Analysing Patient Data at SughaVazhvu – Chief Complaints and Diagnoses of Patients Belonging to Different Age Groups

Research | Leave a comment |    May 7, 2012

by Aarti Sahasranaman, Vice President, Interventions

One of the key functions of ICTPH’s Health Management Information System (HMIS) is to collect health information and maintain electronic medical records (EMRs) of each patient who visits a SughaVazhvu rural micro health centre (RMHC) (Rajanna & Kapila, 2011 1). These EMRs serve important roles at the levels of the individual and of the population. At the level of the individual, EMRs chronicle the health status of each person, making it possible for the physician to view the entire medical history of that person at one go. Access to such comprehensive information enables the physician to make better and more thoughtful decisions about the kind of care that the patient should receive. At the population-level, data from EMRs provides the basis for epidemiological analyses of the communities served by our RMHCs. Such epidemiological analyses become especially important when viewed through the lens of the preventive-promotive approach to healthcare taken by ICTPH. For example, if an analysis of data from the HMIS suggests that there is a high proportion of hypertensives within the catchment area served by one of our RMHCs, it signals to us that there is a need for greater awareness on prevention for hypertension in this community. These data can also measure indicators that will help us determine the efficiency of our processes, and tweak these processes if they are found to be sub-optimal. Furthermore, data from EMRs will also make it possible to measure the impact of our protocols on the health of our populations. Such impact evaluation is necessary to demonstrate the success of our model of primary care delivery through RMHCs situated within rural communities. It is important to remember that for such kinds of analyses to be performed, it is absolutely necessary that we have high quality healthcare data, at the most granular level. In order to validate the HMIS as a tool that can collect such granular data and provide meaningful epidemiological information, I performed a preliminary analysis of the most common chief complaints presented by patients across five of our RMHCs (Alakkudi, Karambayam, Andipatti, Kavarapattu, and Okkanadu Melaiyur) in the six-month period between October 15th, 2011 and April 15th, 2012. The chief complaints were analysed by age of the patient. I also performed a similar analysis of the most common diagnoses made by physicians across these RMHCs.

A quick analysis of chief complaints across all RMHCs in the above mentioned six-month time frame revealed that the five most common chief complaints that patients presented with, in decreasing order of frequency, were-

  • Cold
  • Body Pain
  • Multiple Joint Pain
  • Weakness
  • Infected Wound

While this list gives us a general ideal of the most common complaints, it is likely that this list does not present the entire picture. Since health complaints are closely associated with the age of patients, I decided to look at how chief complaints varied with age.

It is obvious from the above list that a complaint of cold is likely to be symptomatic of an acute episode such as laryngitis or pharyngitis, whereas complaints such as body pain, multiple joint pain, and weakness are likely to signify chronic conditions such as myalgia or osteoarthritis. Given that conditions such as osteoarthritis occur due to aging and normal wear and tear of the joints, it follows that patients presenting with complaints symptomatic of this condition will be elderly. Therefore, it is possible to extend this premise and hypothesise that the proportion of patients presenting with so-called “chronic complaints” like body pain and joint pain will be higher, as patients get older. To test this hypothesis, I analysed the most common chief complaints of patients belonging to different age groups. Patients were categorised into one of seven age groups – 0 – 4y (infants), 5 – 9y (young children), 10 – 18y (adolescents), 19 – 29y, 30 – 49y, 50 – 69y, >=70y. Chief complaints were then placed in four categories:

  • Acute – Includes complaints such as cold, cough, running nose, fever, itching skin, sore throat, stomach ache, and diarrhoea.
  • Chronic – Body pain, back pain, multiple joint pain, weakness.
  • Injuries/Wounds – Infected wounds and accidental injuries.
  • Others – All vision and oral health-related complaints.

Where chief complaint was “not mentioned”, data was excluded from analysis. “Not mentioned” usually (but not always) indicates that the patient was visiting to avail of the CVD voucher entitling him/her to a free lipid profile and blood glucose test.

Figure 1 below details the proportion of each of the above four categories of chief complaints in patients belonging to each age group. In this bar graph, the length of each bar corresponds to the absolute (total) number of visits made by patients belonging to that age group. Therefore, this graph captures both the total number of visits made by patients belonging to each age group, and the proportion of acute, chronic, injuries/wounds, and other complaints with which patients in each of these groups presented.

Figure 1. Proportion of different chief complaints in each age group shown as a function of the total number of visits made by individuals in each age group.

Three observations can be made from figure 1 above. The first is that most patients visiting our RMHCs belong to the 30 – 69y age group, as indicated by the lengths of the bars corresponding to 30 – 49y and 50 – 69y age groups. Secondly, a high proportion of those in the 30 – 49, 50 – 69y, and >=70y age groups appear to be presenting with chronic complaints, with chronic complaints outnumbering acute complaints by almost two-fold in the two oldest age groups. Finally, the absolute number of acute complaints in the older age groups is still higher than the absolute number of acute complaints among the younger patient population.

While figure 1 shows the greater prevalence of chronic complaints amongst older patients, it does not fully reveal the proportion of various kinds of chief complaints for each age group, and how this proportion changes as the population ages. Figure 2 shows the proportion of acute, chronic, injuries/wounds and other chief complaints for patients belonging to each group. Here, the total number of patient visits is no longer considered, as a result of which each bar is equal in length, representing 100% of all patient visits in that age group.

Figure 2. Proportion of different chief complaints in each age group.

Figure 2 clearly reveals that acute complaints constitute the largest burden among patients up to the age of 18 years, with injuries and wounds also contributing significantly. However, the proportion of acute complaints reduces as the patient population ages, with only a slight rise in the >=70y age group. As the proportion of acute complaints reduces with increasing patient age, there is a concomitant increase in the proportion of chronic complaints. These data support our hypothesis that the proportion of chronic complaints increases as the patient population ages. Not surprisingly, we see similar effects when patients belonging to different age groups are also segregated by sex (data not shown).

At a more granular level, the raw data (not shown) reveal that starting from the 19 – 29y age group, body pain appears as a moderately frequent chief complaint. Since most of the population in our catchment areas is involved in cultivation, and this is the age at which young people start working more regularly in the fields, it comes as no surprise that body pain is a common complaint. And the prevalence of body pain increases in the 30 – 49y age group, at which point multiple joint pain also starts appearing as a chief complaint. By the time we reach the 50 – 69y patient population, multiple joint pain outnumbers body pain as the most common chronic complaint. Once again, this is to be expected as joint problems crop up as an individual grows older.

Since chief complaints and diagnoses closely parallel each other, I also looked at the most common diagnoses made across RMHCs in the six-month period between October 15th, 2011 and April 15th, 2012. The five most common diagnoses were:

  • Pharyngitis
  • Allergic Bronchitis
  • Osteoarthritis
  • Myalgia
  • Acid Peptic Disease

These diagnoses mostly parallel the common chief complaints, but for reasons described above, I also analysed the most common diagnoses in patients of different age groups. The hypothesis here is that the diagnosis of chronic conditions will increase as the patient population ages. This analysis was done in a manner similar to that described above for the chief complaints. Diagnoses were placed in four different categories:

  • Acute – Conditions such as laryngitis, pharyngitis, bronchitis, acid peptic disease, gastroenteritis, sinusitis, reproductive tract infections such as cervicitis and vaginitis, tonsillitis etc.
  • Chronic – Hypertension, Diabetes Mellitus, hyperlipidaemia, myalgia, back ache, osteoarthritis, spondylosis – cervical/lumbar, and cervical abnormalities (VIA/VILI positive).
  • Injuries/Wounds
  • Others – Vision problems such as cataract and conjunctivitis, otitis media, gum and tooth problems.

Figure 3. Proportion of different diagnoses in each age group.

