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, August 2, 2009

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 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.

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.

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.

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.


Lokesh said...

In lot of ways healthcare delivery in westernized countries is similar to that in rural India, except for the fact the western healthcare system is awash with fancier equipment and resources. The providers suffer from the same lack of interest in care for the poor and needy. In fact the Medicare population which has become like the rural population in India that nobody seems to be willing to provide care for. This is partially financially driven due to declining reimbursements but also due to red tape. The referral patterns in US are no different the commission based patterns in India. Its hidden and understandable that providers "scratch each others back". There is no open commissions involved. I guess the point I would like to make is that self empowerment should occur at every level of our societies from rich to poor and from urban to rural.

Dr. Priyesh Tiwari said...

Hi Lokesh,
Great to hear from you. Hope you are doing well. Appreciate and welcome your empathy for the deprived populations.
What do you think of the recent healthcare bill? Will it make any difference to those at the bottom of the pyramid?