Brief Reviews

Brief rapid reviews on healthcare in India, technology and mHealth, and mental health needs and care delivery

Courtesy of students in the March 2015 MIT Sloan SIP Workshop on global health innovation focused on mental health in India and Anjali Sastry.

By topic area, each set of notes summarizes the specified resource mentioning what the student thinks is most interesting or valuable. The last point, "Open Questions," discusses what is missing, or what the student wishes they knew more about. This was a quick in-class exercise which did not cover all the readings we assembled.

India's Health Outcomes; Recent News on Budget and Government

OECD Health Statistics 2014 How does India Compare?


New Government Gears up for India's Health Challenges

Health spending in India compared to other counties; and changes in health care policy.

India spends only 4% of GDP on health care. They spend more than 4% on defense.

However, it seems that current government officials are dealing with regulations (whether medicine should be under Health Ministry permit) and control (e.g., privatization).

Missing info on non-government health care system.

IHME GBD Profile India 2010

The article quantifies levels and trends of health loss due to diseases, injuries, and risk factor in India.

Top 3 contributors to premature deal YLLs in India—preterm birth complications, lower respiratory diseases, diarrheal diseases—haven't changed in the last 20 years.
Leading risk factor for adults = Dietary risks.
Leading risk factor for children = Malnutrition.
Contrary to popular belief, this is not just hunger.

Causes of premature death that have shown the most increase are AIDS / HIV (6147%) and Self-harm (147%).

When compared to 15 other countries with similar per capita income, India consistently ranks in bottom 5. Could learn from Vietnam and Palestine.

How is YLD measured? Is it just how long the patient is afflicted or is severity of impact factored in?

In comparing against other countries, it would be interesting to see correlation on other metrics like health spending per capita, literacy rates, etc.
What Does Slashing The Healthcare Budget Mean For India's Ailing Public Health System?"

By cutting it's already low budget for healthcare, India will be doing itself a significant disservice, both in terms of health and economic outcomes.

Notable facts:

  • Non-communicable diseases will cost India over US $4.5 trillion between 2012 and 2030.
  • A United Nations report estimates that 75% of India's health infrastructure and human resources is concentrated in urban centres where only 27% of its population lives.
  • Out of pocket medical expenses already push an estimated 39 million Indians into poverty every year.
I would like to know more about the whole system and where there are potential economic leakages, areas of corruption, or misspending.
India's Health System

IMS: Understanding Healthcare Access


Forbes: Five Things About India's Healthcare System

IMS focused on the high percentage of patients receiving treatment from private healthcare facilities due to the long wait times and unavailability of doctors at public facilities. Since patients often need to pay for treatment OOP, this increases the cost burden to the patient.

An increasing proportion of the population is using private healthcare facilities for both inpatient and outpatient treatments. Long waiting times and absence of diagnostic facilities are among the main reasons private healthcare facilities are chosen over public centres for inpatient treatment. For outpatient treatment, the availability or doctors and quality of care are cited as reasons for selecting a private healthcare facility. However, patients would readily switch to public healthcare centres if these issues were addressed.

Notable: Exhibit 13 and 14—Doctors just aren't available, they are often absent

The levers of improvement in access can be broadly categorized into the following:

  1. Improve physical reach of healthcare facilities, especially in rural interiors of the country.
  2. Improve availability and resourcing of public facilities: E.g., by addressing concerns on availability of physicians and essential medicines, quality of care and prompt access at public healthcare facilities.
  3. Make higher cost channels more affordable (or better financed): E.g. by price regulations, subsidization of treatment costs, increasing insurance penetration and including drug reimbursement as part of insurance coverage.

Forbes piece is a quick read, good starting point for an intro to India's health system.

Why are there not enough doctors? How are doctors being educated and paid?
UCL: This resource may not render correctly in a screen reader.Health and Health Care in India: National Opportunities, Global Impacts (PDF)

The article covers some stats and trends on key population health metrics (life expectancy, infant mortality) together with analysis of resources directed to improve the healthcare systems in India. The authors also discuss what measures can be of most benefit for Indian people 1) Mismatch about what public thinks is beneficial (achieving better public health is via reducing the prices of medicines for treating conditions such as advanced cancers) vs what data say (Indians can benefit much more from the introduction of universal health coverage and a wider use of medicines for preventing and treating early stage vascular diseases, diabetes and cancers). 2) Stats on diabetes and NCD are eye-opening for me (would never guess this) 3) Mismatch about being one of largest producers of drugs paired with very limited accessibility of those drugs to internal population).

1) R&D stats; 2) Drug pricing comparison with other countries.
Mental Health Care in India and More Broadly

Mental Illness, Poverty, Stigma (India Case Control Study)


Rethinking India's Psychiatric Care

Need for a sound mental health policy and access to mental health aid, as well as a reduction of persistent stigma against those with mental illnesses.

