Comprehensive E-Health in Bangladesh

Bangladesh has made massive strides in socioeconomic development since its independence and is has become the 57th largest economy in the world. But with public health spending of USD 8 per capita Bangladesh ranks among the bottom ten countries with the lowest public health spending globally. Health in Bangladesh stands at a paradoxical juncture. With the decline in mortality rates and increase in average life expectancy, Bangladesh's healthcare indicators have definitely improved over the last decade. However, they still lag behind global and regional standards.
Infrastructure and System Structure: The healthcare system structure has evolved in Bangladesh over the past 30-40 years, the coverage and service levels of the entire public health ecosystem remains woefully inadequate. Our healthcare system continues to suffer from several problems, which have created significant inequities in providing basic health care. While our healthcare expenditure has increased in the past, Bangladesh has invested less public money in health than most comparable countries. Bangladesh's overall health spending is 3.6% of the GDP and63.5% of that is private money. Government spends about 9% of the budget on health.
In most developed nations, total spending on health ranges between 8-12% of the GDP, and public money outweighs private money by three is to one; and in middle income countries, the proportion is typically split equally between public and private expenditure.
Substantial gaps in healthcare infrastructure: Total functional beds (in DGHS and registered private hospitals) are 92,404. Hospital bed density in Bangladesh has stagnated at 0.6 per 1000 and falls significantly short of WHO laid guidelines of 3.5 per 1000 patients' population. Moreover, there is a huge inequity in utilization of facilities at the village, district and national levels facilities remaining the most strained.
Research has shown that the proportion of medical and healthcare expenditure in overall personal consumption has risen considerably over the years. In fact the healthcare expenditure is rising faster than the household income. In 2010, Household Income and Expenditure Survey (HIES) 2010 reveals that 24.57 per cent families of the country have been brought under the coverage of social safety net programme as compared to a global average of almost 60%.
Medical manpower remains inadequate: Bangladesh is currently known to have 53,923 available doctors and 33,183 nurses. This translates into one doctor for every 2,894 people. The recommended WHO guidelines suggest that there should be 1 doctor for every 600 people. This translates into a resource gap of approximately 206,000 doctors and with a total MBBS seat of 8,026 per year (Government 3,176; Private 4,850) we can only expect the gap to be widening over time.  We also see disparity in the manpower present in the rural and urban areas. Nearly, 75% of the qualified doctors in Bangladesh practice in the urban areas leaving the rural areas (with around 70% of the population) with practically with very few doctors.
Bangladesh has witnessed a nearly consistent gap between public and private healthcare expenditure and healthcare access for its citizens over the past few years. This possibly implies that greater healthcare funding cannot guarantee better access to the healthcare facilities, unless accompanied by powerful and innovative interventions to improve the healthcare ecosystem.
Information Technology has been making inroads into the Health sector in Bangladesh over the last decade. We now have a slew of systems being used very satisfactorily. There are a few National Level Health IT Programs that utilize technology and data capture methodologies. A few of the programs are presented below.
National Level Health IT Programmes (Selected): Identified e-Health and m-Health initiatives in Bangladesh by managing entities:
1.    Public: DGHS MIS, DGFP MIS
2.    Private ( For Profit): Medinova Telemedicine, eClinic24 by TRCL, AMCARE by TRCL, JBFH Telemedicine , Friendship by mPower, MHSBC by mPower
3.    Private( Non-Profit): mCare by JHSPH, mTIKKA by JHSPH, SAJIDA Mobile Telemedicine
4.    NGO: CRP Telemedicine, BRAC mHealth, MIS by RHSTEP, infoLADY by DNet  
Bangladesh currently has a number of public health IT systems, but working in 'silos'. Most of the public health IT systems at national levels are in reproductive and child health (RCH) due to the public policy and management concerns in respect of women and child. We have two RCH systems concurrently running at the national level. One is DGFP's MIS and other one is RHSTEP's MIS.
