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. (http://www.who.int/bulletin/volumes/90/5/11-099788/en/index.html). 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.

Best Student Paper Award at Health Informatics New Zealand 23/11/2011

Financing of healthcare

Having been associated with the development of this healthcare delivery model from its inceptions, I feel there is still a great distance we all have to travel to achieve the ideals we all aspire for. We have seen value of insurance coverage in many instances as life saving for poorer patients but I agree that there are inherent risks in models like Arogyashree as they incentivise intervention while distracting the focus from primary care.

There is little doubt that treating disease (which we call “demand based service” – where the sick person demands from healthcare providers) becomes more and more expensive at each rung of primary, secondary and tertiary setting. Even more importantly prevention or early intervention (which we call “protocol based service” – where the provider has to follow an agreed protocol) reduces cost at each step. The assumption with managed care models is they would promote the latter approach. There is much to be argued, both, for and against managed care models (as practices in developed countries) because virtually nothing can compensate distorted human values. Does choosing one model over the other compensate for tilted power scales, biased prescriptions and misaligned incentives? We still have the opportunity of learn from the west (of good that is achieved) and not repeat the mistakes they have made before engineering our interventions.

Whether demand based or protocol based, delivering care at grassroots level, in a timely, appropriate and guideline driven manner is not an easy task. Planting a "biologically engineered exotic tree” of western medicine in wild rural Indian climate requires a lot of tendering care. Coping with skill gaps, evidence gaps and resource gaps requires constant innovation and acclimatization to local environment, just like a “wild bush” does. I continue to wonder, how the hybrids will evolve, and how "cross pollination" (of ideas) would influence their future appearance.

Being a great advocate of keeping people healthy within their communities, I continue to be inspired by the value of traditional wisdom hidden within the powerful Sanskrit word "swa-stha" which means 'established within oneself' (swa = self, stha = established - across homeostatic, psychological, financial and spiritual dimensions). It defines for us the concepts of positive health, self sufficiency and local empowerment that could become the underpinning philosophy and possibly contribute towards greater global understanding. Healthcare delivery, health financing and even public health measures could benefit by keeping common values in the centre and attempt to bridge gaps between modern medical interventions and traditional wisdom.

The project won the mBillionth award for mHealth - Congratulations Team

http://mbillionth.in/

South Asia is one of the world’s largest and fastest growing mobile markets – but still suffers from a significant digital divide. Mobile phones are surpassing all other media in terms of penetration in the region: TV, radio, Internet, newspapers, magazines and landlines. Mobile platforms are becoming the natural choice for extending essential and innovative digital services to the broadest section of the population.

In 2014, India’s population is expected to be 1.26 billion, with mobile penetration of 1.01 billion the mobile teledensity would be 80% above. It would mean 8 out of every 10 Indians will have access to a mobile device.

India is the world’s fastest growing Wireless market with 752 Million mobile phone subscribers as of February, 2011. Other countries like Bangladesh and Sri Lanka in South Asia also showing great results as mobile users. The population percentage coverage of mobiles in the region is such – India with 46.37, Bangladesh with 31.11 , Sri Lanka 51 and Pakistan 59 (as in 2010) and the trend is moving upward each day.

South Asia is bearing witness to the power of the mobile device to empower millions with information, content and services. The power of mobile in meeting knowledge, social and economic deficits is a challenge in these countries. On the contrary, the power of mobile innovations and applications in content and services delivery is amazing and exponentially on the rise. It is time that we in South Asia, the nations and governments in the region, as well as service providers, give a thrust on mobile for delivering meaningful services, especially that could empower and enable efficient day-to-day life for the larger masses.

It is imperative now that a situation be created where we have the best of applications, contents, and services accumulated as examples to drive the government and industry to ensure they create meaningful opportunities in last mile mobile content and services. Governance and development is bound to be better with this.

This year Care Arogya the rural healthcare delivery model won the award in category of mHealth for innovative use of this technology to extend the reach of healthcare to masses, at a price that they can afford.

