My radio interview with Tim Lynch

Interview with Tim Lynch on Green planet FM...

http://www.holisticliving.co.nz/members/holisticliving/blog/VIEW/00000010/00000318/Tim-Lynch-interviews-Dr-Pryesh-Tavari-on-technology-preventative-health--the-meaning-of-service.html#null

Technology enhanced de-skilling

Problem of skill shortage

The complexity and criticality of many clinical services demand that an expert makes all important decisions and executes interventions. This is clearly evident in hierarchical decision making in healthcare - and rightly so, for the maximum safety of seriously ill people. But this dependence on experts to make each decision and execute every action is sure to create a bottleneck unless they are supported by a team that executes some of the routine functions on their behalf. An example is commonly seen in teaching hospitals where residents and interns take over some of the clinical responsibilities under the supervision of specialist; or nursing students carry out some of the tasks under supervision of a senior nurse. But there are hundreds of tasks in hospitals, primary care and public health arena that require execution with a certain expertise but seriously fall short of expert hands for obvious reasons.

Rising quality standards coupled with serious shortage of skilled manpower creates a high pressured environment in healthcare where overwork, multi-tasking and stretching of capabilities of existing staff to its maximum (and sometimes beyond) is a common sight. The increasing demand for healthcare services with ageing populations, rising prevalence of chronic conditions and more demanding consumers is expected to further strain the healthcare sector. This grim scenario is a serious setback for underserved populations in remote locations. How can we expect the existing workforce to resolve the needs of rural populations, where the healthcare in cities itself is crashing due to skill shortage!! I do not see any improvement in healthcare delivery to rural populations in coming years unless we look for newer avenues and innovate to optimize our capabilities.

Skill distribution

The trend dictates that more skilled the professional role becomes, rarer their number is going to be. So how can we create a system where without losing the quality or burning out we can enhance the benefit of expertise to more people? The most logical way appears to be controlled skill distribution or "de-skilling".

The real meaning of the word can be understood when we do a thorough work flow mapping and action analysis of a professional in clinical role. For example if we analyse the role of a specialist we come to know that most of the time is taken up by routine tasks like history taking, routine bedside examination and reviewing test results. The real skill of a specialist is realized when the complex clinical problem is resolved and a decision is made after passing through the routine. If most of the routine tasks were handled by relatively less skilled doctor, physician assistant or a nurse and specialist was presented with all the relevant data, his time would be most optimally utilized for problem solving.

However, it is not always easy for a professional to depend on secondary information. Importantly, the solution to successful de-skilling lies in the ability of the juniors to meet the expected standards for basic tasks every time consistently and uniformly. If we can manage this skill distribution successfully then the reach of a doctor can be widened much more, we can care for more people and address skill shortage.

Role of Information Technology in skill distribution

A good IT system for community based healthcare should be able to facilitate standardization of outputs from less specialized workforce and/or feed into the workflow of professional with higher skills for them to be able to make faster, better informed decision that cover wider reach.

In the context of rural healthcare delivery - the community based health worker should be able to complete basic tasks efficiently, uniformly and consistently and be guided to collect appropriate information, seek guidance and execute instructions from a physician. The response to a demand based consultation (when a patient comes with a problem) or Protocol based data collection (when the healthworker makes a house visit) both need to be supported.

The solution design to extend community reach of a physician through the agency of healthworkers should enable some the following elements:

• Redesign work flow to enable graded information processing

• Enable delegation and process automation for routine tasks

• Support training and skill enhancement of healthworkers through knowledge management

• Provide decision support

• Performance mapping and incentive calculation that is linked to performance in the field

Technology to support quality while delivering healthcare at a distance

The physician and the healthworkers are rarely co-located in the same space. In our case the doctors are usually in the cities whereas the healthworkers are located in the villages. In order to match the service needs some of the points that we had to consider were:

• Use of rugged hardware that works in hot, dusty environment and survives rough handling

• It should support multimodal connectivity, meaning if broadband is not available then it should work on GPRS or PSTN line or even be ready for Wi-max connectivity in future

• Since the users are not visible to the decision makers, it is important that user identification is objectively supported (biometrically or banking type solutions)

• System should facilitate cross checking of data integrity e.g. it is not fudged or erroneous (GPS, time, date, user ID stamping on each string of transmitted information)

• System should not only support "on demand" services like consultation, testing or medication dispensing but also support "protocol based services" like hygiene education, immunization records, antenatal screening, water quality tests and chronic care etc.

