Sustaining Rural Healthcare Innovations
By Arunima Rajan
Critical patients travel hundreds of kilometres from rural areas to cities to access healthcare--however, government led innovations are taking place within rural communities as well. Is there anything we can learn from rural healthcare initiatives to change this problem? Do programmes focus more on preventive healthcare than on curative healthcare? What impact do such innovative changes have on ASHAs and their rural patients?
Access to healthcare is a significant problem in India. Providers in both rural and urban regions are torn between two basic structures: Healthcare as a business, or healthcare as the product of disruptive innovation.
Disruptive innovations are usually built around one specific user challenge (typically referred to as "pain point"). An example of this type of issue is in transportation. Coordinating travel within India used to be a big problem. Depending on the traveller's budget, they either had to argue with auto drivers or with taxi drivers.
So, what did the disruptive innovators do? They took the problem and came up with an easy, app-based solution that combined all taxi services into one. Today, most Indians don't even realize how complex the taxi system is underneath the veneer of its simple app interface.
Still, the app's real power is how it brings all the critical stakeholders of the industry to the platform. In other words, it has created a "value network." That's the muscle power of the app. It's more than just an app, it's a platform as a service at scale.
A similar system is in place for food delivery apps. Zomato and Swiggy work because every time you order food from a restaurant, there is a fleet of people trained to pick up the order on time. Simultaneously, a separate group monitors the quality of service.
The question is, is there a healthcare innovation that does something similar? Can technology help to better address the needs of patients of the Indian healthcare system? Let us look at some critical rural healthcare innovations that might fit the bill.
ANMOL & Healthcare Data
Technology called ANMOL (Auxiliary Nurse Midwife OnLine), a tablet-based application, allows auxiliary nurse midwives (ANMs) to enter and update healthcare data into the Integrated RCH Register. The Register replaces multiple unwieldy registers under the Reproductive and Child Health umbrella.
Piloted in Andhra Pradesh, an estimated 15,000 ANMs are working with ANMOL right now. Additional pilot districts include Madhya Pradesh and Telangana.
The objective of ANMOL is to provide effective and timely delivery of quality health services, specifically to rural populations. Another aim is to educate the remotest urban populations, including urban slums and unserved communities, about general health and medical topics.
The educational aspect of ANMOL is delivered through images and videos about government health initiatives, good hygiene, primary health care, and wellness precautions. As for healthcare staff, ANMOL helps establish better communication between ANMs, beneficiaries and doctors, through remote assistance.
Accredited social health activists (ASHAs), designated by India's Ministry of Health and Family Welfare, function as community health workers in these rural areas. ANMOL can potentially make the jobs of these crucial workers— and the compensation— much simpler.
"ANMOL is primarily designed from the perspective of collecting data," explains Oommen John from George Institute. "Some states have also linked it to compensating the ASHA workers because they don't have fixed salaries. The incentives are linked to the number of targets they meet.
"The best ASHA and ANM implementations include ImTecho--that's Innovative Mobile-phone Technology for Community Health Operations— in Gujarat.
"In ImTecho, what they did was they went beyond a routine data collection tool or reimbursement tool. They integrate it into the human resources management systems of the government like the National Health Mission.
"They also brought training modules into the tool. You look at the performance of ASHAs and ANMs and identify those who are making frequent mistakes, [then] identify them for training," says John.
So, does ANMOL actually help ASHA workers, or is it an administrative burden? Do they still maintain paper-based records?
"If you look at ANMOL," says John, "it's a positive step and is being used across the country by ASHAs, who have only minimal education. It has been around for some time despite the challenges. It has also brought transparency into the system. Earlier, it was easier to fudge the reports because it was completely paper-based. When the documents are in electronic format, it's more or less frozen."
The critical question is, has ANMOL improved the capabilities of ASHAs?
