Healthcare for the other India

Few people would have heard of Kavaratti; fewer still, the Indira Gandhi district hospital there. The place is part of Lakshadweep Islands, 220 nautical miles off the coast of Kerala. Till a few years ago, it was a wrong place to fall ill with a disease that required superior medical care. But now, patients effortlessly, albeit virtually, step into Amrita Institute of Medical Sciences (AIMS) in faraway Kochi and meet up with specialist doctors.

There was a time when such patients and their attendants had to be either airlifted or shipped to Kochi at the government’s expense. But telemedicine—delivery of health services via telecommunication network—has changed their lives. This is a story not just of Kavaratti, but also of many remote places in India. Yet, Kerala, Chhattisgarh, Rajasthan and Karnataka stand out because all their district hospitals are under the telemedicine network. Barring Bihar and Uttar Pradesh, all other states, including eight in the Northeast, are reporting progress in implementing the telemedicine project, spearheaded by ISRO. “Our capability to provide connectivity to far-flung and remote places through satellites has been effectively utilised,” says G. Madhavan Nair, Chairman, ISRO.

Studies have shown that 90 per cent of ailments don’t require surgery. “If there is no need for surgery, then a doctor need not touch the patient at all. In that case, there is no need for both to be present at the same place,” says L. S. Satyamurthy, Programme Director, Telemedicine, ISRO. The project targets this 90 per cent who live in urban/rural areas with no access to speciality healthcare. A survey by Narayana Hrudayalaya (NH), Bangalore, reveals that the technology helps rural patients save 81 per cent of the money that they would have otherwise spent on travel and treatment. Amrita Institute’s random calculations show that each patient in Lakshadweep Islands saves Rs 16,200.

That is only logical as the technology enables transmission of patient’s medical records including images, besides providing live two-way audio and video link. With the help of these, a specialist doctor can advise a doctor or a paramedic at the patient’s end on the course of treatment to follow. He can even guide the doctor during surgery.

“ISRO’s telemedicine project has benefitted three lakh people”  - G. Madhavan Nair, Chairman, ISRO

ISRO is driving the project by providing software, hardware, communication equipment and satellite bandwidth, all free of cost. The speciality hospitals chip in with critical medical advice. As many as 263 district/taluk hospitals across the country are linked to 43 super-speciality hospitals via ISRO’s satellite-based network, and the benefit has reached three lakh people, according to ISRO’s Nair.

As this is a rural healthcare project, ISRO has extracted a commitment from tertiary hospitals in return for free bandwidth. When they get patients for surgery from telemedicine, they can collect only concessional charges. NH and Amrita Institute, for instance, assess the patient’s economic condition before deciding on the fee.

NH and Apollo Hospitals pioneered ISRO’s telemedicine programme in India in 2002: while the former took over the cardiac care unit at the government hospital in Chamarajanagar in Karnataka, Apollo introduced telemedicine at its own hospital in Aragonda in Andhra Pradesh. It was the success of these two centres that led some states to devise full-fledged telemedicine programmes and network all district hospitals from 2003 onwards.

“After six years of work, the project has now reached a level of wide acceptability,’’ notes Satyamurthy. “ISRO’s objective is to develop the technology first and address the issues of last-mile connectivity in rural healthcare and create an ecosystem for bringing e-health,’’ he adds.

The idea evidently is to refine and popularise the technology so that even nursing homes in small towns can hook up with hospitals in cities and use telemedicine independent of the government support. Some hospitals like Apollo and NH are already doing it with broadband/ISDN connectivity. In a first of its kind instance, Mantri Developers has tied up with Apollo to provide the facility at its Mantri Espana, Bangalore. The Apollo Telemedicine Network Foundation has conducted about 36,000 tele-consultations so far. “In a country as large as ours and with doctors as few as we have, there is no other tool that can be as beneficial as telemedicine,” says Dr Prathap C. Reddy, Chairman, Apollo Hospitals Group. But as Dr Ajit N. Babu, Director of the Centre for Digital Health at Amrita Institute, points out, telemedicine is not an event but a process. ISRO officials note that the telemedicine project won’t be complete until all hospitals in rural areas are connected.

Business Today takes a look at whether telemedicine has really impacted the lives of poor people in states—Karnataka, Rajasthan, Kerala, Chattisgarh, and Andhra Pradesh—where almost all district hospitals are employing telemedicine.

Karnataka
Network to firm up

The District Hospital in Chamarajanagar, 185 km from Bangalore, stands out as the best example of how a private hospital can test the limits of a government programme. Narayana Hrudayalaya (NH) has taken over the cardiac care unit at the district hospital. It’s the NH team that runs the show here.

When the government and ISRO together launched the project in April 2002, they zeroed in on Chamarajanagar and the Vivekananda Memorial Hospital run by an NGO, at Saragur in Mysore district.

While the Chamarajanagar unit has so far provided telemedicine consultation to about 900 patients, the hospital at Saragur has progressed enough to offer speciality care in a few disciplines such as woman and child health, orthopaedics, pathology, etc.

The telemedicine unit in Chamarajanagar in Karnataka has treated 900 patients so far

Dr Narendra Kumar, the doctor at the Chamarajanagar unit, says patients are advised hospitalisation only if surgery is necessary. “We have treated 52,000 patients so far using the telemedicine network,” says Dr Devi Shetty, MD of Narayana Hrudayalaya. “Large hospitals like ours should drive the project without expecting any financial gains,” he adds.

Karnataka has networked 26 district hospitals with six super-speciality hospitals. Since the project is not effectively run in some districts, the government is setting up a dedicated team to coordinate between the district and referral hospitals. The government, however, is not looking at extending the programme to taluk hospitals for now. “We are working on strengthening the existing network by roping in more tertiary hospitals from both government and private sectors,” says M. Madan Gopal, Health Secretary, Karnataka.