Melinda Gates beautifully captures in her words what we learnt from our expereince

Publication in HINZ Journal

http://www.hinz.org.nz/uploads/file/Journal_Jun10/Tiwari_P3.pdf

Mobile Doctors and Premium Payments: How Technology Can Improve Insurance for the Poor

"Shagun" is a young woman living in a small village near Yavatmal, India. She makes and sells bread in her village, proudly contributing to her family's income that is often less than $50 a month. One day she was feeling feverish, and wondered if she had malaria. The nearest doctor was two hours away by bus, and she would lose a day's wages and have to pay for transportation to get there. Luckily, her neighbor, "Nalina," had helped her enroll in a health insurance program a few months ago. Nalina was trained by a not-for-profit called CARE Foundation to be a Village Health Champion (VHC) who provides "healthcare at the village doorstep." She has been trained to ask the right questions, and to record basic medical symptoms and vital statistics such as blood pressure, heart rate and temperature, and identify emergency symptoms. For routine diagnoses, Nalina can use a hand-held terminal with a built-in clinical decision support system to provide appropriate medical advice and order prescriptions. In Shagun's case, Nalina liaised with a remote CARE doctor who recommended treatment through an SMS prescription. Over-the-counter drugs were dispensed by Nalina from her medical kit, and within a few days, Shagun was feeling better and back to making bread!

CARE's rural health delivery and microinsurance scheme focuses on the provision of outpatient care in the village setting. Final testing of the technology, training of health workers and product design are being completed. The product will be piloted this fall, with a target outreach of 50 villages that have approximately 100,000 low-income residents by 2012.

ICT to increase outreach, reduce costs and improve client value

CARE's tele-medicine and hand-held terminals represent the frontier of microinsurance: using technological innovation to offer higher quality services to remote clients while keeping costs low. Microinsurance, or insurance designed to serve low-income clients, has become a better-known poverty alleviation strategy in the last ten years. However, there is much to be done before poor people are well-protected. Only about three percent of the low-income people in the world's 100 poorest countries benefit from microinsurance, leaving approximately two billion vulnerable to economic shocks. If microinsurance is to reach these two billion people, technology will be key.

Why technology?

Access to information technology in the global south is increasing at astonishing rates. Subscriptions for mobile phones in developing countries have grown from a few hundred million at the beginning of the century to three billion in 2008, and in Africa there are on average 40 mobile phone subscribers per hundred people (Lloyds 2009). Falling prices of mobile broadband and the increasing availability of 3G, the new generation of wireless technologies, are expected to improve internet access considerably in coming years.

Furthermore, the "global digital divide" could potentially have a silver lining, as developing countries can "leapfrog" obsolete phases of technology and jump directly to new advancements. These advancements, such as satellite data, Global Positioning Systems (GPS) and point of sale terminals, have the power to improve microinsurance in a variety of ways.

According to the World Resources Institute, "Technology does two key things that help drive the development of financial services: it cuts costs, and bridges physical distance." These two issues - high operating costs and clients that are spread out and difficult to access - represent two of the biggest barriers to microinsurance development. The Microinsurance Innovation Facility's partners are testing a variety of technological solutions to overcome both of these challenges.

Bringing Additional Value to Clients

Like Shagun, poor people often live in remote locations, making it difficult for them to access microinsurance. Microinsurers are experimenting with new technological innovations to bridge these distances. Point-of-sale devices are an example of one of these solutions - they allow customers to enroll and make premium payments remotely, saving both time and money. Mobile phones can also be used to improve access: in Kenya, British American Insurance (Britak) has recently launched a new personal accident insurance product that features enrolment and premium payment via cell phones.

Health microinsurance also presents unique opportunities for technological innovation to increase client value. The tele-medicine aspect of CARE's product is another valuable offering, since many poor clients live in areas where physicians are scarce. Technology also plays a key role in health insurance schemes that offer "cashless" claims. This type of coverage allows clients to access medical care without having to pay any money up front, which can be of life-saving value for extremely poor clients who have little access to capital. Well-designed software to manage data that can help the liaison between the insurer and the health care provider and better identify clients and store their information is crucial to making health insurance product work.

Back Office Efficiency

In order to be sustainable, a microinsurance scheme must minimize operational costs. Insurance requires a large number of policyholders in order to reach economies of scale. It can involve costly claims verification processes, cumbersome data management, and a high volume of transactions due to regular premium payments. When this model is translated to a micro scale, maintaining a good ratio of operating costs to premium payments becomes difficult. According to Richard Leftley, CEO of Microensure, "If 50% of a poor client's premium goes toward administrative costs, claims payouts are meager and client value plummets. If you had a dollar to invest in your microinsurance scheme, I'd strongly recommend spending it on back office efficiency.We're trying to bring uniformity, evaluating the possibility of using electronic points of sale to aggregate information on clients." Though back-office solutions lack the glamour of other technological advancements, the further development of affordable management information systems (MIS) will be critical for the future of the microinsurance industry.

