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, March 21, 2010

Poverty and Illness – Can anything be done?

Poverty, like disease, comes in several varieties. The lack of supporting institutions like educational and healthcare facilities (and services), lack of infrastructure (such as roads, market places, electricity or telephone, sanitation, potable water) lack of leadership and a dependable food supply are more community related problems. These differ from personal experience of poverty and disease, where personal suffering is highlighted.

Just as a symptom is indicative of underlying systemic imbalance, lack of money is a measure and a symptom of poverty. Treating the symptom or the measuring device will not cure the disease. The causes of the social problem of poverty lie in several factors, especially the big five: disease, ignorance, dishonesty, apathy and dependency. Interestingly, many of us have seen these five to co-exist. Poverty and ignorance contribute to disease, and all others contribute to poverty. Therefore poverty and disease are both somehow linked to more subtle infestations of collective consciousness.

Ignorance may not be a person's fault. It might be caused by isolation so that some people do not know some things simply because they have not heard of those things (information) or have heard distorted versions (mis-information). A lower availability of education and information is the first and perhaps the easiest hurdle to cross. Undoing mis-information is even more difficult. The more the people are aware of commonly known reasons, causative factors and consequences; it is more likely that positive behavior will arise. Liberal exploitation of educational opportunities, sharing of stories & personal experiences between close knit groups, leveraging media & social events regularly and repeatedly over a period of time will slowly drive the point home.

Dishonesty, in turn, is a major social problem. When a person in a position of trust diverts a hundred units of value towards personal use (including accountable public health agencies, doctors and healthcare personnel who take shortcuts), the society at large may lose much more than a hundred units of value that could contribute to development and to the reduction of poverty. That is part of what economists call the "multiplier effect." Dishonesty thrives in an atmosphere of apathy, ignorance and dependency, so here is another example of the inter-linking of factors of poverty and disease. Though we may not alter dishonest behavior of others, but we can choose to be honest and transparent in our dealings and in the way healthcare delivery system is designed. We found that people in villages have somehow been used to cheating and exploitation that they tend to have very poor levels of trust in any new intervention. Therefore, it was advantageous to ride the program on social equity and goodwill of previously active agencies, role models and opinion leaders. Allowing the community to choose the premiums, transparently see the utilization of funds, consistently experience value of insurance in emergency and efficacy of treatments would build their trust in micro-insurance driven healthcare program. Importance of quick wins in early phases cannot be less emphasized. Another important designing factor for us was ensuring accountability. The GPS enabled handheld device with authentication and tracking features bridged the need to a great extent. Just an acknowledgement of the fact by the health worker that each action is being tracked - is a deterrent in itself.

 Apathy is both a learnt behavior as well as matter of personal confidence. Shaken confidence in deprived settings makes people apathic. On top of this, health seeking behavior has always been a matter of trust and faith. Therefore it is extremely important for us as healthcare providers to be consistent and positively communicative despite challenges. The caring sentiment toward fellow beings and valuing human life ignites a bond of selfless love which pulls people out of their shells. This has nothing to do with clinical skills, but with the human qualities that we tend to leave behind while maturing as busy professionals.

Dependency on other people to help solve a complex problem is a natural human inclination. In many ways it can become a good contrast to apathy. Charity with a kind heart may help inject sensitivity but unfortunately it does not solve dependency unless the root cause is being addressed. However the same dependant situation can become a doorway to self sufficiency if handled wisely. In dependant situations whether it is poverty or illness, there is a window of motivation - motivation to be healthy or motivation to be wealthy. Channeling this motivation is complex but highly rewarding. We attempted to touch the subject by mixing the two for the family of Village Health Champion. Enabling a low profile local young housewife by education, exposure, training, financial support and public recognition created a role model that other ladies wanted to follow. Involving a self help group (ladies who regularly saved money for health and other emergencies) further consolidated the mutual sharing of independence and responsibility. The local patient is no more a liability on healthcare system- he/she demands and receives the dignity of a consumer because basic healthcare costs are enabled to be within his/her pocket's reach.

These small and seemingly insignificant moves over a period of time may have a more lasting impact than simply becoming another healthcare provider.