Addressing Health @ Bottom Of Pyramid

Despite making breathtaking developments in the field of medicine, we are far from making its benefits reach the last mile. Health disparities remain painfully under-addressed almost across the globe.

Though there have been various attempts made globally to solve the problem of Access, Affordability, Awareness, Accountability and Adequacy of Healthcare Services, our efforts are still fragmented despite years of experimentation. Perhaps the lack of resources and collaborative teamwork with existing stakeholders in a complex system undermines committed people from achieving what is often intended.

Unlike other essential services, healthcare is multidimensional that needs re-engineering of entire ecosystem. Though it sounds like a mammoth task but we need to address major elements impacting healthcare "all at once", in order to create a successful healthcare delivery model that is sustainable, scalable and replicable accross geographical boundaries.

Our extensive field research has pointed us in the direction that our Rural Health Care Re-engineering efforts must include atleast 4 interdependant models that should be seamlessly integrated to achieve desired results. Each pillar of the model recognizes the value of collaboration, i.e. by pooling of expertise, fostering partnerships and sharing of resources, skills & experience wherever possible.

1. Service Delivery Model -

This pillar focusses on facilitating locally empowered and motivated agents of change that can deliver need based services in the village itself. These services should be designed on the basis of primary epidemiological data, address consumer preferances and offer a range of services which may be "Demand based" or "Protocol based". The services be broad enough to include preventive as well as therpeutic interventions, leveraging best of modern allopathic system and traditional alternative systems of medicine.

The components of service delivery are not only delivered in the field but also rely upon strength of established hospitals and Institutions. These could be partner hospitals at local district level as well as larger tertiary care facilities that have dedicated administrative, telemedicine and ambulance command center support.

Essential component of service delivery model is meticulous data collection and analysis that generates useful insights for planning of timely and appropriate interventions and to monitor progress. The program would develop in a constantly learning & evolving fashion.

The bed of this model essentially rests upon mutually supporting partner networks. No single player would have enough capability and resources to meet all the challenges at once. Like minded social entrepreneurs can share their strengths and contribute in collaborative fashion into a common platform. NGOs that work towards nutrition, sanitation, education, local empowerment, entrepreneurship and agriculture are indirectly contributing to improving health. Direct partnership can be as simple as doctors contributing their time online at their own convinience, or be large scale biotechnology, pharmaceutical and biomedical engineering companies contributing innovative solutions. Moreover, public health specialists, engineers, programmers, educationists, social activists, agri-business companies, Governments, funding agencies - there is scope for everyone to contribute "coherently" as team players.

2. Technology Model

The technology can enable a vast range of activities which were not possible in the past. The doctors can see the patients, interact with them and acquire relvant clinical information and even advise using Information & Communication Technology. The entire Medical Record can be maintained online in digital format and be interfaced with Hospital Information Systems, Financial Institutions and all other stakeholders.

3. Supply Chain Model

The doctor's prescription can reach the village in digital format but it is of no use unless it gets executed by either medication supply, sample testing, referral or emergency transportation. These products have to reach the consumer in timely manner, with accuracy and accountability. This pillar attempts to solve the problem of logistics - for making preventive and curative solutions, Medicines, Cheap Point Of Care Diagnostics, Health related products reach the last mile.

4. Financial Risk Pooling Model

All said and done, someone has to bear the cost of the service model. Either the Consumer bears it directly or someone else on his/her behalf. It may be Charity, Government, Risk pooling funds or Other mechanisms that bears the cost to make it sustainable. Innovations in financial model can ride on and support the innovations in abve 3 models.

Our vision is to let innovations in these diverse fields be synthesised and matured to achieve single common objective - "To make it possible for all human beings enjoy the fundamental human right to access healthcare when they need it and in cultually appropriate manner".

We have made a small beginning, you are welcome to join hands.

Sunday, May 27, 2012

Bringing systems thinking into M Health

A recent article in WHO bulletin identified important challenges to make M Health initiatives sustain beyond demonstrations and pilots. ( For the first time I saw some systems thinking evolving as the world begins to develop understanding of delivering healthcare at the bottom of the pyramid.

Disconnected development of applications in absence of significant alignment with healthcare delivery models, financing models and supply chain of goods and services is most likely to remain limited in its impact. I have attempted to express my views taking on board the lessons learnt from small pilots and looking towards a promise of better healthcare delivery system.
1. M-health needs to move towards sustainability and then develop an evidence base: It is desirable to build an evidence base for a new way of doing things but the real challenge is to ask the right research questions and measure the right things. Evaluating isolated systems not built on systems thinking may show some positive outcomes when compared to no intervention. Something will always be better than nothing, but does that provide answer to a range of issues and problems? Is the intervention scalable? Is it compatible with existing healthcare system and its drivers and does it align with regional/national agenda? How will a limited intervention (e.g. focussing on HIV or malaria or smoking using mobile phones) look like in light of bigger picture where equally important illnesses/contributing factors would need to be addressed?

What I am trying to emphasise is – it would be far better and perhaps sustainable for funding agency to support M health initiative as a part of larger drive to achieve a sustainable healthcare delivery system and then perform a rigorous evaluation to develop an evidence base. I don’t think an M Health intervention to support antenatal care and another to support HIV medication use and a third to track institutional delivery would deliver value as against a seamless one. Having a systems approach and collection of evidence in itself would still be limited if we cannot compare and Meta-analyse results across regions/countries. Therefore measuring similar parameters in standard format is perhaps the best way forward.

2. M-health systems should be interoperable with existing e-health initiatives and M-health should adopt and implement the same standards already present in e-health: These are essentially two sides of the same coin. There is no interoperability without standard based communication. If we continue to develop patchwork of interventions one for every disease and do not follow standards based coding then we will have the same problems as rest of the healthcare system, but probably even worse given lack of incentives and funding support post pilot. Moreover, many interventions tend to offer solutions without bringing physicians and hospital based systems into the loop. It may be harder in situations where private healthcare providers work independently, but again standards based design could easily enable opening of information pipelines as the model moves towards integration.

3. M-health should take an equitable and participatory approach: It is not only about patient’s participation in managing information but also provider’s participation is equally important. The issue becomes critical in developing world where illiteracy and disempowerment stand as barriers to patient participation. In such cases often intermediary health workers need to get involved. An ideal solution would enable transmission of data multidirectional between patients, providers, health workers and managers of the healthcare system. Such an approach will help to develop clinical and analytical grunt to the designing and planning and delivering services. Furthermore, participatory approach could be extended to the design process. Including potential stakeholders right from the start and designing while addressing each one’s needs would probably deliver a more sustainable intervention. A good healthcare system delivers for every one not just of the rich or the poor.

4. M-health needs to focus on health, not on the technology: Often the systems get designed with technology in forefront given the excitement of innovation. In healthcare, technology has always remained as an enabler of service provision - not a provider of services in itself. Ignoring this important principle has led to siloed, disconnected and incomplete solutions. Conceiving the services first and using workforce, technology, financing mechanisms and supply chain issues to seamlessly form a synthetic whole to design a healthcare delivery mechanism, is probably what we need. Technology has been tested, it will continue to evolve and become more reliable but in itself it will deliver limited advantage unless one sees technology in larger perspective of larger healthcare system.