—K. R. BalasubramanyamKerala
First in telemedicine

After undergoing surgery at the Regional Cancer Centre (RCC), Thiruvananthapuram, patients need not visit the hospital for follow-up check-ups unless it’s necessary. They can visit any of RCC’s five Early Cancer Detection Centres across the state.

The prescription is dispensed via telemedicine. “Last year, about 2,500 patients had telemedicine follow-ups,” says RCC Director Dr Balakrishnan Rajan. The southern coastal state was the first to bring all its 14 district hospitals under ISRO’s telemedicine project. When it kick-started the programme five years ago, the place it selected promised maximum impact: Sabarimala, the holy town, which draws lakhs of pilgrims during winter months.

Currently, Sri Chitra Tirunal Institute, Thiruvananthapuram and five medical colleges besides RCC and Amrita Institute of Medical Sciences, Kochi, are providing expert opinion via satellite to district hospitals.

Kerala suffers from underutilisation of its telemedicine potential

Amrita Institute’s Physician Coordinator Dr Kumar Menon says the hospital conducts about 20 consultations per week. Yet, the project is limping or dysfunctional in districts such as Idukki, Wayanad, Alappuzha, Kasargod, etc. ISRO’s equipment is available in all the places, but it is often not put to the best use.

Many government doctors, who have thriving private practice, see this as additional work. When they don’t, experts are not available or connectivity plays truant. “We need a little bit of strengthening, which we are doing through periodical reviews,” says Dr Vishwas Mehta, Secretary, Health and Family Welfare, Kerala.

—K. R. BalasubramanyamRajasthan
To go mobile

The third state to report full coverage, Rajasthan’s network of 32 district hospitals is the largest among the four states. They are connected to six medical colleges and the Sawai Man Singh (SMS) Hospital through VSAT.

Each district hospital is connected to one medical college and the SMS Hospital for providing super-speciality medical advice. Says Dr G. N. Saxena, Professor (Medicine), SMS Hospital and Chief Officer for Telemedicine in Rajasthan: “The project targets districts that are in need of medical advice in branches like cardiology, pathology, neurology, etc. So far, more than 2,300 patients have been treated this way.”

Rajasthan government will soon take VSAT-enabled mobile units to rural areas

The state government also plans to run VSATenabled mobile telemedicine units soon. The vans will operate from medical colleges and help people in remote areas. Says Saxena: “This connectivity would enable real time transmission of data, voice and video to the referral hospital.”

—Manu KaushikAndhra Pradesh
A hand that heals

Located a few kilometres from Chittoor, a small town in Andhra Pradesh best known for its sarees and jaggery, Apollo’s facility at Aragonda was the first in the country to provide telemedicine. Aragonda is the native place of Apollo Founder and Chairman Dr Prathap Reddy. Apollo provides its services free to villagers from Aragonda and surrounding villages. That’s great for Yugendar.

While trying to untangle his kite from electric wires, nine-year-old Yugendar inadvertently caught hold of a live wire and electrocuted himself, losing two fingers and suffering burn injuries on his arms and legs, where the power entered and exited his body. Rather than rush him to a nearby city for super-speciality care, his parents instead went to the local Apollo Hospital and after an initial check-up, the boy was remotely referred to Apollo Chennai for further diagnosis.

Telemedicine has become something of a saviour for villagers in Aragonda and thousands of others residing in surrounding hamlets. Apollo kicked off its telemedicine initiative at Aragonda eight years ago, by connecting the 50-bed hospital to its large Chennai hospital and has since expanded its network nationwide.

Eight years on, after 40,000 consultations, telemedicine in Andhra Pradesh is a resounding success

Aragonda Apollo has become a magnet for medical consultations for more than 5,000 villagers from surrounding hamlets, who have visited the hospital for consultation on everything from cardiology to paediatrics and endocrinology. “We have undertaken over 40,000 consultations since inception,” says Dr K. Murugesan, Telemedicine Co-ordinator at Apollo Aragonda.

According to him, specialists are available within minutes for emergency cases, or in a couple of hours from Apollo hospitals around the country. From being able to remotely examine patients, advances in technology have allowed specialists to do much more, including listening to heart sounds, examining endoscopies and looking at CT scans.

—Rahul SachitanandChhattisgarh
Stymied By the Naxals

Not many states can match Chhattisgarh’s record when it comes to telemedicine infrastructure. It was the second state to network all its 16 district hospitals under ISRO’s telemedicine project. Each of them can hook to a super-speciality hospital like the Government Medical College, Raipur, or Apollo Hospital, Bilaspur, or the All India Institute of Medical Sciences, Delhi. Even Escorts Hospital in Raipur has done its bit—it has stood in for the lack of cardiac care facility at the Raipur medical college.

The telemedicine facilities remain idle because Naxals threaten doctors and there is no power supply

When the Chhattisgarh government launched the project three years ago, it was introduced only in a few districts where communication facilities were reliable. Subsequently, it was extended to other places.

While that’s the brighter side of the story, there is a darker side as well. The facilities have remained idle in most places either due to threats from Naxalites, who are driving doctors away or due to disruptions in power supply or connectivity.

But the government is not giving up. “We are going to strengthen it and it should be functional in about two months from now. Later, we will extend it to hospitals at block levels,” says R. S. Vishwakarma, Secretary and Commissioner of Health, Chhattisgarh. Doctors, he says, are cooperating, but some places do not have technicians, a problem the government will fix soon. Adds Dr B.S. Sarwa, Director of Health, Chhattisgarh: “We are a new state and we are doing our best to make telemedicine tick.”

—K. R. Balasubramanyam