Importance of shifting from "Infrastructure Focus" to "Productivity Focus": Bangladesh's healthcare spending has increased at a compound annual growth rate of nearly 10 per cent over the past decade. Ideally, this spending should have generated corresponding improvements in Bangladesh's healthcare access, which, for the purpose of this analysis, has been defined as a collective function of health infrastructure, medical manpower availability and health insurance penetration. While both spending and access have improved over the past decade, it can be argued that the returns on increased healthcare expenditure have been suboptimal. This possibly indicates that a larger funds allocation for healthcare cannot by itself guarantee better access to healthcare unless accompanied by powerful and innovative interventions to improve the healthcare ecosystem.
The comprehensive adoption of Information Technology (IT) practices is central to the success of the following recommendations which aims to bring productivity in the healthcare system.
Recommendations
1. Hospital Information Systems and Record Digitisation:
Hospital Information System can? help overcome several challenges like accessibility, portability, affordability, awareness but one of the biggest advantages it offers is enabling patient- centered coordinated care. It significantly improves the operational and clinical efficiencies of hospitals. It has the challenge to ensure that various functions within a healthcare setup (public and private) talk to each other. Following?are the key objectives for implementing hospital information system. A) Integrated healthcare delivery through efficient processes.?B) Maintain and access patient electronic health record at point of care delivery for informed decision making C) Unique patient identification in different care settings across centersD) Exchange of data between different healthcare delivery units at primary, secondary and tertiary across public and private sector E) E-referral or electronic referrals which?enables the seamless transfer of patient information from a primary?to a secondary treating practitioner's hospital information system.
2. Automation of Supply Chain:
Supply chain management system for drugs, vaccines and other consumables, along with equipment and other hard assets, is the cornerstone of all successful healthcare systems. In Bangladesh, the 11 implementing authorities procure drugs and medicines. They first store the medicine to Central Warehouse and from there the medicine goes to regional warehouses. The supply chain would be managed more effectively by integrating the SCM system with other healthcare systems in the ecosystem.
The key objectives for implementing supply chain management system for drugs, vaccines and medical supplies at every level should follow: e-procurement, including auto procure for low value items , efficient inventory management, tracking of consumption and expiry dates till PHC and Sub-Centers, management of Supply interruptions, eliminate stock outs due to non-supply and expiry, transparency in drug procurement, counterfeit tracking.
3. Empowering Citizens through Information Dissemination:
A citizen portal would aim at providing information and services transparently to public with the vision to enhance the citizen's experience. The entire healthcare system will be under one roof where people from any part of the country would have access to information and services through citizen portal. The portal should be available both on web and mobile (also through an SMS/IVR gateway). People in rural areas should, therefore be able to access citizen portal more easily through mobile application as mobile penetration is quite significant.
4. Handheld Based Data Collection:
Given the limitations of providing hard IT infrastructure in the vast reaches of rural Bangladesh, it is proposed that handheld-based data collection modules would result in significant advantages such as - cost savings, data collection at source (rather than periodic data updating), effective feedback loop integration (through prompts, video chats etc.) which can therefore enable diagnostic decision support, on the spot basic analytics, real time information availability to decision makers etc.
5. Analytics enabled Real Time Disease Surveillance:
The current notification system is mostly paper based, with Primary Health Centers and District Hospitals sharing information with the Public Health Authorities on a periodic basis. While big private hospitals do have systems in place to notify these diseases to appropriate authorities, the smaller players, especially individual practitioners, which form a majority of private providers, do not have any involvement in a notification system. Given the fact that private practitioners would first encounter a large chunk of such diseases, especially in the urban and semi-urban areas, it is very likely that there is a huge information leak in the notification of these diseases. Therefore, analytics enabled real time surveillance for patients has key role to play in the health care system of Bangladesh.
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The writer is managing director of Rupam IT Limited. He can be reached at: [email protected]