The Champions of India’s Telemedicine

“We asseverate our knowledge, skill, competence and spiritual strength to the conquest of human sufferings of birth, life and death.”

Those were the words inscribed on a plaque I received from the Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India at the conclusion of our Telemedicine Class’s visit there during the first week of August ‘08. “Asseverate” is a word I hadn’t even come across at any time before my reception of that plaque. A big word definitely, but it is one that truly captures the deep sense of purpose and service that exuded from practically every member of staff  involved in the institute’s telemedicine programs. It is quite possible that they were playing to the gallery, faking their enthusiasm to impress us, knowing that we had traveled halfway across the world to do a case study of their programs,. But that was not the impression I got over the course of the three days during which we stayed with them taking lectures, visiting satellite sites and historic places, doing shopping, and more. Every single person I met served by their dedication to the project to reinforce my belief that it is not the technology that matters; but the people who decide on goals, strategize on how to achieve those goals using technology, and implement selected strategic options. It is only when goal congruence exists among stakeholders can an organization begin to entertain the hope of achieving set goals. In the case of telemedicine, this is definitely the situation when practically every doctor you meet is extolling the virtues of using technologies to extend their services to the underserved populations. That is exactly what you would discover at SGPGIMS. But I am getting ahead of myself. First of all, I explain why we decided to visit India.

Intuitively, telemedicine, defined as the use of ICT to provide access to medical service where distance separates provider and user, should have widespread adoption among developing countries because of their proportionately larger rural populations and lower doctor-to-patient ratios. This is more so because of the existence of cost effective WAN technologies such as VSAT which these countries can leverage to deliver healthcare to their underserved rural areas. India is one such country that is known to have made a lot of progress building up its telemedicine infrastructure. Our trip to India was to acquire first hand knowledge of telemedicine as practiced in a developing country setting.

India is a nation in transition—a transition from an old historic tradition exemplified by the richness of its historical relics, monuments, and other tourist attractions to a new world order that is a blend of that older tradition and modernization stemming in part from low factor costs and strong competencies in IT. This modernization can easily be discerned in newer cities such as Gurgaon, just south of New Delhi, and home to such ICT giants as Microsoft, Oracle, Alcatel Lucent, and others. Concomitant with this modernization is a steadily growing productive base benefiting from an unprecedented inflow of foreign direct investment.

Looking to the future, as the western business model continues to emphasize the outsourcing of factor inputs, India’s low factor costs and sound comparative advantage in IT intellectual capital doubtless give promise of a virtuous cycle of growth, investment, and even more growth. The macro effect is the flow of wealth from the richer industrialized countries of the west into India. This in turn has led to the emergence of a burgeoning middle class with greater purchasing power than ever before. Greater purchasing power attracts more investment. And, so the cycle spirals.

It is truly a wonderful time to be an Indian IT professional as year-in, year-out, the demand for IT services outstrips supply. This revolution, championed by the private sector, derives mainly from strong competencies in software and IT services. For instance, FLEXCUBE produced by i-flex solutions, a company resident in Bangalore, has for years been among the leading banking system software around the world. It is a commentary to this company’s success that Oracle has acquired significant holding of its equity and is projecting it as Oracle Financial Services.

Healthcare, however, is a mainly government initiative; and in India’s welfare economy, it is ideally considered a merit good that should be accessed by all, irrespective of barriers of geography, income, and physical ability. It is refreshing to know that, the success achieved by the private sector in IT is being replicated by government in its healthcare delivery. Several imperatives are obvious in the country’s adoption of information technology in healthcare delivery.

India’s unique characteristics of high population—national, rural, and underprivileged—as well as a lack of commensurate medical facilities and personnel to service this population has given impetus to the adoption of ICT as a veritable platform for extending and improving the quality of medical services. But then, it is a credit to its IT savvy population that this country is at the forefront in the application of ICT in healthcare delivery, whether it be PACS, HIS, biomedical informatics or telemedicine.

With regard to telemedicine, India’s high rural population, low doctor to patient ratios, and a concentration of specialist care in urban areas are adduced to be the chief drivers of initiatives geared towards expanding the reach of healthcare. It is, however, pertinent to point out that around the world there are many developing countries with similar conditions of inadequate healthcare, which have appallingly failed to even consider the extension of healthcare to the underserved population as a worthy goal to be pursued, let alone reflecting on the application of telemedicine technologies as a potential means of achieving that goal. It would seem that the resourcefulness of its people and a service-oriented approach to IT adoption are proving to be equally essential in the successful application of telemedicine in India.

Most of these initiatives are at the instance of government through institutions such as SGPGIMS. Thus, its welfare economics is certainly another important driver. In addition to providing funding, the government is allowing these initiatives pro bono access to its satellite communication infrastructure. Where the topography allows it, fiber optic cables are being laid to link institutions, thereby laying the infrastructural foundation for telemedicine.

Within government and across medical institutions, from tertiary to primary healthcare providers, there is a sense that ICT is essential to expand, extend, and improve the quality of healthcare services. In my opinion, this has been the case principally because of the presence within these institutions of champions investing all they have, for no pecuniary benefit, towards winning the buy-in, support and awareness of significant others regarding the value and beneficial outcomes of investments and partnerships in telemedicine. During our recent visit to India, I had the singular privilege of meeting one such champion and one of India’s most prominent telemedicine personalities, in the person of Dr. Saroj Mishra.