"If you look at ANMOL, there are multiple modules within each vertical programme," John explains. "It is only recently that they have tried to integrate everything. So, if there's a 40-year-old patient whose details are present in the Reproductive and Child Health Vertical, if she gets TB, all her details will have to be added separately in the TB register. Even though these solutions are digital, it has been designed as a typical register. So, it has not been used to the extent to which it should be used. Most of the time, they keep parallel records so that they can quickly consolidate and give reports to seniors when they ask for it."
India Health Accelerator Programme of George Institute for Global Health aims to support early-stage innovators to validate their solutions in a health systems context and generate the evidence needed for scale-up.
NI-KSHAY (Ni=End, Kshay=TB)
Primarily driven by the private sector, the NI-KSHAY programme to end tuberculosis has been a success in India as well. The programme follows an earlier initiative known as 99 DOTS, which focused on medication adherence and mitigation of the disease.
For TB, non-adherence to medication is one of the major causes of drug-resistant variants of the disease. The World Health Organization worked with 99 DOTS to allow healthcare workers with TB patients to share QR codes or barcodes from medicine doses to show their progress. That way, providers could track the people who failed to finish their medication.
"What the WHO team realized is the fact that most of the TB cases have been identified by the private sector. And there was no mechanism for disease notification. When somebody became TB positive or was diagnosed with TB, there was a lag between them being picked up in the private sector and being updated in the national TB registry. It was later automated," adds George Institute's Oommen John.
Today, the backbone of India's TB programme is NI-KSHAY— a reasonably robust platform that brought together different technologies to solve the TB data flow problem.
NI-KSHAY is a web-enabled patient management system for TB control under the National Tuberculosis Elimination Programme (NTEP). The platform is linked to all the microbiology centres in the country. Because TB is a notifiable disease, every notification of TB comes on the NI-KSHAY platform with geographic details, and there is a complete audit trail.
"The platform connects different data points, which are necessary for the TB control programme. Stop TB is supported by different NGOs; all these partners came together and discussed how we could bring different innovations under one platform, and that is what NI-KSHAY is."
Mobile Academy & Kilkari
Mobile Academy is a free audio training course designed to expand and refresh the knowledge base of ASHAs and improve their communication skills. Launched in 2016, over 70,000 ASHAs have completed the Mobile Academy course since its inception in Bihar, Chattisgarh, Himachal Pradesh, Jharkhand, Madhya Pradesh, Rajasthan and Uttarakhand.
The Kilkari programme sends weekly audio messages to expecting mothers, as well as new mothers, about how to prepare for and care for a young child. The information about pregnancy, childbirth, and childcare comes directly to families on their mobile phones.
First rolled out in Bihar in 2012, the Kilkari programme has been scaled to 13 states. It is supported by the Ministry of Health and Family Welfare, National Health Missions, and donors that include the Bill and Melinda Gates Foundation and the US Agency for International Development.
Here's a link to a podcast where Radharani Mitra, Global Creative Advisor at BBC Media Action, talks about the learnings from Kilkari and Mobile Academy. Radharani has spearheaded many national and international public service campaigns such as the Condom Ringtone, Mobile Kunji, Mobile Academy and Kilkari, plus a TV drama on gender called AdhaFULL
Dr Mohan Des is the trustee of CEHAT and works closely with healthcare workers who practice in rural areas. He believes that the Indian healthcare system doesn't trust rural community representatives, such as ASHA workers.
"Government employees like IAS officers, doctors and nurses at CHCs need to be monitored. An ASHA worker is supposed to be an advocate of people's needs and demands. Why do policymakers need to monitor her? Because she collects data, and the data has to be accurate?
"They need to be trained and not monitored. They need medical training, training about patients' rights, and an understanding of health in a holistic manner. Superiors exploit grassroots-level health workers. That's why I work in the field of healthcare communication," Des explains.
He adds that recorded audio and video messages are potent tools of healthcare communication. "I am very grateful for the digital revolution. Healthcare workers in rural areas often get calls from people about snake bites and scorpion bites. So, I am all for audio and video messages which educate people."
Mother & Child Tracking System
Mother & Child Tracking System (MCTS) is a centralized web-based application aimed at pregnant women and children up to the age of five. It works via name-based tracking and service monitoring.