As can be seen in Figure 3 above, the proportion of chronic conditions diagnosed increases as the patient population ages, while the number of acute episodes decreases. However, the number of patients diagnosed with an acute condition still outnumber those diagnosed with a chronic condition right up to the 30 – 49y age group. It is also important to keep in mind that a single patient can be diagnosed with multiple conditions, both acute and chronic. Interestingly, the proportion of “other” diagnoses made also increases, with “other” contributing a significant burden in the above 70y age group. This increase in the proportion of diagnosis of chronic conditions as the patient population ages justifies our approach of pro-active preventive healthcare, and is a reminder that we must continue this focus to achieve optimal health outcomes for our communities.

Since the proportion of chronic conditions appears to increase with aging of the patient population, I then looked more carefully at the various chronic conditions that patients were diagnosed with, to understand if the proportion of individual chronic conditions also varied with age.




Figure 4. Proportion of diagnoses of various chronic conditions in each indicated age group.

In each panel in figure 4, the total number represents the number of chronic conditions diagnosed in that age group. In the 19 – 29y age group, myalgia represents 50% of all chronic diagnoses made. As can also be seen, only seven of the ten possible chronic conditions are diagnosed in this age group. There are no diagnoses of hypertension, diabetes or osteoarthritis in this age group. This is not entirely surprising since age is a filtering criterion for screening for diabetes, and these younger individuals might not have undergone a blood glucose test due to the absence of other risk factors. As mentioned before, osteoarthritis is also caused due to aging, and it, therefore, makes sense that we do not see this diagnosis being made in the 19 – 29y age group.

In the 30 – 49y age group, we already observe that more different kinds of chronic conditions are being diagnosed. We see that there are ten conditions that are now diagnosed, with myalgia being the most common at 37%. Hyperlipidemia (13%) and osteoarthritis (11%) are the next most common diagnoses. In the 50 – 69y age group, we see that myalgia is no longer the top diagnosis. It is replaced by osteoarthritis (35%), followed by myalgia (20%), and hypertension (14%). Finally, in the above 70y age group, osteoarthritis is the most common chronic condition diagnosed (43%), followed by hypertension (17%), and myalgia (14%).

As mentioned above, an interesting observation from figure 3 is the increase in the proportion of “other” diagnoses as the population ages. In looking carefully at the various conditions in this category, it became apparent that cataract contributed a huge burden to this group of diagnoses (data not shown), and the contribution of cataract increased with age of the patient population (Figure 5).

Figure 5. Contribution of cataract to all diagnoses increases with age of patient population.

In the 30 – 49y age group, mature cataract represents 1.4% of all diagnoses, and 9.1% of “other” conditions. This number increases in the 50 – 69y age group, with mature cataract contributing 7.3% to all diagnoses, and 36.6% to all “other” conditions. Finally, in the above 70y age group, mature cataract represents 15.1% of all diagnoses, and 60.1% of all “other” conditions diagnosed. These data are consistent with the fact that cataract is a common problem in the elderly. Since cataract is also one of the leading causes of preventable blindness, these data point to the need for us to establish a referral pathway to enable such patients to get treated before it is too late.

The results of the above analyses of chief complaints and diagnoses of patients visiting our RMHCs is consistent with our expectations and with the emerging understanding that non-communicable diseases contribute a huge burden to the disease profile in low- and middle-income countries. These results also underscore the validity of the HMIS as a tool to collect data that can be used to perform epidemiological analyses. From a research standpoint, such analyses will help us understand the health status of our communities better, and therefore, make more refined predictions about the health of individuals and populations, as a whole. From our standpoint as healthcare providers, such analyses will enable us to determine the kinds of interventions required for specific segments of the population so that our limited resources are optimally employed. In the near future, I also plan to closely look at the data from each intervention to get a better understanding of how efficiently our processes as they relate to each intervention are functioning. Performing such process evaluations will help us get a clearer understanding of what we are doing well, and where we need to pay more attention, so that we can achieve the desired health outcomes for our populations.

1Rajanna, D., & Kapila, S. (2011). IKP Centre for Technologies in Public Health. Retrieved May 4, 2012, from http://ictph.org.in/downloads/HMIS-TechnicalNote.pdf

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Geo Mapping our Patient Traffic

Research | Leave a comment |    April 5, 2012

By
Mayank Kedia

The public health system places a Primary Health Centre (PHC) to serve a population of about 30,000 people, one for every 10-12 villages and a Health Sub Centres (HSC) for a population of about 5000 people (about 2 villages). As a primary healthcare provider, one of the biggest design challenges we constantly faced in the run-up to setting up the Rural Micro Health Centres (RMHC) was the placement of our RMHCs within the community. The question is primarily two-fold:

  1. The financial/feasibility with respect to the set-up and operational cost of RMHC
  2. The physical accessibility of the RMHC, primarily ensuring that the farthest House Hold (HH) within the catchment is accessible on foot.

As we went ahead with the RMHC expansion, we conceptualised (and built) RMHCs which serve a population of 10,000 people or about 2000 households. We’ve been monitoring how many of these people have actually visited us and what sort of difference does distance make to the likelihood of a household seeking care with us.

Preceding the launch of a RMHC, we deploy a unique marketing and population based enrolment tool which enables us to geo-tag all Households(HH) and identify their residents. A bar coded Household based identity cards is linked to all the collected data and distributed to each household. This provides us with a systematic data base for provisioning continual care to the population. Upon their visit to the RMHC, these bar coded cards allow us to map utilization of our services across the catchment area, along with epidemiological trends and transition. Another field based tool, the Rapid Risk Assessment (RRA) allows the RMHC to build further on the risk profile of the population served as they identify high risk individuals through Household(HH) visits, for example for cardiovascular diseases (CVD) (based on height, weight, blood pressure, tobacco consumption, and waist and hip circumference as risk markers), and reproductive tract infections (amongst women) are exhorted to seek treatment at the RMHC immediately.

Through this post we share with you basic data insights from four of our RMHCs namely – Andipatti, Alakuddi, Kavarapattu and Okkanadu Melaiyur. All the data presented has been extracted from the Health Management Information System (HMIS), as developed by ICTPH and deployed by SughaVazhvu Healthcare. Listed below are interactive maps as developed using the GeoCommons platform of data illustration. These maps deal with only visit data and we’ve tried to map visit data around our clinics to see the distribution of the people accessing our services in the community. You will see two kinds of illustrations presented below:

  1. Total Coverage Map: These maps have been made by plotting all the households in our catchment area in each of our clinic in blue against the households which have visited us atleast once at the RMHC in a different colour (graded according to the number of visits from each households). The total coverage maps for Andipatti, Alakuddi, Kavarapattu and Okkanadu Melaiyur RMHCs are illustrated below.
  2. Time Line Map: The timeline map primarily aims to illustrate the month-on-month uptake of our services from within the catchment population. With the initial months limiting utilization to the immediate proximity of 1-2km, within 10 months the utilization of services was seen to show a radial distribution of up to 3-5km. The time line map of Andipatti is illustrated below.

All the maps indicated are interactive and you can select the layers you want to see on them. The layers for March, 2012 have been colour graded according to the number of total visits made by the household to the RMHC.

Mapping visit data is useful because it gives us a sense of how well placed, our RMHC’s are with respect to the catchment population. We envision all sorts of maps being looked at, by the physicians in the near future, allowing them to make better decisions pertaining to the provision of care based upon the sort of disease trends they see on these maps.

Kavarapattu Map – This is our 4th RMHC, it was launched on December 5th, 2011.

Okkanadu Melaiyur Map – This is our latest RMHC which was launched on February 1st, 2012.

Alakuddi Map – This is our oldest clinic, but this data pertains only to the time since the enrolment process, i.e. June, 2011.

Andipatti Map – In this map, there are layers of data for households who have visited us until May (2011), June (2011), August (2011), October (2011), January (2011) and March (2011). Andipatti is also our diagnostic hub, where all our diagnostics are done.