• The technology should facilitate Point Of Care testing - atleast for basic parameters

The solution should enable recorded billing, issuing receipt, supply chain and transaction management for transparency in cash management and sale of products and services at a remote location

• It should also facilitate quality control by identifying and pointing out errors, emergency situations etc. also facilitate automatic escalation of information based on flagged events

• It should facilitate professional time optimization by mix of asynchronous and real time communications

• As far as possible the system should manage data locally and transmit coded information for decryption at central level in order to address security and optimization of data transfer

Sustainable clean drinking water services

THE PROBLEM
Access to clean drinking water reamins a major challenge in developing world. Epidemics of ADD (acute Diarrhoeal Diseases) and other simple to treat/prevent water borne illnesses are letdowns for the 21st century medicine. It is not the creation of innovative solutions or treatments but ensuring uniform access to what we already have, that often gets overlooked. More than half of Indian villages have poor access to safe drinking water.It is not only the avalability of water (in many places it is a few kilometers of walk to a water source) but also contamination beyond critical levels of what is available. The contamination is not only by biological infectious agents but also chemical (heavy metals, pesticides and fertilizer residues etc.).

The public health initiatives in India have been trying multiple ways of ensuring this basic service and there are examples of success in larger towns but have failed in most rural communities. The villages that are closer to large water bodies are better in terms of availability. The digging of borewells and fixing of handpumps has worked for some other areas but dropping underground water tables and seepage of wastes into underground sources limit their value. It is not uncommon to see pepole bathing, washing their animals, clothes/pots being washed and open defeacation nearby, which contaminates most sources.

LOCAL CHALLENGES
Depending on governments or international agencies to solve every problem is too ambitious hope. It is through local initiatives alone that some long term solutions can be envisioned.  These initiatves may invoke external support to become more comprehensive and subsidized in long run. Even government and philathropic agencies now expect local bodies (gram panchayat) to take leadership role with public funding support. But just constructing storage tanks, laying down pipelines is not enough (infact that is already done in many areas) but ensuring regular procurement, safe storage, filteration/purification to acceptable standards over a long term, is a skill that requires local capacity.

When we being creating local capacity it soon dawns that "everyones responsibility is no-one's responsibility". Taking theoritical approach to community empowerment and collaborative co-creation often fails to sustain after some initial victories, unless we loacte self motivated and well incentivised individuals who would drive it.

Sustained sourcing depends not only in locating/creating a source of water supply but also in ensuring recharging the source on an ongoing basis. Most programs ignore this repeated charging of water source, especially underground water which dries up eventually if not recharged.

Though it may be true that supply of safe drinking water from a community source solves problems to a certain extent, building up hygiene awareness and sanitation infrastructure in addition to piped water suppy gives best outcomes. However, it is a careful balance between the affordability of ideal solution with practicality of basics, at least in the beginning that supports a sustainable and evolving plan.

A POSSIBLE SOLUTION
Partnerships and collaborations between parties sharing common interest to be forged that enables technology that harnesses the best out of a given situation. This collaboration should happen even before the local communities are approached. because once you have appropriate experts on board then solutions are easier to craft and implement. We would attempt this by involving organization offerring water management technology on one hand and a microinsurance company on the other because each has a motivation and interest. One has an interest in expanding reach and the other is motivated to keep people healthy. This deliberately keeps governments out of the picture at this stage. But can invoke some field assistance at a later point in time.

Next step would be locating and training a local enterpreneur who is willing to take up this responsibility to run water suppply as a method of his family's livelihood. It is by securing interests and creating job opportunites with a growing potential that would attract local talent. This would also be incentivised to align with local stakeholder's interests and conforming to a quality control program that is monitored centrally. Financial enablement of capital expense and ways of loan repayment can be worked out at reasonable terms.

Once these two anchors are secured then launching a cost effective and simple solution would become feasible in stagewise fashion.

The Context of Healthcare Delivery in Rural India

The ground realities of remote rural settings are often difficult to comprehend unless one has been through the challenge of actual delivery of healthcare services. It is rare to find blogs and web sites on Global Health, e-Health or Telemedicine addressing the real issues, except a very few. It is important to understand the context of extreme poverty and social isolation in this so called "globalizing" world. It is not as simple as demonstrating a high tech video conference but engaging with the communities on a long term basis in practical, sustainable and feasible ways. In our challenging pilots we realized early on that depending on long term charity or hoping for government strategies to have significant impact is going be more frustrating than self initiated actions.

THE VICIOUS CYCLE OF POVERTY & POOR HEALTH
The first well known fact to become highlighted for us was Poverty traps people in vicious cycles of poor health. Being poor means poorer nutrition, more exposure to environmental agents including snakes, pesticides (the cheap labours are the ones who spray them) and unhygienic living conditions. The resulting stress from poverty and its consequences (including discrimination, exploitation and loss of loved ones) often drains the emotional resources to an extreme where resignation, addictions and abuse become a part of life. There is no initiative to learn about health because survival is of immediate concern.
On the other hand falling sick of any family member not only means additional strain to go to a doctor, buy medicines and get tests done, but also travel for long distances, arrange for food while travelling on top of loosing daily wages or other income opportunities. The Hospitalization remains one of the foremost causes for pushing people down below poverty line, because paying hospital bills often means no other choice but to borrow at high interest rates or selling huts, land, livestock and loose sources of income.