The objectives of MCTS are to ensure that all pregnant women receive complete Ante Natal Care (ANC) and Post Natal Care (PNCs) services, to encourage institutional delivery, particularly of high-risk mothers, and to ensure that children receive their full immunizations at the right age. MCTS is intended for healthcare providers to use RCH portal to identify and track individuals throughout the reproductive life cycle and collect obstetric history.
Market Access Programme
In 2017 the Government of India launched Ayushman Bharat, a programme designed to achieve Universal Health Coverage. As part of this programme, the National Health Authority runs a Market Access Programme (MAP) that brings healthcare providers, knowledge leaders, and start-ups together on a shared platform.
"The complexity of the healthcare industry combined with the diversity of Indian healthcare delivery complicates the road to market for innovations. Leading industry veterans are joining the MAP initiative to clear the fog for healthcare innovators and help shape new health innovation paradigms," states the official website of MAP.
New Innovations
Nachiket Mor, who was a member of the Planning Commission's High-Level Expert Group on Universal Health Care, is partial to the Samhita initiative.
"Pharmacies are our de facto primary care providers. Enabling them to do more by using carefully written protocols will help us get essential services deeper into the hinterland in a controlled manner. Pharmacists are well educated, familiar with most medicines, have refrigeration capabilities and good supply chains, and are often digitally connected with doctors for prescriptions.
"Many countries, both developed and developing, have taken this approach, as can be seen from this report," he adds.
Challenges for Rural Innovation
Dr Arvind Badrinarayanan, CEO of MUSEinc India, points out that building original hardware in India is a near-impossible journey. He adds, it just gets more challenging as we grow.
"If we take something like medical hardware that is truly innovative, then you are building something that hasn't been done before. So, this is even more different and difficult than, let's say, building an electric scooter or vehicle. What we are building is much more fundamental and revolutionary. It's like we are inventing the clinical thermometer. Because, every single health professional uses it."
Taal Digital Stethoscope
Badrinarayanan claims that their Taal digital stethoscope is a revolutionary next-generation medical device. He explains, "It fulfils the objective of digitizing the traditional stethoscope and filtering unwanted ambient noise, and our user-friendly device comes at an affordable price of $150 / INR 11,500. It has unique features such as high-quality data transfer, live streaming, a 24+ hour battery life and noise cancellation."
The digital stethoscope works with Surr, an integrated software application that helps users store, sort, share, analyze and learn more about the different heart and lung sounds.
"With a robust and light aluminium design, Taal is exceptionally compact and easy to carry along. Taal, along with Surr, can help improve access to healthcare in rural and remote areas by enabling the people in rural areas to exchange heart and lung sounds with the doctors instantaneously," Badrinarayanan continues.
Taal also functions as a highly reliable screening device for the provisional diagnosis of diseases in other systems. It can monitor the status of the digestive system, or even the fetal heartbeat in pregnant mothers.
"The requirement for such a medical innovation was amplified during the pandemic, especially in rural areas," says Badrinarayanan, adding, "Unlike traditional stethoscopes, which cannot be used with PPE kits, Taal enables minimal contact with patients and even remote monitoring if needed."
"Taal as innovation is imperative to minimize the problems such as limited access to healthcare in remote rural areas, where a lack of transportation results in patients having to travel long distances to access any medical facilities. Taal was developed by a veterinarian and a musician/sound engineer who brought their skill sets together to develop this cutting-edge product in Bangalore,” he concludes.
Mobile Innovation Now & in Future
Imagine the world in 2050. What wonders do you see? But will we ever arrive at an ideal future? Are we headed in the right direction? Looking at the state of innovation, it's hard to say for sure. Healthcare innovation is all about continuous growth and tinkering. As far as healthcare is concerned, there is no such thing as a finished product. It definitely requires prioritization of the patient's needs over IT procedures and increased responsiveness to changes. If we want more innovation in the future, we need to focus on cost-efficiency, efficacy, and an open exchange of knowledge.