The current GOI focus seems to be centralized around key themes:
- Digital Payments
A lot of efforts have gone or is going in these 3 themes. RBI led demonetization engrossed the nation for 3-4 months with people literally sweating it out to manage the situation. This has been followed by a huge drive on digital migration for payments and the outcome of all this is seemingly being tied to addressing corruption. Many a steps have been taken either before or in the budget, right from reducing digital transaction fees, limiting cash transaction limit for political donations, higher %age of rural subsidy being pushed through DBT (direct benefit transfer) and efforts being made by Income Tax authorities in bringing to book alleged corrupted individuals/ recover black money.
The efforts are laudable and there are positive outcomes too (at least expected in longer run). The focus & the drive have surely helped in putting in limelight the challenges on the above issues. Some early trends (e.g. RBI data on %age of digital transactions etc) indicate significant improvements. Economic survey also points out to a strong use case for JAM (Jan Dhan accounts, Mobile, Aadhar) for driving cashless in rural, better financial inclusion and minimizing leakage in subsidy targeting as well.
The challenge is that the focus seems to be much skewed considering that there are equally or probably more important issues/ challenges the country is facing. Two areas stands out, they are ‘Health’ and ‘Skill Development’. We strongly believe that not only statistics justifies the need for focus here but also there are strong ‘use case’ of using Mobility/ JAM to drive a better inclusion/ focus here. For this report, our focus will be ‘Health’, as we believe that it will have the biggest impact if we have to really achieve “wiping every tear from every eye of the still poor and vulnerable”
- Economic Survey 2016: “Government spending on healthcare in India is only 1.2 per cent of GDP which is about 4 % of total government expenditure, less than 30 % of total health spending. The failure to reach minimum levels of public health expenditure remains the single most important constraint to attaining desired health outcomes”
- Human Development Index 2014 (UNDP): Ranks India at 135 out of 187 countries
- India’ contribution to total population is 17% but accounts for 21% of the disease burden of the world population (WHO 2013). The greatest burden is with maternal, new born & child.
As per WHO data, the greatest burden is with maternal, new born & child. It is not that we are not improving on key health parameters! We definitely have improved significantly from our situation in early 1970’s but it is the comparison with other countries (we will take BRICS) that highlight the lacunae.
First the good news, a few graphs which will illustrate the improvements we have made as a country in last few decades.
But there are challenges:
- Disparity across states in level of achievements. For example, Kerala is at 15 for Rural Females (for Under 5 Mortality rates) while it is 48 for AP & 82 for Assam. Rest is illustrated in the graph below. So surely we have been far from being equitable on our achievements
- Rural Urban Gap
- Laggard in the race: Indian figures do not augur well when compared with the other countries. For instance, in ‘Under 5 Mortality rate’, India is last among BRICS nation, similarly in infant mortality and children (under 5) who are stunted.
For India to progress, we should be able to address these critical issues much more effectively that we have been able to do till date.
We are seeing a few poor countries making significant progress in ‘health for all’ by leveraging mobile health. Consider some live cases of leveraging Mobile Health (m-Health) across the globe:
- SMS for Life (Country Tanzania): Used for tracking & support review of weekly stock of a few critical medicines using SMS, electronic mapping technologies. As per one report “Results of a pilot in three districts of rural Tanzania, involving 128 health facilities and covering a population of 1.2 million, reported a decline in the stock-out rate from 26 percent of health facilities to 0.8 percent over a 21-week period. Following a request from the Tanzanian Ministry of Health, SMS for Life has been extended to all 5,099 health facilities in Tanzania” (The Center for Innovation & Technology in Public Health Public Health Institute)
- M Trac (Uganda): Somewhat similar, it uses SMS for tracking outbreaks of diseases and providing medical supplies. “The initial pilot reported a response rate of approximately 90 percent from the 170 health facilities in two districts of Uganda. Ugandan is now in the process of rolling out the program nationwide through 5,000 health facilities and 8,000 community-based drug dispensaries.” (The Center for Innovation & Technology in Public Health Public Health Institute)
- Fighting chronic disease e.g. diabetes (USA): A mobile phone based coaching where patients can enter their critical data (featured & smart phone both) and receive ‘real time’ response through a software.