Dr. Saroj K Mishra is the quintessential telemedicine champion. A full time professor and Head of Endocrine Surgery at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, he was instrumental in setting up his department of endocrine surgery at SGPGIMS in 1989 and in steering the clinical, teaching, training and research in this discipline. He has since 1999 been involved in application oriented Telemedicine Research and Development projects, serving untiringly as a research collaborator in various Indian and International e-health projects. He is a member of India’s National Task Force on Telemedicine, and also sits as member and/or chair of various National e-Health Project Review Committees as well as ITU and WHO.

He is currently involved in building up the telemedicine capabilities of the School of Telemedicine and Biomedical Informatics, which is recognized as a National Resource Center of Telemedicine by DIT, Government of India.As part of the Summer 2008 Telemedicine class, Professor Samir Chatterjee had arranged for an excursion to India so as to enable the class experience first hand the application of telemedicine technologies in a developing country setting. It turned out to be a grand tourist excursion, as it enabled us to also visit tourist sites Delhi, Lucknow, and Agra. In the process, I got to learn about India’s illustrious past as well as the makers and shakers of that golden age. We also got to eat a variety of Indian dishes—my own culinary expedition to the real India; and a most successful one at that. I mean, it was in search of the same spices used in preparing those tasty dishes I savored that Columbus landed in the wrong India. Or, so I learned.

Well, back to Dr. S K Mishra; he is a guy that makes things work. During our visit to his institute at Lucknow, he provided us with accommodation, transportation, and meals. He also scheduled for us to receive lectures on various aspects of the institute’s telemedicine programs—teleradiology, telepathology, telementoring, tele-education, and research and development. Interspersed with these lectures were visits to satellite hospitals that provided us with first hand knowledge of distances and terrains patients would cover to access specialist healthcare in the absence of telemedicine. All through the period of our stay in Lucknow, guides were at our service, taking us to historic sites and shopping centers. Listening to his talks about the institutes telemedicine program, you cannot help but appreciate how easily he could use his various high ranking positions to influence and garner government support for telemedicine.

The following is a concise bulleting of what I learned from Mishra and other professors of the institute regarding the telemedicine program in SGPGIMS

Purpose

• Push healthcare to those in need
• Reduce patient travel time and associated costs, plus, the patient gets needed family support
• Provide a quick access to specialist care
• Provide a platform for specialist knowledge sharing and mentoring, thereby expanding the reach and quality of healthcare

Technologies

• WAN
  • Satellite
  • Fiber optics
• Telemedicine software, hardware
• Videoconferencing infrastructure and equipment
• Videoconferencing equipment and technologies

Program scope

• Telehealth Care
• Distant Medical Education. The importance of educating the next generation of telemedicine practitioners cannot be overemphasized. Intellectual capital ranks amongst the most fundamental telemedicine infrastructural modules.
• Research and Development
• Developing Core Competence
• Participants in National Policy Initiatives
• Telemedicine Consultancy and Solution Providers
• Organizational activities in Telemedicine

More to Be Desired

In general, India’s successful telemedicine program is a model worthy of emulation by other developing countries. Interestingly, the country stands ready to assist others in Africa and Asia in telemedicine capacity building, if policy pronouncements to that effect are anything to go by. This singular example of kindness by the Indian government is one that deserves commendation, especially from those who favor welfare economics in particular and humanity in general.

Having said that, I however observe that despite the progress it has made, India still has much to do to successfully push healthcare to those requiring it the most. Sabera, my classmate who was originally from India, noted during class discussions that the south-western part of India seemed to be left out in the general scheme of telemedicine adoption. My take on this is that the private sector has a better sense of the market. To that effect, research is required to determine ways and means of attracting private sector participation, which as yet is mainly restricted to offshore outsourcing contracts.

One such means is the development of business models that should help attract private sector patrons and partners, including the highly desirous foreign investment. During a lecture at India Institute of Management at Lucknow, Professor Samir Chatterjee tasked the MBA students to begin thinking in terms of conceiving viable telemedicine business models that would serve to attract private sector entrepreneurs. This charge could not have come at a more opportune moment in India’s telemedicine adoption process. Clearly, the government sector cannot do it all alone. In addition to its investment in general telemedicine infrastructure and equipment of the hospitals and institutes, it needs to motivate private sector participation. Yet, for private companies to venture into telemedicine projects, business plans must provide assurance that projects will be profitable. Producing such plans requires a thorough understanding of the issues at play in India’s healthcare system, its telecommunications sub-sector, the steadily growing IT industry, the general business climate, and the changing demographics of the population. It is, thus, not a case of business as usual. The usual goal of extending healthcare service must, for business organizations, be considered within the purview of profitability. Consequently, to succeed in attracting meaningful private sector participation, government should for instance consider giving some incentives—such as the granting of pioneer status and/or permitting some sort of subsidized access to its satellite communication—to telemedicine startups that meet set policy criteria.

This is a tribute to the Mishras of this world—the select club of the rarefied few infused with the uncommon zeal to serve out of a general honest thought and the common good of all.

Anaga Ojo

anaga.ojo@cgu.edu