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.

Friday, January 8, 2010

Self empowerment is healing

Sometimes I wonder what really is poverty? ... Is it personal, social, spiritual or karmic state of being in relationship to rest of the universe? Is it a sickness that needs to be treated, is it an opportunity for service or is it merely a perceptive bias where a majority of population chasing material wealth coins a term for those who do not conform to their standards? Probably each one could be argued as valid explanation, but more clarity could be gained if we look at the situation from the "so called" poor person's point of view. Everytime I have interacted with them, unfortunately common themes of - helplessness, hopelessness and being trapped in vicious cycle of losses, lack of opportunities with no-one to care for them, - have dominated the story.

Poverty glaringly exists even in most advanced societies and even developed & rich countries. "Haves" and "have-nots", seems to be part and parcel of every social structure. From healthcare perspective people at lowest rung of socio-economic ladder tend to have poorer health status and obviously higher healthcare needs (and resulting expenses) in any country's health statistics. Although poor in America would have better health status than poor in Somalia, but the quantum gaps between countries does not alter American statistical observations about poorer health of its poor. The type of ailments and access to healthcare may vary from country to country but somehow being makes people healthier in most societies.

In my more ignorant days I assumed that if we could create good healthcare infrastructure then the health status of people could be transformed. My assumptions were seriously challenged one day while I was serving a tribal community in a remote village in India immediately after my graduation. We saw tuberculosis  being rampant in that community and started distributing antibiotics. To our surprise even after one year of running the clinic the disease not only remained unabated but we started seeing more and more multi-drug resistant cases. Mass campaigns, posters, house-to-house visits nothing worked!

One day we decided to investigate the reason as to what was going on. The discovery opened my eyes. The patients took the medicines from the clinic, took them for while then walked down to the local pharmacist and sold them off for packet of biscuits or a packet of Bidi (leaf wrapped local cigarettes) and resumed life as usual. Somehow for them treating a serious symptomatic condition was not important at all!

As I grew up and travelled around the world I saw the same story being repeated in different forms and shapes almost in all societies. People take bunch of antihypertensives or antibiotics from their doctors and pharmacies only to throw them off into dustbins after a few days. I observed leading journals reporting non-compliance rates as high as 80% even in most advanced healthcare systems. People continue to be non-compliant; they smoke, drink, abuse and skip appointments with doctors, no matter how much we emphasize the importance of healthy behavior. And as one would not be surprised, this sickness behavior is highest in poorer communities!! Affluent people are more likely to follow healthier lifestyle and medication regimens than their counterparts. So, is there any correlation between the habits that make you rich and make you healthy at the same time? Is health a direct outcome of affluence in cause-effect manner or a deeper common root cause is shared by the two in certain common behaviours that determine both?

My understanding of poverty became clearer when I read Nobel Peace Prize winner Mohd. Yunus's fascinating biography "Banker for the poor". What he observed that giving charity to poor people does not make them rich. Most people take easy money to do everything else except the right thing. They will drink, party, visit prostitutes and waste the money in other insignificant efforts and land up poor again. (Not too different story of being given free medicines and expecting cure). Millions of dollars of charity made by World Bank over decades has made no dent on the socio-economic status of poor. Millions of dollars wasted on public health alone has made little improvement in health of population. The real change is seen only in areas wheere both poverty and healthcare are addressed together.

Again I looked at reasons why micro-finance (MF) could transform poverty and noted some very important common patterns. I saw in the success story of MF, that it is only when the people take self initiative they change. When they collaborate and support each other in doing right things (and also when things do not go right), when they gather courage to stand on their own convictions and make investment in themveselves, that people build resources bit by bit. Poor people remain poor because of imiting bliefs and behaviours. In my understanding a major portion of poverty comes from this "self-disempowerment". They do not trust their own abilities to grow ......and repeated sufferings re-enforce those beliefs over generations. They allow themselves to be treated as inferiors. It also dawned upon me that seemingly lazy behaviour and lack of dynamism (also seen in roadside beggers of advanced countries) could be more due to self-resignation, apathy and lack of confidence. They kill their own dreams and complain, they demand from governments, politicians and often expect a savior to come and deliver them.

Doesn't it sound very close to what we see in healthcare settings? People indulge in un-healthy behaviours and expect the doctors, hospitals nad health ministry to solve all their problems? It is not to say that these providers are un-necessary, yes they are required for many situations, but less likely to solve majority of health problems. It is ambitious to expect that top driven vertical programs will have much effect. In the short run they may show some benefits and gain applauses from voters, but in the long run people will continue to treat doctors like messiahs but will not follow much of advice that they are given.

Unfortunately the western healthcare system encourages this paradigm. You approach the system in need and system treats you. Doctors see themselves, their pills and procedures as the only option to save suffering humanity. Typically the western system does not trust people’s capability to heal themselves. There is always an "external solution", which may be good in emergencies and short term, but the long term solution is more likely to come from people's participation in their own health.

Now, resuming the argument that poor are most self disempowered, it will not be surprising to note that they have highest incidence of un-healthy behaviours. They tend to be more non-compliant with health promoting advice and make poorer health choices. Does the solution then lie in creating empowerment or in provision of health services? Probably both ... but my understanding is leaning towards believing that poor people can only be taken to next level of health by building their own skills at community, family and personal levels and not just by asking doctors to serve in village dispensaries.

In my opinion a lasting transformation would not be driven by doctors or public health experts, but self driven by local communities with their help. The difference is subtle... but of great importance !!

Next I would try to touch some of the insights as to how this self-empowerment can be facilitated in so called poor (or self disempowered) communities. Interesting link -


vijaya said...

glad to find your blog.great write ups.vijaya

Dr. Priyesh Tiwari said...

Thanks Vijaya,
I hope this inspires atleast one more person in this world to start looking at others outside of thier own circle..!