The Future of Technology and Microinsurance

According to Pranav Prashad, a Grant Officer at the Facility, "Players in the microinsurance field need to cut costs and they recognize that technology is the solution, but given the current scale of operations, they aren't sure how much to invest and in which technologies." To help assess which strategies work and which don't, the Facility will offer one final call for proposals for Innovation Grants in fall 2010, supported by Zurich Financial Services, with the theme of "Scale and Efficiency". This round will focus on projects that are using technology to make microinsurance more affordable and accessible to low-income clients.

Ten years ago, it would have been difficult to imagine that a poor Indian woman would file a claim and receive a medical diagnosis electronically from her rural home. The next ten years will undoubtedly bring new and equally unexpected technological developments - developments with the power to bring the security of microinsurance coverage to the two billion people who need it most

Recognition of Innovative IT model to support Microfinance

The software designed by our teams in collaboration with P4K technologies was recently awarded NASSCOM's AppFame award.

The software enables a unique handheld device that can be carried by healthcare workers in the field to register, record, triage patients and to transfer health data to a web based electronic health record accessed by remote doctors. The device can also establish tele-link with remote physicians to enable a collaborative treatment planning.

For micro-insurance policy holders enrolled in the program (who pay approximately 10 USD for a family of four, as annual premium for basic primary health services) the entire service chain including administration, authentication, delivery and claims is automated thereby reducing administrative cost of running a complex insurance scheme.

Offering prepaid coverage for basic services at a cost that the people can afford, brings essentials of modern healthcare within the reach of people living at the bottom of the pyramid.

The rules for health innovation in developing world - A Mckinsey Report

 Health care is consuming an escalating share of income in developed and developing nations alike. Yet innovators have found ways to deliver care effectively at significantly lower cost while improving access and increasing quality. They are uncovering patterns for raising productivity, and leaders across health sectors—public, private, and social—should take heed. With the recent passage of health reform legislation in the United States, for instance, tackling costs is imperative there, but it is also an important goal in every other part of the world.



New approaches to the delivery of care abound. In Mexico, for example, a telephone-based health care advice and triage service is available to more than one million subscribers and their families for $5 a month, paid through phone bills. In India, an entrepreneur has proved that high-quality, no-frills maternity care can be provided for one-fifth of the price charged by the country’s other private providers. In New York City, the remote monitoring of chronically ill elderly patients has reduced their rate of hospital admissions by about 40 percent.


Unfortunately, health care can be an isolated and local activity: innovations are not widely known across different systems or beyond sector boundaries. Merely identifying and promoting innovations isn’t enough, however—leaders need to understand whether, and how, the lessons of innovators can be replicated elsewhere. To this end, McKinsey conducted research in partnership with the World Economic Forum to study the most promising novel forms of health care delivery and, in particular, to understand how these innovations changed its economics.


Many of the most compelling innovations we studied come not from resource-rich developed countries but from emerging markets. Two factors help explain why. First, necessity breeds innovation; in the absence of adequate health care, existing providers and entrepreneurs must improvise and innovate. Second, because of weaknesses in the infrastructure, institutions, and resources of emerging markets, entrepreneurs face fewer constraints (this is one upside of the lack of meaningful oversight, which obviously also has many drawbacks). They can bypass Western models and forge new solutions.


The nearly 30 successful innovations we looked at pursued a handful of strategies to change the economics of health care delivery in a fundamental way. In other words, they were not successful by chance. By understanding the opportunities these innovators seized, leaders throughout the health care system can identify opportunities for their own organizations.


A broad scan of innovations across the field, as well as an in-depth analysis of the business models behind 30 of them, showed us that successful ones use at least several if not all of the strategies described below.


Get close to the patient


Innovators can lower distribution costs and improve adherence to clinical protocols by moving the delivery of care much closer to the homes of patients, providing services that take advantage of their established behavior patterns, or both. VisionSpring, an organization that brings affordable eye care to the poor in 13 countries, succeeds because it takes care givers close to patients through a low-cost franchise model. It teaches local “vision entrepreneurs”—members of the mainly poor communities they serve—how to diagnose problems such as presbyopia (an inability to focus on nearby objects) and how to determine what type of mass-produced eyeglass would correct it. The company also provides its entrepreneurs with a “business in a bag” that contains all the required products and equipment. Distribution costs are low because information, products, and services are standardized, and the model is simple to implement, even if the workforce is relatively unsophisticated.