  • Interesting link to childbirth mortality leading to mental health issues
  • In order to de-stigmatize mental illnesses, need to embed mental health services within general health services
  • About getting individual help: Perhaps not such much about stigma, versus lack of knowledge
  • Possible intervention: Telepsychiatry to target range of income levels
Other ways to weaken the stigma against mental illnesses. Because lack of employment aggravates mental illnesses, what can be done if economic development is not synced up? Are there solutions for areas that don’t have this growth available?
The Movement for Global Mental Health The Movement for Global Mental Health, which is a collective actions that aim to close the treatment gap for people living with mental disorders worldwide. Why the movement is meaningful, how does this sharing of information is helping improving the global mental health, and what impact has it made so far.
Novel Models for Delivering Mental Health Services and Reducing the Burdens of Mental Illness

The resource is about the limitations of the current model for delivering mental healthcare. Since mental healthcare in America is typically one-on-one and administered by a masters or doctoral level professional this limits its ability to be exported internationally or be easily expanded.

I thought the potential tools for making mental healthcare more scalable were very thought provoking. Certainly having virtual care or email correspondence with a mental health professional far away from the countryside would allow more people to access care that would otherwise be unavailable. It was also interesting that the authors noted the limitations of such treatment and cautioned against the effectiveness of such methods when compared to traditional, and more intensive, treatments.

The article does not delve into the relative effectiveness of informal mental healthcare. Certainly strong familial and community support is key in treating mental health issues. Many of the strongest communal ties are in the developing world where villages may have strong tribal allegiances that help to bolster mental health.
'Someone like us:' Delivering Maternal Mental Health through Peers in Two South Asian Contexts

"Studying the potential for untrained peers to deliver mental health services for maternal depression in low resource settings."

Given the stigma attached to mental health I think it was interesting to see that most of the reporting centered on having someone they can relate to.

There is no discussion about the quality of care or a review of potential unintended side effects.
Improving the Scalability of Psychological Treatments in Developing Countries: An Evaluation of Peer-led Therapy Quality Assessment in Goa, India

Assessments of lay therapist quality ratings and of acceptability and feasibility of peer-led supervision compared to expert-led supervision, in Goa, India.

The conclusion is solidly backed by some empirical trials comparing the effectiveness / acceptability of peer-led supervision on lay therapists practice, compared to expert-led practices. Simply interesting to see that lay therapists can be as effective as experts at a statistically non-significant level.

Article mainly IDs the issue, there is not much discussion about potential solutions.
Would love to know the scale of the problem and the current availability of expert care—how big is the pool of people affected by mental health problems and how many experts / professional therapists per patient are available to them.
India Healthcare Delivery, Service Quality, HR, Task Shifting
In Urban and Rural India, a Standardized Patient Study Showed Low Levels of Provider Training and Huge Quality Gaps Understanding whether investments in healthcare workforce and infrastructure are being undermined by poor quality. Takeaways: Very interesting and jarring results—very low levels of training, high levels of inaccurate diagnoses, urban performed a bit better but not much; training did not necessarily result in better outcomes.
On Social Factors, Poverty, Equity Issues in India

This resource may not render correctly in a screen reader.Are We Reluctant to Talk about Cultural Determinants? (PDF)


Making the Invisible Visible

The first item, an editorial, was about the importance of taking culture into account during the research process, in addition to factors such as income, education, and occupation.

The second article was about the prevalence of urban poverty and the miscalculation of its existence in India due to a number of factors. The article was about the importance of accurately accounting for the urban poor and the effects that leave them out has on health interventions and outcomes.

Specific examples that helped to make the author's point were really valuable, such as the effects that male alcohol consumption has on the family's economic status, which then has effects of the nutrition of the family.

The data and stats on this issue were interesting, especially that the prevalence of poor health in the urban slums is higher than that in the rural settings.

I wish there were more examples to support the author's proposals.

I also want to know more about the demographics in the slums, why people choose to live there as opposed to rural settings, and rates at which people are moving to rural areas.

The Health of India: A Future that Must be Devoid of Caste

Although India has gained a new leader, Narendra Modi, it still must acknowledge values of caste that have been entrenched into the society and how they exacerbate health inequities.

When India gained independence, it looked to Gandhi to set the social norms. His stance on the Caste system has appeared to support the caste system and a segmented society.

There is no data showing the health outcomes of each caste within the society. It also doesn't explain the history of the caste system within India.
Technology, Mhealth
Kahol: Mobile Messaging for Health This article looks at the use of mobile messaging to improve the adherence to HIV treatments. The study showed no significant difference compared to a control group. But emphasizes the need to focus on the design of the messaging and not yet draw conclusions about its effectiveness.

I thought the conclusion of the article was very interesting. It goes along with what we heard in the lecture and the need for more data. I liked the notion that just because these initial tests did not show significance, we should not rule out utilizing mobile messaging but rather look for an improved design.

I wanted the article to include more info on the various types of messaging that have been tried and its effectiveness. Though this information may not exist yet.

MIT Tech Review: Data-driven Healthcare

This article is about how we use the wealth of data being collected in healthcare today to improve outcomes. I was interested in how they touched on what appears to be 3 main topics:

  1. Personalized medicine and getting more specific about patient treatment on the life science side,
  2. Patient engagement, with the rise of wearables and patient's actively being a part of their own patient record, and
  3. Using tech to leverage delivery models and replace docs, e.g., Watson, etc.
The article didn't spend much time discussing the challenges of HIPAA in the implementation of longitudinal health records, but perhaps it was more about potential solutions and not about the major hurdles faced in US policy.