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Our Managed Care Thinking at ICTPH

Research | Leave a comment |    March 28, 2012

By Ankit Jain – AVP Operations, A.R. Selva Swetha – Research Analyst

At a recent Spark Session held at IFMR Trust, we presented our Managed Care thinking to the larger ecosystem, outlining our basic premise as to why a Managed Care setup would be a feasible solution to healthcare delivery in India, and how we propose to evolve SughaVazhvu to the role of a Managed Care provider.

16/03/2012 on Prezi

In tackling the issues of healthcare accessibility and affordability, a lot of the focus has been on government-run public health insurance schemes providing secondary or tertiary care (hospitalization) coverage. One of the large scale schemes is the Rashtriya Swasthya Bima Yojna (RSBY) launched by the Ministry of Labor and Employment of the Government of India in 2008 with the primary objective of shielding low-income households from the burden of major health expenses. It provides a hospitalisation cover of up to INR 30,000 (USD 667) per family for a majority of procedures at any of the national network of 8,686 private and public empanelled hospitals. The scheme is targeted at Below Poverty Line (BPL) population, with the premium co-financed by the State and Central governments.

The scheme has enabled a large BPL rural population to use hospitalization services. As of 22nd March 2012, in the 448 districts where the scheme has been operational, there have been more than 3 million hospitalization cases since the inception of the scheme. The usage of a strong technology framework for enrolment, managing cashless hospitalization and fraud control has contributed to the operational efficiency of the scheme. Standardized rates for all procedures have been implemented across the empanelled hospitals for the first time through a centrally regulated system.

Operational success of these schemes however does not undermine the key structural issues they fail to incorporate. The schemes do not address the core issue of disease burden on the ground. With very poor primary care and equally poor existing health-seeking behavior, they have resulted in an upward drift towards higher levels of care. The insurance schemes are designed to intervene in hospitalization cases which could have been taken care of at the primary level through low cost diagnosis, early stage medications and life style modification.

Insurance schemes make it easier to access secondary care as well as improve the supply of secondary care services. Over time this shall lead to higher insurance premiums leading to inflation of health care costs. The only solution is to try and address the disease burden early, improve supply of primary care facilities, introduce gate-keeping functions at the primary care level and strongly limit the supply of secondary and tertiary care facilities.

Given the large unregulated private health sector, there is another critical issue of information asymmetry between the healthcare providers and patients that needs addressing. Healthcare providers may have an incentive to do unnecessary procedures because they are reimbursed on a ‘fee for service’ basis, which might lead to unnecessary cost explosion. In an ideal health system, the incentives of the various players should be aligned towards the health outcomes and the patient’s ‘Wellness’.

The High Level Expert Group (HLEG) on Universal Health Coverage (UHC) constituted by the Planning Commission has recommended the setting up of an ‘Integrated Care Network’, (See Zeena’s blog post) a Managed Care – like set up wherein the government would contract private and public health care providers at all levels.

Such an integrated network would have the following components at the core:

Strong focus on primary and preventive care delivery through systemic interventions for various diseases and conditions, and with a focus on early risk detection and intervention.

Capitation fee based contracting of health care providers, where against a fixed cost the enrolled population would be entitled to a carefully defined health package. So it would be in the best interest of the health providers to keep the population healthy and the cost low which would address the issue of unnecessary prescription of drugs.

Gate-keeping function at the primary care level, with the primary centres acting as gateways for cost control and referral to secondary and tertiary levels of care.

Technology aided Regulatory Framework to track the quality of delivery and health outcomes for a population and defined incentive structure for all entitled health care providers.

In the above context, we at ICTPH are in the process of demonstrating a first of its kind Managed Care setup for rural populations. SughaVazhvu as the ‘Managed Care’ provider would take on the accountability for the quality, cost and overall care delivery of a pre-defined health package against a fixed premium.

This shall entail an integrated health care delivery across primary care, specialist outpatient care and secondary & tertiary care. While the primary care would be provisioned by us, higher levels of care would be provided at providers contracted by us. At our small scale, where we wouldn’t be in a position to house the financial risk of secondary and tertiary care on our books, we would work with an insurer to finance this piece with an insurance product.

Over the next month or so, as we develop a Managed Care product, some the key issues we would be working on include:

Defining the overall health package that we want to offer
Pricing the health package
Exploring Financing Mechanisms
Developing an wellness tracking framework and an incentive structure
Devising a community driven marketing strategy

Working with our key partners IFMR Rural Finance on the product design and appropriate financing mechanism, KGFS for distributing the product, and insurance firms to co-develop a micro health insurance product, we are keen to evolve a model that will serve as an example of how integrated healthcare and financial protection can be provided to a rural population.

References

  1. Rashtriya Swasthya Bima Yojna, http://www.rsby.gov.in/
  2. Centre for Insurance and Risk Management – IFMR, Sept. 2011, ‘RSBY Performance Trends and Policy Recommendations’, (Retrieved from http://www.cirm.in/library/publications)

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Trans-disciplinary Problem Solving: Implementing Public Health Interventions in Developing Countries

Zeena's Note | Leave a comment |    March 22, 2012

By Zeena Johar, President, ICTPH
and Prof. Ramesh Raghavan, Brown School, Washington University in St. Louis

Late in 2010, individuals from ICTPH and the Brown School at Washington University in St. Louis began exploring the idea of co-teaching a course. In the summer of 2011, 14 students arrived in Chennai to spend their summer with ICTPH, here in Thanjavur as the part of the School’s first ever off-campus three credit course.

Orientation of the student cohort at IFMR, Trust Office in Chennai before their departure for the SughaVazhvu field site in Thanjavur, Tamil Nadu

The overall purpose of this course was for students to develop and propose a plan to implement household- and community-level interventions that could mitigate public health challenges faced by the communities located in SughaVazhvu Healthcare’s field practice areas. For ICTPH this was a novel foray into pedagogy. For the Brown School, this was the first time that transdisciplinary problem solving – the motivating and organizing principle of the School’s Master of Public Health (MPH) program – was operationalized and integrated into an overseas course.

Field visits to the SughaVazhvu field sites, accompanied by SughaVazhvu staff members

Through the 8 weeks that this course lasted, students were tasked with solving five dominant public health challenges – previously identified by ICTPH – that were facing these rural communities. These included high rates of cardiovascular diseases, incidence of diarrheal diseases especially among the young, challenges in assuring maternal and child health, increased rates of oral cancer, and challenges with oral health service delivery. Students worked collaboratively with Brown School faculty, ICTPH staff, SughaVazhvu Healthcare’s community health workers, and community residents to first identify the determinants of these challenges, develop household- or community-level interventions to address these determinants, develop a plan to implement these interventions, and propose a plan to evaluate the effectiveness of these interventions.

Field observation exercises – Better understanding of local practices, to adapt interventions towards higher contextual relevance and acceptance

This was achieved through lectures, dialectic discussions with faculty and ICTPH personnel, team-based problem solving, structured visits to field practice areas, shadowing of village health workers and interactions with various community residents. Course activities commenced with a set of orientation sessions in St. Louis; the purpose of these activities was not only pedagogical, but also logistical. Staff from the Brown School’s international programs office facilitated visas, travel documents, and provided information on the health and safety issues involved with working in rural India.

Oral Health Intervention – Skills Laboratory Session

Upon arrival in India, students spent the first week of the course in Chennai. Student teams were introduced to their ICTPH mentor who had specific expertise in the topic on which a team would spend the next two months working. Students were then transported to Thanjavur. Didactic and discussion sessions were held at ICTPH’s facilities in Thanjavur, and were focused around modules for each of the public health challenges faced by these communities. Each module was designed to be integrated, with an instructional component, a skills laboratory, and a visit to a field practice area where the effects and determinants of the five public health challenges could be witnessed directly.

