from government healthcare system and turned people ignorant towards their own health until it becomes unbearable (Prakash, 2019). In the end the out of pocket expenditures in the critical stage pushes people into poverty trap.
The state’s expenditure is higher than national average, but the budget allocation is insufficient and unequally distributed i.e. more resource being concentrated in cities/plains.
Despite having a special status privilege under National Health Mission, NITI Aayog Health Index 2019 reports Uttarakhand as one of the worst performing states in almost all the 23 indicators. Uttarakhand stood at 17th position among 21 states, slipping down 2 positions from last year. The report outlines the worrisome mismanagement, high Infant Mortality Rate (child deaths), under five Mortality rates and Maternal Mortality Rates etc. The national Family Health survey (NFHS-4) also puts Uttarakhand among highest in underweight, stunted growth and anemia as highlighted in the following table.
The debilitating healthcare infrastructure in the hills exposes the crumbling rural healthcare causing hill people to migrate to plains. The poor primary care and lack of awareness on preventive care has jammed ill-equipped district hospitals across state. If the primary healthcare system could be strengthened, the tertiary cases will go significantly down over the years saving lives and immense costs of managing it.
COVID-19 Impact on Healthcare
With healthcare at the epicenter of pandemic COVID-19, it has turned the entire healthcare planning upside down. The focus on non-COVID illness had come to a temporary pause and stringent lockdowns exacerbated the non-COVID patient care. It is obvious that the state’s health indices will further deteriorate.
Telemedicine: Sanjeevani for Better Healthcare Delivery Services in Hills
Telemedicine interface provides a real-time Patient – Doctor consultation through text/audio/video. The platform uses ICT for the exchange of information for the diagnosis and treatment of diseases by a certified medical professional. The applications aim at addressing the health issues of patients by health workers without unnecessary exposure to infections. The application provides immediate support and delivery of healthcare services to the underserved communities in rural and urban areas without travel.
In hills where distance is a critical factor, the telemedicine aims to ease the delivery of services. It is highly flexible and can be developed as the desired geography and people. The penetration of telecommunication followed by exponential growth of smartphones offers an opportunity to take preventive and curative medical services to the palms of common man in hills. The model empowers skillsets and fosters an entrepreneurship among youngsters helping them to earn a dignified livelihood and thereby becoming role models in the society. Thus developing a low dependency on government funds.
Fig. Telemedicine Technical & Operational Setup for Hills
Some of the key benefits of a telemedicine are highlighted below:
- Telemedicine is an inclusive, accessible, acceptable and affordable which blends the modern technology with efforts of healthcare establishments to provide services to the last mile reach leverages the advancement in technology and human resource.
- Focuses on providing primary care at minimal cost to prevent the critical cases. Early detection of any critical illness will avoid unforeseen fatalities.
- Uses real time data to develop focused intervention against specific diseases.
- It has capacity to cater the people with disabilities who are mostly left out of the mainstream healthcare system.
- Reduces the inconvenience/impact to family and caregivers and social factors.
- Increased legal protection of both the parties with good documentation management
- Provides patient’s safety, as well as health workers safety especially in contagious diseases.
- Enable the availability of vital parameters using medical devices.
How to do it?
- Robust Platform Development: It is the backbone of the system. A technology platform with simple UI and easy navigation is desired. The platform must be developed such that it is able to perform smoothly with enough backup for the multimedia data storage.
- Cluster of Villages: In hills, hub & spoke model suites the terrain. Common point of a cluster of villages is called hub, preferably small market and villages around are part of spoke. A cluster can serve 25-30 small villages. Multiple clusters will be required for last mile outreach.
- Doctors’ Empanelment: The doctors needs to devote a fixed time for telemedicine. All the queries shall be addressed during that stipulated time. The government doctors can be deputed to address the patients. Intermittently Doctors needs to schedule visit to clusters to earn
- Micro-Health Entrepreneurs (MHE): Amid COVID-19, entrepreneurship is a path to lure youngsters to stay back. The system requires ambitious youth who could be trained into health entrepreneurs. The local chemist shops can use this technology to extend health services on a minimal charge. They will also conduct non-invasive test like BP, sugar checks on a meager charge MHE can operate in clusters serving around 25-30 villages in hills.
- Bike Ambulances: The likes of a pizza delivery boxes could be mounted on the back of an efficient motorcycle. The box shall have compartments where non-invasive test kits and medicines packets will be kept separately.
- Doorstep Delivery of Medicines and Test: Either the people can come to a nearby empaneled chemist shop operated by a MHE to receive or with a minimal charge the MHE can deliver medicines to his cluster of villages. ANM/ASHA could be instrumental in last mile delivery.
- Patient Support Centers: In villages women and senior citizens are more comfortable over call than a mobile application. A patient support center will entertain calls and fix appointments for them. They will also address queries if there is any concern in delivery of services.
- ANM/ASHA: The government appointed ASHA/ANM can be used for last mile delivery of medicine. They can also train local people in application usage or support senior citizen in consultation process. Also as outlined above they too can perform non-invasive test and medicine delivery at door steps like an MHE.
- Jan Aushadhi Stores: These governments subsidized stores needs to open in the remote places. They offer very affordable medicines in generic form. The MHE can be awarded these stores to supply low cost medicine to people.
Nutrition Awareness for Pregnant Ladies
Complementing the telemedicine system, an IVRS (interactive voice recording system) can be added to disseminate key dietary information to mothers based on the pregnancy week. The embedded IVRS into system helps to raise awareness on proper nourishment for a mother and child. The mobile number and pregnancy week registration can be done by local ANM/ASHA and thereafter she would receive audio messages. For any issue she may directly reach out to doctors through a call/app via Telemedicine platform.
Are we doing right things in wrong manner? Uttarakhand healthcare system need to question this to itself. Instead of blindly adopting the National Health Mission guidelines, the government needs to adopt a sophisticated method of healthcare delivery model customized to the landscape diversity and needs of hill people. A grassroots based model it provides an opportunity for youngsters earn sustainable livelihood. Foreseeing any COVID-19 like situations, the telemedicine offers widespread opportunities for preventive and curative care. This also helps in providing data that can be factored into the future policy planning. This is probably a way to prevent any more Revati Devi’s die in such an unforgiving manner.
- Prakash, Meghna (2019). Uttarakhand Health centres sans health facilities. Gaon Connection.