Use existing technology to reinvent delivery


“Repurposing” mobile-phone systems, call centers, and other existing technologies and infrastructure allows innovators to extend health care access, increase the standardization of care, and improve labor productivity. For a fixed fee of $5 a month (payable on phone bills), Mexico’s MedicallHome, for example, offers its one million subscribers access to professional health advice at a cost far below the charge for a physician’s visit. In Mali, Pesinet uses SMS (short message service) technology to make diagnoses of malnutrition more accurate and reduce childhood mortality. Health workers in the field send a child’s age, height, and weight by SMS to a central server, which determines whether the child is at risk and sends a message back to the health worker.


The use of the existing technology infrastructure would be useful in any part of the world where health care resources are scarce. Yet this approach can also provide benefits in developed countries. Technology could be used, for example, to reduce emergency-room overcrowding by providing phone- or Internet-based advice and triage services during evenings and weekends. Similarly, it could be used to deliver care remotely for patients who require ongoing treatment for diabetes, asthma, or other chronic diseases.


‘Right skill’ the workforce


Some smart innovators challenge existing practices—and professional assumptions—about which health workers are allowed to do what. As a result, they can tightly link skills and training requirements to the tasks at hand, thereby lowering labor costs and overcoming labor constraints. In India, LifeSpring uses midwives to provide most of the care at its maternity hospitals. This allows just a single doctor to oversee significantly more patients by focusing on tasks that specifically require a doctor’s attention. The company charges only $40 for a normal delivery, rather than the typical $200. In the United States, MinuteClinic uses nurse-practitioners rather than physicians to staff primary-care clinics.


In some countries, this approach also helps to ameliorate shortages of medical talent. In sub-Saharan Africa, for example, the HealthStore Foundation has trained community health workers to diagnose and treat the region’s top five diseases, which together account for more than half of preventable deaths there.


Standardize operating procedures


Whenever possible, successful innovators use highly standardized operating procedures to minimize waste and improve the utilization of labor and assets. The use of standardized clinical protocols also raises the quality of care and facilitates the transfer of knowledge. In India, Aravind Eye Care System, which provides cataract operations to the blind and the near-blind, standardizes the entire end-to-end patient pathway—from initial diagnosis to surgery, recovery, and discharge—with ruthless efficiency. Also in India, Narayana Hrudayalaya hospitals can offer high-quality cardiac care at dramatically lower prices than its competitors charge because it employs a high-volume, highly standardized model of care. Both organizations use a form of production specialization (a factory-like approach to delivering care), borrowing process flow, management, and improvement techniques from manufacturing industries.


Borrow someone else’s assets


Smart innovators use existing institutions, infrastructure, and networks of people to reduce capital investments and operating costs. They then pass the savings on to consumers. India’s Health Management Research Institute (HMRI) takes advantage of established supply chains by operating medical convoys—mobile health facilities and health workers delivering care in hard-to-reach rural areas—from public hospitals. HMRI also operates a medical hotline (dial 104 for 24/7 advice) that piggybacks on existing mobile-phone systems, as do MedicallHome, Pesinet, and similar organizations. The model benefits from the widespread adoption of mobile phones and a comprehensive cell network across India. MinuteClinic operates its facilities in retail stores to benefit from their foot traffic and lower its overhead costs.


Open up new revenue streams


Many health care innovators extend their activities into other sectors—even shops and restaurants—to capture additional revenue streams, use them to subsidize costs, or both. Business activities in other sectors can even promote core health care services. Thailand’s Population and Community Development Association (PDA), which focuses on family planning and the prevention of sexually transmitted diseases, established a chain of restaurants and resorts to raise revenue—and to get out the message. Greenstar, a Pakistani nongovernmental organization that focuses on family planning, operates an entire network of retail outlets that sell products such as condoms and offer family-planning advice and health services for women and children.



As leaders of health systems ponder their cost, quality, and access problems, they should draw comfort from the fact that at least some potential solutions already exist. Innovators around the globe have demonstrated effective new ways to reach and interact with patients and treat them at significantly lower cost while improving quality. The real challenge is how to implement, not how to invent. Given the pressure on health systems everywhere, their leaders should do everything possible to help organizations adopt successful innovations and thereby reap the benefits they can provide.

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.

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 well-to.do 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 - http://www.scn.org/cmp/modules/a-mod.htm

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.