Cardio-pulmonary resuscitation (CPR) training session as a part of their Basic Life Support, certificate training conducted by TACT Academy for Clinical Training in Chennai

Over the eight weeks, students learned to work successfully in an international public health environment, understanding the social ecologies and contextual available health infrastructure, and designing their health interventions within the constraints imposed by these contexts. A field-based approach allowed for participation of local stakeholders, facilitated by SughaVazhvu Healthcare’s field personnel. Engaging with interdisciplinary and transnational teams, transcending language barriers, and bridging cultural differences in conceptualizations of disease and arriving at an appropriate solution offered to students a ‘real’ world experience.

The closing session, sharing learning and experiences with the larger audience at IFMR Trust Office in Chennai

Such collaborative platforms that bring together academic institutes and field partners in an in vivo situation are, we believe, the best way to teach and do global public health. Through such bidirectional exchanges, ICTPH hopes to institute such course work at its field site, which will allow international public health experts to participate in India’s transforming health sector.

We hope you enjoy reading the work of our students!

Trans-disciplinary Problem Solving – Brown School and ICTPH

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Integrated Care Networks – A HLEG Recommendation

Zeena's Note | Leave a comment |    March 19, 2012

By Zeena Johar, President, ICTPH

The High Level Expert Group (HLEG) on Universal Health Coverage (UHC) constituted by the Planning Commission of India was mandated towards developing a framework for providing easily accessible and affordable health care to all Indians. With financial protection as the primary objective UHC also required the availability of adequate healthcare infrastructure, skilled health workforce, and access to affordable drugs and technologies to ensure the entitled level and quality of care to every citizen.

Dr. Manmohan Singh, our Prime Minister declared in his Independence Day Address on August 15, 2011, that health would be accorded the highest priority in the 12th Five Year Plan which would become operational in 2012, clearly articulating governmental intent to increase the public financing of health to 2.5% of India’s GDP, during the course of the 12th Plan.

Universal Health Coverage (UHC), as defined by the HLEG panel of experts is defined as delivery to all persons of a package of services at the primary, secondary and tertiary levels. The HLEG report provides a detailed design and implementation framework for the UHC system.

The proposed increase in public spending will mostly be routed towards establishing primary healthcare systems. The conditional central assistance to states will ensure aligned incentives as they begin to implement the ‘change’. The mostly unorganized primary healthcare sector as of today, calls for a radical architectural transformation to achieve the goals set by UHC.

In our attempt to delivery universal health care, we primarily have three paths to follow (a) direct public provisioning at all levels (b) insurance led fee-for-service mechanisms; (c) capitation fee based contracting-in of private healthcare providers.

The HLEG report strongly supports, establishing ‘integrated care networks’, wherein the government would contract-in both public and private providers of healthcare at all levels. Multiple health systems across the world have adopted this methodology to provide their citizens access to universal health care, most notable the National Health Service (NHS) in the UK.

Establishing such care networks will bring the onus of appropriate referral on the defined first-point of contact, which will be the registered primary healthcare provider. ‘Gate-keeping’ as this is be defined in functional managed care set-ups globally, most notable the Kaiser Permanente network in the US.

Financing UHC providers based on number of registered members in the allocated population, and establishing methodologies such as ‘no registration denial’ will ensure that providers are not selective to enrol only the healthy inhabitants. Such an obligatory and no denial environment have ensured universal health coverage through private health insurance driven systems, most notably in Switzerland. Incentive mechanisms for UHC providers based on quality of care and population level health outcomes monitored through federal regulation and community based organization, will ensure no care denial and cost containment.

Costing a publically financed, capitation fee based healthcare delivery system calls for careful experimentation before national implementation. Models based on current expenditure levels will underestimate cost, as it will sideline the latent demand as the financial barrier to access will be resolved on launching UHC. Probalistic estimates accounting for the above mentioned features, driven by on-ground care-network delivery experiments will help evolve a model for national adoption.

Having outlined a framework for universal healthcare delivery, and the proposed pathway it becomes even more essential to consolidate models that have managed to demonstrate care delivery not only at higher levels of care but most essentially primary care, not only for urban populations but most essentially rural populations.

A framework that seeks to deliver health outcomes at the population level through a combination of community level monitoring and the provision of continuous care at the local level, will deliver the outlined objectives of UHC. Pro-active care driven methodology, specifically for the rural populations, providing the broadest possible range of healthcare services (including dental fillings and scaling, cervical cancer screening, vision screening and dispensation of glasses, and management of chronic diseases) at the primary level, will guide the delivery of sustainable healthcare.

Aligned with the national goal of provisioning UHC, research at ICTPH is primarily driven by four focus areas – human resource, technology & infrastructure, interventions, and financing. Population mapping and risk profiling catchment populations coupled with a village-based physician led care delivery outline the ‘pro-active’ care methodology at ICTPH. The model for delivering primary healthcare to remote rural populations in India, as conceptualized by ICTPH provides for a wide range of village based healthcare services ranging from acute care, chronic disease condition management, ophthalmic care, dental care, and population level screening and aggressive management of the health of those individuals that are deemed to be at high risk.

ICTPH is working towards establishing a first-of-its-kind “Managed Care” programme for rural populations, building on their unique primary care delivery model to offer a full-service model of healthcare and financial protection. Evaluating cost-efficiency of end-to-end care delivery in models like ours will add towards the national level experimentation of designing and pricing the optimal universal health cover for its citizens.

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ICTPH – Reimagining Health Systems (An Overview Note)

Nachiket's Note, Zeena's Note | Leave a comment |    March 16, 2012

By Zeena Johar and Nachiket Mor

The Indian Healthcare Context

At over 3 million square kilometres, stretching 3,000 kilometres from one tip to another, in both directions, with a population crossing 1.2 billion individuals living in over 600,000 habitations, India is one of the largest countries in the world. With 70% of Indian population residing in rural habitations but with 70% of India’s medical infrastructure being available only in urban locations, there is significant disparity in access to basic healthcare. On average, India annually spends approximately Rs.2500 or $50 per capita on healthcare with the government spending limited to only Rs.500 or $10 per capita. Over 70% of healthcare expenditure in India is out-of-pocket, more two-thirds of which is attributable to expenditure on primary care. An additional 20 million people in India are driven below poverty line every year due to catastrophic health expenditure.1

While India perhaps has a reasonable supply of secondary, and tertiary care services in the cities, the limited supply of qualified healthcare practitioners (the doctor:patient ratio for rural India stands at 1:30,000) in modern medicine2, willing to work in rural geographies, leaves the health of rural populations largely in hands of unqualified and unlicensed practitioners, who today define the large unorganized primary healthcare market in India. State governments across the country have sought to fill this gap by offering healthcare services through a combination of sub-centres and primary health centres. However, the actual record of the delivery of these services remains very mixed even at these centres, in large part because of the challenges of inadequacy of human resources as well as a paucity of funds.

SughaVazhvu provisions healthcare to a catchment population of 50,000 rural Indian through a network of five Rural Micro Health Centres

The central objective of the research work at ICTPH is develop frameworks which address these challenges of human resources and limited finances so that both the public sector as well as the private sector that is interested in these issues, can ensure the delivery of high quality healthcare even to the remotest of rural Indian populations.

The framework developed by ICTPH seeks to deliver health outcomes at the population level through a combination of community level monitoring and the provision of continuous care at the local level. In our approach, which has a focus on rural India, a community-based, physician staffed healthcare centre, assisted by a village based Health Extension Worker (HEW), providing the broadest possible range of healthcare services (including dental fillings and scaling, cervical cancer screening, vision screening and dispensation of glasses, and management of chronic diseases) at the primary level, sits at the core of a sustainable model of ‘pro-active’ healthcare delivery.

ICTPH in collaboration with Sughavazhvu Healthcare, a local health care provider in Thanjavur, Tamil Nadu, has rolled out its healthcare delivery model to field-test it and to eventually demonstrate its effectiveness in a rural Indian context. Over a period of time it hopes to work with multiple such field partners across the country including in states such as Orissa and Uttarakhand. ICTPH and Sughavazhvu are also collaborating to develop a full “Managed Care” programme for rural populations, building on their unique primary care delivery model to offer a full-service model of healthcare and financial protection.

