Connecting rural health

The Care Foundation supporting the Care Hospital chain has developed a self-sustaining model to reach out to patients in peripheral towns and villages, providing them primary to tertiary care. Sonal Shukla takes a look at this unique programme

A health worker deputed in a remote rural area visits a person suffering from fever for around a week and not responding to the treatment of the local quack. He records the symptoms and signs using his telemedicine-enabled handheld device resembling a mobile phone, custom developed for this purpose and beams it up via the GPRS mobile network. Within a few minutes, a doctor receives it on his server, checks the report and calls back and asks the patient a few questions, and instructs the health worker to do a simple test using the kit he is carrying. The report is entered and sent back to the doctor. Immediately, the doctor types a prescription on his computer and sends it to the device that automatically prints it at the point of care. The health worker organises the medicines and helps the patient to understand the dosage. The next day the health worker makes a follow-up call, to see whether the patient is responding to the treatment or not and reports back to the doctor, who updates the status on the patient's Electronic Health Record.

Sounds interesting? This is a regular scenario at the district level centres in the Vidarbha region of Maharashtra state-implemented by Care Arogya Kendra. In Yavatmal district, the health workers are called Village Health Champions (VHCs) and work closely with local opinion leaders. They provide the entire range of basic healthcare services, educating people about health-related issues, arranging timely referrals and aligning regular inflow of medications from the hub pharmacy into village homes and outflow of blood samples to the hub laboratory.

"Care Arogya -Rural Health Initiative aims to meet rural healthcare challenges in terms of accessibility to doctors and specialists, infrastructure, affordability and monitoring" - Dr Krishna Reddy CEO and MD Care Group of Hospitals

"The rationale was to develop a self sustainable integrated rural healthcare delivery model through innovative service delivery, technology and micro insurance programme" - Dr Priyesh Tiwari Chief of Community Health & Wellness Programme Care Group of Hospitals

Based on the concept of E-Choupal, this is a project led by Quality Care India Limited (QCIL) and Care Foundation, and is currently funded by QCIL.

"People in cities have plenty of doctors and options to choose from. However, in the peripheral towns and villages the situation is not so good. Top management realised that the philosophy of the organisation is only partially fulfilled by current hospital-based services. There is still a huge gap where a difference can be made in people's lives," opines Dr B Soma Raju, Chairman, Care Group of Hospitals.

"Care Arogya -Rural Health Initiative aims to meet rural healthcare challenges in terms of accessibility to doctors and specialists, infrastructure, affordability, monitoring and analysing the health status of the community, and to create a network of secondary care hospitals at district level and tertiary care hospitals at city level, in line with former president Dr Abdul Kalam's vision of Providing Urban Facilities in Rural Areas (PURA)," informs Dr Krishna Reddy, CEO and MD, Care Group of Hospitals. Today, almost one lakh people are covered comprehensively with one doctor, 20 health workers and support staff.

Getting Started

It all began with the organisation realising the need for reaching out to suffering people in remote and deprived locations. Care Hospital created the department of 'Community Health and Wellness Programme' under the aegis of Dr Priyesh Tiwari. The team rapidly studied various models in India and other countries before coming up with the idea of a dynamically evolving self-sustaining model that addresses the core issues effectively. "The rationale was to develop a self sustainable integrated rural healthcare delivery model through innovative service delivery, technology and micro insurance programme which was not comprehensively addressed by previous models," shares Dr Priyesh Tiwari, Chief of Community Health and Wellness Programme, Care Group of Hospitals.

A Web of Innovations

Service Delivery Model: The programme decided on a service delivery model that provides basic primary consultation and prescription in the village itself, arranges for good quality medications, and facilitates basic investigations, in addition to referral assistance in emergency. Additionally the service model was to use the local workforce, train them and keep them motivated and also generate a career path for them so that performers can grow as in any other career and not simply remain rural health workers for the rest of their lives.

Technology Model: "The programme aims at designing a solution that uses the power of telemedicine and yet operates on a low cost, uses very low bandwidth, uses rugged hardware and software that is user friendly for semi-literate people and works in local languages," says SG Prasad, Telemedicine Engineer, Care Foundation. It facilitates village health surveys and database management, maintains patient electronic health records, biometric identification of users, records financial transactions, allows printing of receipts and prescriptions and interfaces with telemedicine peripherals. The system is compatible with GSM/CDMA network and works on a mobile platform where field operations are portable, enabling even for GPS localisation of the health worker.

