The devil is always in the little details. Uttar Pradesh is notoriously corrupt, with its broad sweeping brush not sparing even the sick and ailing. Yet, Hilauli is often cited as an example of how a few good men with a few good intentions can use funds of the national rural health mission (NRHM) to transform the health map of a block. On the surface, a lot has changed. The sub-centres (SC), primary healthcare centres (PHC) and the community healthcare centres (CHC) of the block are freshly painted, the laboratory area is Spartan but clean and the cabinets are well stocked with generic medicines. Brand-new autoclaves, which is like a medical pressure cooker to sterilise needles, gauzes and other medical supplies, Bunsen burners, test-tubes, electronic microscope, pipettes, rapid diagnostic kits, blood slides are all present even at the sub-centres. To use a digital terminology, the hardware is more or less there.

The Indian public healthcare system predicates a seamless integration of its four fundamental layers of sub-centres, primary healthcare centres, community healthcare centres and the district hospital. There are clearly documented guidelines for the establishment of these four layers — one SC for a population of 3,000-5,000, one PHC for every 20,000-30,000 people and one CHC for every four PHCs.

There has been a massive focus on thickening this network in recent years and it has shown results. There are over 1.5 million sub-centres in the country today and yet, as the Economic Survey points out, there is still a shortage of over 20,000 SCs, over 4,800 PHCs and 2,500 CHCs. This gap is under intense scrutiny and several efforts of the ministry of health and family welfare (MoHFW) are focussed on eliminating it. Quite rightly so too. But the devil is not in this gap. It’s in something more innocuous.

The seamless integration that our health planners almost routinely assume depends on what medical professionals call the ‘referral system’. It’s quite simple really. A patient who comes to a sub-centre wants to know what’s wrong with him. In order to find that out the laboratory at the sub-centre should be able to test his blood and other samples. Based on results of the test, the doctor at the sub-centre can make the right diagnosis and prescribe the appropriate course of treatment and medicines. If the doctor finds the patient cannot be treated at the sub-centre, he writes an official medical note to his counterpart at the PHC for treating the patient.

In theory that’s how the ‘referral system’ is supposed to work. But like all theories, there are several imponderables that come together and conspire to fail it. For instance, tests are possible only if the laboratories have technicians, and such tests can be interpreted only if doctors are available. In digital terms, there’s a shortage of software.

Just to put this theory in perspective, the US has 2.672 doctors per 1,000 people and 3.1 hospital beds per 1,000 people, while we have a mere 0.599 doctor and 0.9 hospital bed per 1,000 people. To say that our medical education system is not producing enough doctors would be a tad unfair. It does churn out a substantial 31,000 doctors every year. Quality of the doctors, however, is a different issue. But the sheer gap in numbers is so wide that experts estimate it would take over three decades to produce 2.4 million new doctors and over 2 million more hospital beds, necessary to reach the same proportions as the US. Even a relatively well-endowed Hilauli faces a unique imponderable that often derails the referral system.

While most referral cases are able to reach the PHC, CHC or the district hospital as the case maybe by their own means, there are a few patients, especially expectant mothers and old people, who are not ambulatory — another one of those curious ‘medicalese’ for people unable to move on their own. Such people require the services of an ambulance. Each health centre is given a certain allowance for the purchase of diesel for ambulance and generators. The allowance is expected to cover daily running costs of the ambulance and keep the ubiquitous electricity generator, a standard feature of a power-deficient Uttar Pradesh, running for at least four hours each day. Pilferage of diesel apart, diesel meant for ambulances is invariably channelled into generators as several districts routinely face power cuts of up to 10 hours. In short, despite having a functioning ambulance and a ready driver, the showcase Hilauli healthcare centre cannot provide for ‘referral support’.

It isn’t surprising then that the National Family Health Survey-3 (NFHS-3) finds that a majority of households in both urban areas (over 70 percent) and rural areas (over 63 percent) get treated by the private medical sector, while the WHO’s world health statistics finds that almost 60% of a common man’s total health expenditure comes out of his own pocket. The case for strengthening the Indian public healthcare network has never been stronger. But despite pure intentions, trying to strengthen it the conventional brick-and-mortar way is going to take some doing, and a lot of time. This is where various government institutions, the public and private healthcare sector and civil society organisations working toward affordable and accessible healthcare to all Indians must take into account three inter-related digital phenomena.

First, several digital authorities, including computer giant IBM, predict that in the next five years digital devices will evolve from a purely touch-screen environment to one incorporating touch, feel, taste, hear and smell. A digital device will have cognitive capacity of a human being. “Just as the human brain relies on interacting with the world using multiple senses, by bringing combinations of these breakthroughs together, cognitive systems will bring even greater value and insights, helping us solve some of the most complicated challenges,” says IBM. The computing giant also predicts that digital devices will feel textures, recognise and interpret images and understand colours. “This will have a profound impact for industries such as healthcare, retail and agriculture allowing diagnostic devices to automatically differentiate healthy from diseased tissue,” says the company.

Second, the burgeoning applications market for smart digital devices is slowly but surely moving away from gaming and entertainment apps to utilitarian and functional apps, from GPS-enabled location services to health monitors. In fact, in a first, Samsung customised its popular Galaxy S II range of smartphones for a healthcare application company Preventice for a product that used smartphones to transmit data from a patient’s heart monitor to a doctor. Preventice chief executive officer Jon Otterstatter said, “In less than six weeks Samsung made the necessary changes and agreed to pick up roughly $40,000 in engineering costs. I saw a huge company with huge resources move very quickly.”

The demarcation that exists today between application development and devices is likely to disappear in the next five years, lending to a more integrated suite of systems and services.

Third, digital connectivity across geographies and devices is going to expand in terms of scale, scope and speed. With 4G and its associated technologies of LTE and Wimax, and the national optic fibre cable network coming up fast, speed of 100mbps can be achieved with relative ease. With such connection speed, doctors can get connected to the remotest of sub-centres to diagnose patients and recommend treatments.

A combination of high internet speed and cognitive digital devices with specific diagnostic and medical capabilities will transform the concept of telemedicine in the next five years. Several private sector health companies like Apollo Group, Narayana Hrudayalaya and the Manipal Group are already positioning themselves for this revolution, investing heavily in telemedicine services.

The government must also seriously look at rolling out the second phase of NRHM with the objective of strengthening and thickening India’s public healthcare network using digital devices and pathways.