- Mediphone, Aravinds Eye hospital mobile system, Apollo Telemedicine, e-MAMTA (Gujarat) have seen some success in India
The advantage the country has today is the JAM trinity. The problem & complexity of the large country, we are, needs a more holistic approach that will need a lot more deeper involvement of the Government and can’t be left to a few experiments at specific pockets of the country. Talking of JAM, let us look at the coverage:
- 125.5 million Jan Dhan bank accounts (J)
- 17, 757 million Aadhaar numbers (A)
- Approximately 904 million mobile phones (M)
With the JAM trinity we have a huge opportunity to go beyond ‘financial inclusion’ and actually transform life literally at grass roots by addressing ‘health inclusion’.
We showcased a few use cases earlier, but from a more strategic impact of the trinity are better understood from this diagram:
Now what do we mean by each of the 3E’s?
- Empower: Provide not only monetary intervention at right time (e.g. during the child birth), but also provide lot of important information/ ease of consultation (w/o need to travel to care facility), which empowers the individual to address many of his/ her needs effectively & quickly
- Enable: Enabling health advice/ consultative care reaching across the country, nearly every place where there is a simple mobile connectivity. Smart phone can be an advantage, but case studies exist for feature phones as well. Bridging the ‘supply-demand’ gap!
- Elevate: Between Aadhar & Jan Dhan, which has now extremely good coverage, the pointed interventions by different players (as highlighted earlier), can be elevated to a more country wide scale, provided there is a strong Government push especially in financing & managing the program
Why it may work?
A close look at the ‘Major cause of Death’ across Rural & Urban, highlights that there are many defined reasons (easily identified) where timely advice can help in reducing mortality or even reduce the debility impact of the diseases:
If we look at more details, a few top level use cases come to mind easily:
But the administration of JAM trinity for ‘health inclusion’ is not as easy as it may look on paper.
- A study done in India, indicated that 98.8% of such a call based mobile health initiative were prepaid mobile customers and most of them did not had enough credit to pay for the service. Here we are talking about consumer payment of < 60 cents/ 40 Rs per consultation: This is a golden case where Gov intervention through JAM can help. Based on customer profile in Aadhar, the scheme can provide payment directly from Jan Dhan account adjusted against health subsidy allotment for the individual
- The same study highlighted that 64.5% of the calls were for seasonal ailments such as allergy, cough & cold, fever: These are more easily addressable remotely and can prevent them from spreading & becoming chronic as well
- Also there is the well known difference between ‘value proposition’ for the providers (Doctors, clinics etc) and the consumers (patients) for such a service. Without Governmental support/ management, this difference is difficult to bridge and would prevent wide scale adoption/ scalability of current pointed m-Health engagements across the country.
To conclude, we as a country have lot to catch up with respect to provide a healthy life to our people. Healthy life is also a great economic booster as it reduces the state & family burden and uplifts the overall productivity of the country as well. JAM trinity provides a wonderful opportunity but the government dispensation is currently skewed towards financial inclusion & better targeting of subsidy but an equally critical area of intervention is ‘health inclusion’. Unfortunately for reasons unknown, this has not got the same visibility beyond the “Swach Bharat” initiative. But that’s a very basic starting point, and we need to do much more for such a basic requirement of the people.
- Potential of mHealth to Transform Healthcare in India: 2016, Journal of Health Management
- Green Paper on Mobile Health: European Commission 2014
- India Economic Survey 201516, 201617
- Emerging mHealth; Paths for growth: PwC
- UNDP Health Data for countries: UNDP website, hdr.undp.org
- Causes of Death Statistics: 2010-2013, GOI
- India Mortality & other data: GOI, data.gov.in