Each Rural Micro Health Centre serves a catchment population of 10,000 individuals and is managed by a physician and a village based health extension worker

ICTPH Research Priorities

Research at ICTPH is primarily driven by four focus areas – human resource, technology & infrastructure, interventions, and financing. Population mapping and risk profiling catchment populations coupled with a village-based physician led care delivery outline the ‘pro-active’ care methodology at ICTPH. The model for delivering primary healthcare to remote rural populations in India, as conceptualized by ICTPH provides for a wide range of village based healthcare services ranging from acute care, chronic disease condition management, ophthalmic care, dental care, and population level screening and aggressive management of the health of those individuals that are deemed to be at high risk.

The human resource innovation is in tapping the large qualified Ayurveda, Siddha and Unani talent pool in the country (who are legally permitted to practice allopathic medicine) and training and certifying them on our evidence based protocols so that they can serve as ‘independent care providers’ in a rural setting. In our view this talent pool is already large (750,000 qualified registered practitioners), can much more easily be expanded than the pool of physicians trained in allopathic care, and is currently being severely under-utilized by the country. In the ICTPH model, the physician is aided by a local HEW who facilitates patient triage, follow-up visits, and community engagement activities. The physician and the HEW form the local service unit for a population of 2,500 rural families and serve them through a Rural Micro Health Center (RMHC) designed by ICTPH. Technological facilitation at all the RMHCs through our Health Management Information Systems (HMIS) ensures delivery of closely monitored, evidence based care, for the families under our care.

Care Delivery Pathway – A Value Network Creation:

The ICTPH design principles are being implemented in close collaboration with our Thanjavur based field partner Sughavazhvu Healthcare. ICTPH and Sughavazhvu currently serve a population of 15,000 rural families through a network of six RMHCs.

Site Identification: A contiguous rural geography of 50,000 rural families has been identified. The RMHC expansion follows the proximate catchment methodology in order to benefit from word-of-mouth awareness building, optimal supply chain management across the network, and most importantly, measurable health outcomes throughout the Sughavazhvu value network.

Enrolment and Population Risk Screening: Epidemiological mapping through GPS markers for households, basic house-hold (HH) level information and non-invasive risk screening is accomplished at each house hold (HH) using android based mobile phones synchronised real-time with the HMIS. Bar coded individual identity cards provide a systematic data base for provisioning continual care to the population. Identified very high risk individuals, for example for cardiovascular diseases (CVD) (based on height, weight, blood pressure, tobacco consumption, and waist and hip circumference as risk markers), and reproductive tract infections (amongst women) are exhorted to seek treatment at the RMHC immediately. The enrolment protocol has been implemented across five RMHC sites, enrolling a total of 46,189 individuals. The community based risk assessment protocol has been implemented at one site, (Karambayam RMHC) screening 3,781 adults at their homes, wherein amongst other risk parameters, 524 adults were diagnosed as being at high risk for hypertension and referred for confirmatory diagnosis and treatment to the Karambayam RMHC.

The village based health extension worker assists the physician with evidence-based patient screening and management protocols

RMHC and its Functioning: Each RMHC serves an enrolled and risk graded population of 2,500 families. Each RMHC is staffed by a locally hired physician assisted by a HEW who is hired from amongst the families served by the RMHC. The physician typically holds an undergraduate degree in Ayurveda or Siddha systems of medicine. The three month training and certification physician program at ICTPH, among other things, corrects their identified knowledge deficits in areas such as pharmacology and drug interaction. The rigorous training on evidence based protocols equips the physician to multi-task as they manage infectious diseases, non-communicable diseases, dental treatments including scaling and fillings, comprehensive eye examination and prescription and dispensation of spectacles, mental health counselling and treatment (under development), and cervical screening including cervical cancer screening using the VIA/VILI methodology. Up to the end of February 2012, through a network of five RMHCs, a total of 10,897 patient visits have been managed by Sughavazhvu.

Vision screening protocol as implemented by the health extension worker

Provisioning near and distance vision glasses through the RMHC network

Health Management Information Systems (HMIS): The HMIS as developed by ICTPH is the first-of-its kind primary healthcare management tool in India.  Other than capturing patient-physician interaction the web-based, open source HMIS has fully functional units for supply chain management, monitoring and evaluation, clinical audits and integration with android based mobile platforms for data integrations. Modules such as human resources management, training management,  clinical data analysis and community disease mapping aided by geo-visualization are under development.

Diagnostics at SughaVazhvu – Rural Micro Health Centres, provisioning better chronic care management
to rural populations

Community Engagement: Various methodologies are implemented throughout the network to ensure maximum participation of populations served. RMHC based specialist camps, such as for cervical cancer screening, vision and dentistry, village based self-help groups, and school based preventive strategies are some of such activities anchored by the local RMHC physician and the HEW.

Wellness Tracking: Identifying high risk individuals through systematic community based interventions and managing their risk profile from high to moderate status defines the wellness tracking methodology. Evidence based protocols for management of diabetes, hypertension, and hypercholesterolemia are the chronic conditions managed by the network at present.

Health Financing: The present model of financing explores various user fee based structures for all the services offered. The objective of the health financing vertical is to demonstrate a self-sustaining healthcare delivery model through mechanisms such as fixed price pre-paid primary healthcare coupled with insurance mechanisms which help risk pool for higher forms of care. These mechanisms would demonstrate a model to effectively insulate populations from catastrophic and out of pocket health expenditures with gate-keeping mechanisms developed by ICTPH ensuring quality of care and sustainability. They could also serve to augment the limited public funds that are available for the provision of these services.

Washington University in St. Louis’s first off-campus Trans-disciplinary Problem Solving Course co-taught in Thanjavur in partnership with ICTPH

Academic Partnerships: ICTPH’s standardized protocol driven primary-care service modules have been developed in partnership with the School of Nursing, University of Pennsylvania. ICTPH’s partnership with the Warren Brown School of Social Work at Washington University in St. Louis executed the first off-campus, on-site trans-disciplinary problem solving course co-taught by faculty at the Brown School and senior researchers at ICTPH. ICTPH’s summer global internship program has built a platform for international collaboration with students across campuses such as Johns Hopkins, the Wharton School, Massachusetts Institute of Technology, and Columbia Business School.

1 High Level Expert Group Report on Universal Health Coverage for India – Instituted by the Planning Commission of India

2 Central Bureau of Health Intelligence, Ministry of Health and Family Welfare, Government of India

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Financial Sustainability: Ensuring Growth through Evaluation

Field Staff, Sugha Vazhvu Partnership | Leave a comment |    March 10, 2012

By Johanne Chu

My name is Johanne Chu, currently a sophomore at the Wharton School of Business, University of Pennsylvania. I arrived at ICTPH on February 2, 2012 wanting hands-on experience in health care. While I had no prior experience in the area, I agreed with the members of this organization that health care is an infallible human right. I came equipped with an educational background in business and willingness to learn. With Karthik Tiruvarur (Chief Operating Officer, SughaVazhvu Healthcare) as my mentor, we quickly narrowed down project possibilities that would allow me to apply what I’ve learned but also be of use to ICTPH.

This fiscal year, ICTPH is looking into expanding its Rural Micro Health Centres (RMHCs) at a record rate and starting exciting new initiatives that will benefit its patients. To look ahead, it is vital for ICTPH to look around first to examine its financial status and capabilities. That became the basis of my project. Ultimately the project was finalized to be twofold: the first part was to understand inventory management and evaluate drug margins at the point of sales, the RMHC; the second part was to propose re-pricing for our diagnostic tests.