A Perfect Fit

For implementation of the scheme, the Care Arogya programme needed a suitable partner that already had enough penetration into rural areas with a complementary mindset. ITC wanted to start a similar initiative catering to the healthcare needs of the rural masses. It has four functional hubs in the districts of Amrawati and Washim. Since healthcare is not ITC's core business, they decided to lease out their space to a healthcare provider.

"When Care started looking for partners to start its pilot programme the situation looked appropriate, and we decided to lease out the health centre space from ITC to experiment with the idea," shares Dr Varun Bhargava, Medical Director, Care Hospital, Nagpur.

The Process

The programme followed a three-pronged strategy aimed at engaging local human resource, creating IT networks and operating delivery centres. The Hospital thus started with a Care Arogya Kendra, at the district level hubs in Wardha and Yavatmal, with services in telemedicine, laboratory, pharmacy and consultations.

A qualified physician, lab technician and pharmacist are located at the hub with a fully-equipped automated lab and pharmacy stocking quality medications. The Care Arogya Kendra is located within the ITC Choupal Sagar in order to increase accessibility for villagers.

The hub clinic is linked to the village-based workforce. VHCs located in an E-Choupal area coordinate with the choupal sanchalaks. VHCs deal with community mobilisation, common ailment treatment, household survey, monitoring health profiles, public education and awareness. They are equipped with medicines and first aid, a kit for basic diagnosis, and a bicycle. They are screened and trained in social skills and communication skills, use of handheld devices, basic clinical services, recording and reporting protocols and conducting public health intervention either independently or by advocacy, local responsibility creation and facilitation of government schemes. A doctor visits the community every day to organise healthcare programmes.

The challenge was to connect the district headquarters to the catchment villages. "We brought in handheld devices carried by the VHC for treating common ailments in the village, with access to a doctor on the other end with a prescription delivered and printed through the hand-held device," shares Dr Tiwari. To bridge the gap for tertiary care advice, the Care Arogya Kendra is connected through a microwave link to Care Hospital, Nagpur for consultations with the specialists through video conferencing and to electronically exchange clinical data for expert opinion.

"The hand-held devices helped telemedicine reach every home. We started with a baseline survey to map the health status of the community in the areas of mother and child health, infectious diseases, lifestyle diseases, nutritional and geriatric problems," informs Girish Babu, DGM Operations, Community Health & Wellness Programme. Based on the data, the objectives and interventions were planned. The interventions were demand based when a patient approached with a problem, and protocol based when antenatal checks, vaccinations, chronic disease monitoring, hygiene and sanitation and public health education were required.

Challenges in Pathway

The first challenge was in developing the models for service delivery, technology and micro-insurance, because all demanded high degree of innovation. The partners who developed each component found it a difficult task to achieve. "However, continued brainstorming and actively exploring options by dedicated teams made this possible," Dr Tiwari says. The next challenge came from implementation, through pre-operational funding, manpower identification, training dropouts, local appreciation and scepticism.

Thirdly, the local people, used to RMPs and their prevalent 'quick-fixes', found it difficult to accept remote consultations and had little value for 'just a prescription'. "With time, sustained efforts, and visible case examples the faith of people was slowly won," Dr Tiwari explains.

Future Plans

Partnership with local Governments is being explored and plans are afoot to scale up the pilot to cover more districts in the region. Discussions are on with the largest micro finance institution, SKS, to cover 45 lakh people across the country and also with Cholamandalam Fertilisers through their 'Mana Gromore' centres, a retail chain at the rural district levels. The initiative is also exploring partnering with Nimagadda Foundation to reach multiple locations across AP. Other partnerships underway are with Scojo Foundation for supplying cheap reading glasses, Mobiquest, Delhi for software and mobile-based solutions and with National Institute for Nutrition, Hyderabad for assessment and intervention tools.

"The model has also attracted significant interest from Global Health Initiatives of Duke University, North Carolina, Johns Hopkins and Mayo Hospital. The Haseltine Foundation is actively giving moral support and other international agencies are keen to join hands as well as study the model for its applicability to the Third World," Dr Tiwari reveals.

The initiative also aims at the development of micro insurance model to integrate with the service delivery model for access to outpatient and hospitalisation services (including pre-existing illness) at very low cost.

It has plans for 'Green Health Kiosks', from where the VHCs will be working. These Green Health Kiosks will be instrumental in creating awareness of health issues in the rural population and will be a platform for the demonstration of green technology like rainwater harvesting, generating safe drinking water, use of alternative power sources, recycling waste and creating clean living conditions.

The objective of making healthcare affordable and accessible to the masses seems obtainable with Care Arogya - Rural Health Initiative in operation.

sonal.shukla@expressindia.com