ROLE OF GOVERNMENTS
It became clear to us that simply distributing free medicines, bed nets or mass vaccinations are useful - but are only partial and temporary solutions. A sustainable infrastructure is undoubtedly the need, but after decades of efforts and billions of dollars spent, international and other Government initiatives have had little impact. Basic solutions like supplying clean drinking water, sanitation and availability of credible healthcare services seem to be near impossible tasks in most developing countries. Governments are not only limited in resources and in finding motivated skilled people to fruitfully engage, but also they keep on doing more of that which has not worked in the past, instead of innovating and doing it differently. Improving infrastructure is too big a task for single entity in a complex environment. It is not only governments responsibility but that of all of us who can think and do different things and to share our learning to complement each other in our common effort. Achieving MDGs too is a common challenge for Private as well as Public sector in any self respecting nation. It became clear that a strong Public-Private Partnership Model would be the best bet in long term. But persuading public sector and its bureaucratic decision makers to be a part of any experiment is another equally difficult challenge. Despite harping PPP there is hardly any proactive effort explore partnerships. Poor ethical standards, lack of motivation to achieve and willingness to cede control are well known barriers in corrupt systems. We have been experiencing cold shoulders to outright resistance more often than encouraging remarks or any concrete action from our "potential partners". However, not having given up the idea, we continue to do our bit with the hope that one day the right opportunities will present themselves.

THE HEALTHCARE PROVIDERS
It is true that there is shortage of skilled manpower in India. But the shortage is less absolute and more relative i.e. mal-distribution. The large cities are full of fiercely competing doctors and hospitals, constantly struggling to hold on to their "market share". The gloss of western style working environments in private hospitals create an obvious diversion for medical graduates. They have hardly any incentive to serve once they have acquired an "expensive degree" that gives them a short route to becoming a millionaire. Neither they are exposed nor trained to work in real rural settings, having studied the American and British textbooks that are praising the latest "Evidence Base". There is hardly any evidence base for healthcare delivery in rural India and expecting asceticism from children of well groomed families is blasphemy!
Further dimming the lights is the fact that quality of medical education in India is mediocre at its best. Our medical schools do an excellent job of converting best of country's young minds into mediocres. With hardly any emphasis on hands on skills, original research and field experience they become half baked theoreticians at undergraduate levels with poor employment prospects unless they complete post graduation. It is common to see most interns spending time studying for prePG competitive examinations instead of visiting the field. The hospitals beyond big cities are in pathetic condition. The primary health centres are worse. I have seen dogs and cows roaming in middle of dirt in these places. No wonder every time compulsory rural postings are imposed the doctors find their way through corrupt system to bypass the "punishment'. The same habit continues when they join government jobs that post them in the field. There are ways of getting full salary paid without a single days attendance at the clinic! Therefore, I have little hopes from compulsory rural postings solving the service delivery gap unless these doctors are given infrastructure, tools and intellectual stimulation befitting their needs. In most districts more than 80% of healthcare is delivered by private hospitals and doctors despite presence of government hospitals. The govt. salary sucks, drugs are not available and hygiene is poor.
Contributing to the problems is the culture of RMPs (Registred Medical Practitioners) who deliver 80% of healthcare from private sector in rural India. These are ill informed quacks who have been recognized by the government as healthcare professionals in extreme desperation. They usually offer a standard mixture of steroids, antibiotics and analgesics. They have been selling these injections as the "cure for all" in addition to IV lines as the "bottle for strength". Winning the trust of ignorant minds with sweet words coupled with immediate relief has a powerful impact on collective consciousness. This has conditioned rural mindset where they see anything less than an injection as non-professional !! Moreover, spread of infections with contaminated needles too is a major issue.
The entire private healthcare infrastructure in India works on nexus of referrals. The RMP gets a share every time he refers cases to a hospital or a doctor. The Doctor gets a share every time he/she refers a case to a specialist, lab, radiologist or to a hospital. The share is grand if the specialist or hospital does an expensive procedure (creating ideal situation for biased treatment decision making). Without any treatment guidelines, quality control and monitoring mechanisms the patients end up being significantly lighter in their pockets. The insurance mechanism does not work because it is expensive (insurers are aware of the market practices and have to hedge their risk) and it has longer list of exclusion criteria (in fine print of course) than the covered diseases. No wonder people do not see value in health Insurance and less than 3% of the country's population is insured.
In light of such activities establishing credibility for sincere providers has been doubly difficult because they are not "injection doctors" and at times get actively criticized by those whose unethical business was challenged by good efforts.

SUMMARY
The context of healthcare delivery in rural India is complex. The poor people have problems of Access - both physical access to quality healthcare as well as financial access for their inability to afford the costs of even simple to treat problems. Poor health environment, conditioning by local quacks to depend upon quick fixes and side effects of poverty present huge challenges to any preventive care program. The disease burden is high and is getting worse because poor people are afraid to access quality healthcare, ignoring symptoms that can be tolerated, poor control of infectious diseases as well as increasing prevalence of lifestyle disease. This "double whammy" locks the productivity of majority of country's active population from contributing to growth of agriculture based economy.