In evaluating profits, I wanted to see how close the ‘real’ gross profit margin was to the current estimates of ICTPH. In other words, if drugs are one of the few areas in which we make a profit, what is the breakdown of those profits? To have an in-depth understanding of every facet related to drugs, I combined literature learning, HMIS briefing, and primary documents. Firstly, I looked at the operations and studied our relationship with pharmaceutical companies and the general supply chain in our Rural Micro Health centres (RMHCs). Then, I studied the drugs in stock at every RMHC to enhance my understanding of their medical usage, their composition, their side-effects, and so forth. Thirdly, I looked at invoices for the past ten months with the pharmacist at SughaVazhvu Healthcare, Manimekalai Pichaivel, to see the breakup of all the costs related to drug orders and gauge a suitable time frame in which to obtain the data for analysis. Lastly, field visits helped me gain hands-experience with regards to the functioning of the drugs supply chain at SughaVazhvu.

To minimize bias while ensuring sufficient data, I ultimately settled for the six months time period from August 2011 to January 2012 for the above mentioned analysis. In June 2011, the business team at SughaVazhvu reoriented the stock, retracting drugs deemed too expensive or unsuitable for the populations’ needs, as driven by their evidence based care methodology. By August 2011, the updated inventory had been used for several months and the list did not go through any significant changes through the six months that followed. The period of study also observed the expansion of the RMHC network by only one unit.

The primary information used was the Drug Consumption List and the Product List. Combining the data generated the master spreadsheet – Final Drug Margins. I calculated the purchase price per unit, the MRP per strip, along with information on sourcing, to get the margin per strip and margin per unit for each drug. In addition, the profit on cost was also calculated to measure the price markup of the drugs from the purchase cost. I computed the revenue and profit earned on each drug, and after accounting for the disposed drugs’ cost, arrived at the current gross profit margin.

I hope that this part of the project would give a better idea on how to best price drugs for SughaVazhvu. The debate addressing patient affordability may attain useful pointers from my model as SughaVazhvu explores to prices below the MRP to further enhance patient experience.

Moving onto the second part addressing financial sustainability, I wanted to explore a logical and pragmatic method of setting prices for the diagnostic tests offered by SughaVazhvu Healthcare. I started by figuring out what fixed costs to account for, such as diagnostic equipment, reagents, salaries, electricity etc., I studied our enrollment process and the Rapid Risk Assessment methodology, which serve as the diagnostic test starting point for many of our patients. The HMIS records gave me an idea of diagnostic test utilization within the system. The Field Visits, as always, provided unexpected developments that proved helpful for my project.

I considered value-based pricing, psychological pricing, and target return pricing before settling on a cost-plus pricing strategy, which considered all direct, input costs to arrive at a product’s Unit Cost. I focused on the five most frequently conducted diagnostic tests: Triglycerides, Total Cholesterol, HDL, Blood Glucose (fasting), and Blood Glucose (post-prandial). I did a breakeven analysis considering all the relevant fixed costs and compared the figures to the accumulated diagnostic test counts. For the variable costs, I used the procedures for the tests and the order invoices to calculate exactly how much consumable are consumed through each test, from a single-use syringe to the reagent composition. I also visited three local diagnostic labs in and around Thanjavur to get their price lists. By calculating the averages, I calculated the markdown percentage for us versus the market.

Ultimately, I put forth two sets of proposed prices. One based on variable cost ensuring cost recovery, and the second based marking our services below the market competitive rate ensuring the prices to be 30% below the local diagnostic labs’ prices.

This project highlighted the operational and logistical details for the diagnostic laboratory and the blood movement supply chain which is maintained across the entire network of SughaVazhvu’s RMHCs.

Being a part of ICTPH for the past five weeks has been an enriching experience for me. I wish all the success for this innovative community driven business model approach of delivering healthcare to rural populations of India.

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Camp-Based Approach to Community Engagement and Human Resource Training

Sugha Vazhvu Partnership, Training & Development | Leave a comment |    March 9, 2012

By Aarti Sahasranaman, Vice President – Interventions, ICTPH

SughaVazhvu organised its first RMHC-based camp for cervical screening during the weekend of February 25th and 26th, 2012. The screening camp was organised in Kavarapattu on the 25th, and Okkanadu Melaiyur on the 26th. These RMHCs were chosen because they provide cervical screening services on a daily basis, and therefore have all infrastructure required to perform these examinations. The cervical screening examination and medication were all provided free of cost on camp day. There were two primary objectives behind conducting these camps:

  1. To organise an event that would allow us to engage with our communities on a larger scale. One of the principal differentiators that separates us from other primary care providers is the range of services we provide under one roof. However, informal feedback received through various channels led us to believe that we have not been particularly successful at communicating how we are different, and exactly what it is that we have to offer to our communities. Therefore, it is imperative that we engage more actively with the communities that we serve so that they understand what SughaVazhvu stands for, the services we offer, and how they can appropriately access these services.
  2. To train our HEWs to perform VIA/VILI examinations for cervical screening. Currently, VIA/VILI examinations are being performed by physicians or trained nursing officers at our RMHCs. However, in our model, we envision task shifting wherein the HEW will perform these examinations. Because VIA/VILI examinations are very subjective and therefore provider-dependent, it is important to examine a large number of women to get an understanding of the various diagnoses that can be made. We felt that a camp-based approach would allow us to gather a large number of eligible women who could then be examined.

The training was conducted by the team of Dr. P.O. Esmy of the Christian Fellowship Hospital at Ambilikai, Dindigul. In addition to Dr. Esmy, the training team also consisted of two staff nurses. Dr. Esmy’s team is part of a cervical screening project under the aegis of the World Health Organisation (WHO) and the International Agency for Research on Cancer (IARC). SV staff members who participated in the camp included all our HEWs – Vanasundari, Ayulrani, Premavathy, Prema, Saranya, Praba, and Josephine, women’s health trainers – Viji and Vanitha, and physicians – Dr. Suganya, Dr. Uma, Dr. Shanthi Priya, Dr. Shanthi, and Dr. Saranya. In both Kavarapattu and Okkanadu Melaiyur, two independent screening stations were set up. The trainees were split into two groups, with each group assigned to a screening station.

The training team and trainees outside the Okkanadu Melaiyur RMHC on February 26th, 2012.

Women who walked in for screening first signed the consent form for the examination and were then enrolled. Subsequently, they were issued a token number and an abridged PISP was performed to assess CVD risk. Visual acuity was not measured because of time constraints. Those at risk for CVD were issued vouchers and asked to visit the RMHC at a later date for further assessment.

Sharmila, Administrative Officer at SughaVazhvu, enrols a woman for the cervical screening camp.

Dr. Esmy of the Christian Fellowship Hospital addresses women assembled for the camp on the importance of preventing cervical cancer through regular screening sessions.

Women were then sent in for screening based on their token numbers, where Dr. Esmy and her staff performed the initial examinations while training our staff members. Dr. Esmy’s team had also brought in their colposcope, which allowed for a 20-fold magnification of the cervix. After these initial examinations, our staff members performed VIA/VILI examinations on their own under the supervision of Dr. Esmy and her team. By the end of the second day, our staff members were comfortable with performing VIA/VILI examinations.

We screened a total of 109 women on both days of the camp. The break-up of data for each RMHC is as follows:

Day 1 – Kavarapattu
Total number of women screened = 63
Total number of VIA/VILI Positive women = 5
Total number of first-time visitors to the RMHC = 41
Total number of women issued CVD vouchers = 49
Total number of CVD vouchers used so far = 5
Of the five women who availed of their CVD vouchers, two were found to be hyperlipidemic.

Day 2 – Okkanadu Melaiyur
Total number of women screened = 46
Total number of VIA/VILI Positive women = 2
Total number of first-time visitors to the RMHC = 18
Total number of women issued CVD vouchers = 34
Total number of CVD vouchers used so far = 9
Of the nine women who availed of their CVD vouchers, one woman was diagnosed with hypertension and diabetes and has been started on medication. Four women were found to be hyperlipidemic, and one was found to be pre-hypertensive and pre-diabetic.

