By Prof. Ramanan Laxminarayan
Family physicians or general practitioners (GPs) are the gatekeepers of our healthcare system. They are the first point of contact for patients for any sickness or preventive visit. India has about 800,000 medical doctors of which about 600,000 are GPs. But more than three quarters of these are in urban centers which make up only about 20% of India’s population. Access to a doctor in urban India is about the same as it would be on average in the United States. However, the ratio of GPs to patients outside these metro areas is about 1 GP for every 7500 patients on average and as low as 1 for every 25,000 people in more remote areas.
Most Indian villages don’t have population to sustain GPs
Why is that the case? Although India is densely populated, the economics of being a GP don’t really work unless there is a catchment area of at least a few tens of thousands of paying customers. Moreover, a support infrastructure of labs and pharmacies is also needed. Most villages don’t have the population to sustain a GP, which explains the concentration of GPs in urban and peri-urban India. The gap is filled by over 2 million rural medical practitioners or quacks who have no formal medical education but prescribe medications and are de facto, the healthcare system for much of India.
This situation is unlikely to change anytime soon. Even to bring another 200 million Indians under the coverage of a GP using density norms of the World Health Organization, we will have to invest in training another 200,000 GPs, or in effect, increasing the current number by a third. Moreover, simply training more doctors will not solve the problem if the economics of practicing in rural areas is unsound.
Technology is changing healthcare and role of doctors
The fundamental economics of GPs has not changed in nearly a century. But in that period, technology has changed a lot and is augmenting the role of doctors to enable them to do more. Twenty years ago, most ECGs were read by a cardiologist. Today, most are machine read and the most advanced algorithms and neural network-based systems are more accurate than 99% of cardiologists. This does not mean that a machine can replace a cardiologist. It can simply remove some of the more routine and mundane tasks that a cardiologist would spend time and allow them to focus more on their patients’ wellbeing and treatment. This is no different that smart phones which enable us to not have to remember phone numbers or addresses and allows us to retain our memory for more important things.
Technology has revolutionized every part of medicine including surgery, cardiology, cancer diagnosis but it is missing in action in primary care. The equipment at the disposal of most GPs is still a stethoscope, blood pressure apparatus and perhaps an otoscope. In fact, the most advanced piece of technology in a GP’s office may be a smart phone, but one with 1000 times the computing power of the equipment that put man on the moon. That seems like a lost opportunity. Could a GP be doing more for more patients with that technology. Could we somehow use this connectivity to “see” more patients than the 20-30 who show up in their waiting room every day. That was the promise of telemedicine, but sadly most of telemedicine has not advanced beyond a video portal that connects patients to doctors. But there is more to medicine than a video chat – without the human touch and some ability to “feel”, “touch” and “measure” vitals and diagnostics, medical consultation is meaningless.
In Kenya, such a model is already underway supported by the Bill & Melinda Gates Foundation. Ten clinics, operated by the NGO CFW are located in remote parts of Kenya where the population density would not support a medical doctor’s salary.
A single doctor in Nairobi monitors multiple consultations at the same time. Based on her instructions, a nurse at each clinic is able to carry out diagnostics on more than 50 parameters using HealthCube technology which was developed in India. On average, each doctor is able to see 60 patients a day across rural Kenya. Using this model of remote diagnostics enabled telemedicine consultation, the patient saves on the cost of going to a city for healthcare and a doctor is able to help more patients without traveling.
We have an opportunity to simultaneously solve the problem of non-existent rural healthcare, and the economics of GPs through digital health. Although India leads the world in digital technologies, that advantage is missing in its clinics. It is time we brought technological breakthroughs into primary care.
The author is Founder, HealthCube. Views expressed are the author’s own.