While organising a camp requires a lot of thought and effort, the camp-based approach to screening has some very obvious merits. In terms of sheer numbers, we were able to screen 109 women over two days during the camp, most of who were first time visitors to our RMHCs. In contrast, we have screened 100 women in Karambayam over the last five months, 67 women in Kavarapattu over 2.5 months, and 40 women in Okkanadu Melaiyur in over a month via opportunistic screening. This is not to say that opportunistic screening does not have its advantages, but that a combination of opportunistic and camp-based screening might eventually become necessary for us to be able to screen all eligible women in our catchment areas within a reasonable time frame.

The camp approach also provides us with numerous opportunities to engage with community members. For example, the fact that we performed an abridged version of the PISP allowed us to assess risk factors for all assembled women. Risk assessment is the cornerstone of our preventive approach, and the camp allowed us to carry out this assessment of a large number of first-time visitors. In addition, risk assessment provided us with the perfect segue to talk about our focus on prevention, whether it is through management of risk factors for CVD or early detection and treatment of cancer. Thus, we were able to raise awareness about the importance of cervical screening, and at the same time highlight some of our other interventions.

In terms of training, the camp-based approach proved to be a success. By focusing only on cervical screening for two days and performing VIA/VILI examinations on their own, our HEWs became much more confident about their ability to independently screen women. While they will require continued training to hone their skills, this camp has provided the initial confidence that HEWs require to start performing VIA/VILI. Additionally, the camp also helped to further familiarise our master trainers with the screening and diagnosis process. Ongoing training of our master trainers through camps such as these is critical to the success of our training model.

It is my hope that this cervical screening camp is the first of many community-based activities organised by SughaVazhvu. I am convinced that this approach to community engagement and training can be applied to showcase our other interventions as well. We are now planning on conducting a vision camp, where visual acuity will be measured and refractive error correction performed. I am hopeful that by organising such events, we will be able to more clearly communicate SughaVazhvu’s vision to the communities we serve, and encourage community members to access our services.

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Addressing Human Resources Challenges in Global Health – A Perspective from India

Nachiket's Note, Training & Development | 1 Comment |    February 28, 2012

By Dr. Arun Jithendra and Nachiket Mor 1

Given the critical role that providers play in healthcare, human resources remains one of the most important challenges in healthcare in both developed and developing countries. And, this problem is made more acute by a particular feature of the healthcare industry that is not shared by other service sectors such as financial access and basic education. This is the fact that while in the case of education and financial access for example, the institutions providing the service need to be licensed, in the case of healthcare, with very good intentions, the licensing requirements devolves onto the individual seeking to provide the service. Almost as a direct consequence of this the investment required to become a licensed provider balloons and so does the need to find lucrative opportunities to earn a reasonable return on that investment. It is not surprising therefore that country after country sees the availability of qualified manpower as the most important stumbling block on offering high quality healthcare to their populations at prices that are affordable. Even on the cost front, the advent of generics and the entry of low-cost manufacturing bases such as India have made many essential drugs very affordable leaving the availability of qualified manpower as perhaps the single most important barrier to providing access to good healthcare.

As a very large developing country in which a states such as Uttar Pradesh with a population exceeding 190 million, independently qualifies to be the sixth largest country in the world, has all of the problems of human resources that other developing countries face but multiplied manifold on account its sheer size and remoteness of many of its parts. Over a decade and a half ago to meet the demand for engineers by its rapidly growing Information Technology sector, India responded aggressively by rapidly expanding the supply of Engineering Colleges and letting market forces decide the issues of quality since its own internal regulatory machinery was not equal to the task and the need was urgent. The number of Engineers Colleges in the private sector tripled from about 550 at the end of March, 1998 to 1500 by the end of March, 2006. The number of engineering students entering these colleges during the same period quadrupled from 125,000 annually in 1998 to over 500,000 in 20062.

However, despite facing a similar level of urgency a similar growth in supply of medical students and medical colleges has not happened. There are a number of reasons that are given for this including the need for much higher levels of investment for medical colleges and the fact that, unlike Information Technology, healthcare after all deals with human life and therefore ex-ante attention to quality has to be perforce much higher. However, perhaps the most important reason for the current state of affairs has been the fact that it is very difficult to get permission to open a new Medical School potentially because the existing community of physicians see a rapid increase in supply as a threat and the reality is that they have good reasons to think so. Something very similar happened in the discipline of Engineering. Prior to 1995 it was considered a very attractive career but post the massive expansion of supply while some disciplines such as Computer Science retained their earlier attractiveness, for the most part the compensation an average engineer could command collapsed. The only reason we draw attention to this detail here is to point out how difficult a challenge it would be to attempt to expand the supply of traditionally trained physicians or to permit new categories of physicians such as Nurse Practitioners to emerge, as has happened in the United States.

Confronted with this reality, acknowledging the futility of attempting to make drastic changes in the supply of traditionally qualified physicians, and needing to find low cost solutions, government, non-profit, and for-profit healthcare providers have gone to the other extreme and have launched a number of programmes in which locally hired, often illiterate women, were offered training programmes of variable quality and converted into Health Workers. The largest such programme in the World is the Accredited Social Health Activist or ASHA programme. ASHA when read as a word instead of as an acronym also means hope or expectation in Hindi thus doing double duty of conveying the original spirit of the programme. As often happens in such programmes the original purity of the design has long been lost and the ASHA now is simultaneously a health activist representing the community, an agent of the government’s conditional cash transfer programme, and most controversially, a dispenser of prescription drugs such as Metrogyl. This last function clearly has a weak regulatory foundation but to the best of our knowledge has never been legally challenged perhaps because the existing community of physicians did not see the ASHA as representing a real threat.

The precursor of the ASHA programme was the famous Mitanin or Friend programme launched in the state of Chattisgarh under the visionary leadership of Dr. T. Sundararaman and was able to show a very large impact even with the Mitanin playing principally the role of an activist3 and not a healthcare provider in her own right, and maintaining her independence from the public health system so that her role as an activist was not compromised. However, in its expanded version, the ASHA programme has effectively been implemented in manner such that the worker in addition is now expected to play the role of a primary care provider as well as refer patients to secondary facilities, roles well beyond her technical capacity to perform with any degree of effectiveness. However, at a smaller scale there have been a number of very interesting interventions with some fairly complex and technical tasks being performed by community health workers. The most famous of this is the work by Dr. Abhay Bang and Dr. Rani Bang in Gadhchiroli district of Maharashtra4 in which they demonstrated that home based neonatal care can be delivered very effectively by well-trained community health workers. It is conceivable that a potential direction for the delivery of healthcare in India could be the growth of such highly trained narrow-skilled community health workers across multiple specialities. However, the legal challenge faced by other community workers persists here as well, aside from the challenges of providing such training at scale and finding the resources to pay all of them a reasonable wage.

Registered Auxiliary Nurse and Midwife (RANM) and the Registered Nurse and Registered Midwife (RNRM)5 programmes do exist in India and offer a potentially strong solution to the challenges of human resources for healthcare, particularly if they are able to practice as Nurse Practitioners as they are in the United States. There are, however, three significant challenges that need to be overcome before this can happen:

  1. The training that the nurses at both levels undergo is principally as bed-side and emergency room nurses. There are currently no programmes that train nurses to act as practitioners and would perhaps need to be developed from scratch.
  2. There is severe shortage of trained nurses even for traditional tasks and the supply of nursing schools has expanded very slowly potentially for reasons very similar to those for Doctors.
  3. Neither the Nursing Council nor the Medical Council are interested in allowing nurses to practice independently and prescribe medicines except for what is specifically required for their role as a midwife.

The IKP Centre for Technologies in Public Health (ICTPH) is a non-profit action-research centre which, among other things, is engaged in developing durable solutions to this challenge of human resources for health in India. After many false starts and legal challenges, they now have a set of ideas that seem to address all of the concerns that have been raised earlier, as well as fit into a full health systems design that they have developed for offering high quality health care in India. Their overall solution involved taking several steps:

  1. With the help of a top Indian law firm6 ICTPH first researched the legal options available to them taking the current positions of the Nursing Council and the Medical Council as being immutable. They were able to obtain a land mark judgement from the Supreme Court of India which permits the practitioners of specific systems of Indian medicine to also prescribe modern allopathic medicines as well as offer dentistry services in their role as General Practitioners. These systems are Ayurveda, Unani, and Siddha but the Supreme Court specifically excluded Yoga, Naturopathy, and Homeopathy.
  2. ICTPH then researched the availability, costs, and the willingness of graduates with these backgrounds to serve in remote rural areas. On these fronts ICTPH was able to conclude that a number of such graduates were available and were willing to serve in remote locations at relatively modest compensation numbers.
  3. On the training front ICTPH discovered that the institutions that train these physicians offer a 5.5 year post-high school programme with a one year internship included. In these 5.5 years they develop a strong understanding of the human anatomy and many other aspects of medicine but significant gaps also remain on many other dimensions. ICTPH then developed its own internal training and certification programme for these physicians, which is a mix of classroom and practical training at any one of the clinics of their local health partner7. It is our understanding that within Cuba such models of training and certifying physicians have gained a lot of traction.
  4. In the ICTPH training programme these physicians are not only trained to treat patients for common ailments but also multi-skilled to offer dental services, eye care including dispensing glasses, and women’s health including screening for cervical cancer. Very soon ICTPH expects to launch its mental health programme as well as a broader cancer detection and treatment, and tobacco cessation programme.
  5. All physicians are required to strictly adhere to the internally developed detailed treatment protocols and to enter data for each patient into the internally developed Health Management Information System (HMIS) on a real-time basis. This data is then reviewed carefully by central audit team staffed by experienced nurses and allopaths to confirm that the existing protocols were indeed followed to the letter, to inform the development of new protocols, and to continuously assess the quality of training provided to the physicians.

While research on this is still ongoing, it is our belief that the approach adopted by ICTPH has the potential to offer a durable solution to the challenges of human resources in healthcare for India. The combination of a competent human resource base, intensive training, and a strong control environment, in our view is essential if high quality health care is to be delivered to the larger population. At the secondary and tertiary levels it is our belief also that India has the requisite core competency and that these levels of healthcare would necessarily need to be staffed by physicians and nurses trained in the allopathic tradition. In our view the existing human resource base in the country, with some augmentation in the capacity of both schools of medicine as well as nursing schools would be able to take care of these issues.

1 Dr. Arun Jithendra (arun.jithendra@ictph.org.in) is a Research Associate at the IKP Centre for Technologies in Public Health (ICTPH) and the Head of Training for Sughavazhvu Healthcare. He is also the corresponding author for this article. Nachiket Mor is an Independent Board Member of ICTPH. This note was read out by Nachiket Mor at the “Reflections on Global Health” conference at the University of Pennsylvania on the 24th of February, 2012.

2 http://www.mit.edu/~lrv/writing/Private_Engineering_Education_in_India_Market_Failures_
and_Regulatory_Solutions.pdf, Table 1.

3 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60326-2/fulltext

4 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60034-2/fulltext

5 http://www.indiannursingcouncil.org/types-nursing-programs.asp

6 http://www.businessworld.in/businessworld/businessworld/bw/AZB-Partners

7 http://www.sughavazhvu.co.in/

Posted in Nachiket's Note, Training & Development | 1 Comment

Is Managed Care at all a Possibility in Developing Countries? – A Perspective from Thanjavur

Health Technology, Nachiket's Note | Leave a comment |    February 27, 2012

By Nachiket Mor and Karthik Tiruvarur 1

Developing country environments are characterized by acute shortages of both financial and human resources for healthcare as well as by a high burden of infectious diseases. In the recent past a large and growing burden of non-communicable diseases has also become very visible in these countries. And, while this is not true of all developing countries, there are some such as India and China, which have additional problems imposed upon them by the sheer size of their landmass and a very large population. At over 3 million square kilometres, stretching 3,000 kilometres from one tip to another in both directions, and with a population crossing 1.2 billion individuals living in over 600,000 habitations, India is one of the largest countries in the world. Some of her districts have populations that are comparable to those of entire countries. For example, Burdwan District of West Bengal at 7 million has a population comparable to that of Papua New Guinea and Serbia.

Faced with these very stark realities, developing countries have sought to address their healthcare challenges with a number of different strategies. India, for example, currently has in place a veritable potpourri of “solutions”:

  1. A public health system with, at 1% of GDP or $10 per capita, a miniscule amount of funding, and a decidedly mixed record of performance.
  2. A very large community health worker programme in which very poorly trained and very poorly paid local women are simultaneously expected to dispense prescription drugs, act as the voice of the community to make the public health system more responsive to local needs, and act as the agents of the government for a large conditional cash transfer programme designed to incentivise women to deliver babies at hospitals rather than at home.
  3. Multiple national and state level insurance schemes that, at $6 per capita, for the very first time, have allowed millions of families to gain access to a large number of secondary and tertiary healthcare facilities in the private sector. Multilateral institutions and governments in both India and China have seen such schemes as a low-cost opportunity to entirely by-pass the government owned public health systems and yet offer an apparently comprehensive healthcare solution to their citizens. These schemes have been built with a very strong technology back-bone and appear to be delivering on their promise of low cost healthcare provision to the vast Indian populations.

Despite all these “solutions” being available the reality of India is that her citizen’s end up spending approximately $50 per capita on health care, of which more than $40 per capita is out-of-pocket. Much of this money is spent at the local level and since there is a complete absence of modern healthcare provision at the Primary level either within the government or in the private sector, a large proportion of it is handed over to the numerous “medicine-men” that have existed for centuries peddling all manner of “cures”.

Faced with this state of affairs we want to explore if it is at all conceivable for developing countries like India to offer a comprehensive high quality healthcare solution to all her citizens. It is our view that, given the unique nature of healthcare, a pure laissez faire, demand driven approach will not produce first-best outcomes for India and nor do existing “solutions” that have been mentioned earlier have the potential to do so. Managed Care with its emphasis on offering a structured set of solutions with strong gate-keeping functions, in our view, represents the ideal model both from a cost control and healthcare point of view, irrespective of whether it is operated by the Government or the private sector. One could have a long debate on the pros and cons of Managed Care but even assuming for the moment that we all agree that this indeed is the direction that a developing country like India must go, all the practical challenges that have dogged Indian efforts at providing healthcare do not magically vanish merely because a new model of healthcare has been proposed.

The IKP Centre for Technologies in Public Health is an action-research institution based in India with a large field site in rural Thanjavur – one of the poorer rural districts in the Southern Indian state of Tamil Nadu. Our focus has been on developing a set of ideas that will address the several on-ground challenges that Indian healthcare systems face. In ICTPH it is our view that while a few such viable solutions do exist, they involve multiple design elements working closely together. It is also our view that while India has done a relatively good job of addressing challenges at the secondary and tertiary care level, as evidenced for example by the growing medical tourism industry, on the twin dimensions of provision of Primary care and integration of care across higher levels, we have a long journey ahead. The focus of ICTPH’s work is therefore on these two dimensions. In our view, clever human resources strategies, advanced point of care diagnostics, health management information systems, and expert architectural designs, by themselves will not be able to address these challenges but, when combined together in interesting ways, they have the potential to dramatically transform the provision of Primary healthcare and the integration of care across levels. Our research work examines health systems along four complementary dimensions of: (i) Human Resources; (ii) Infrastructure; (iii) Interventions; and (iv) Financing and seeks to combine them to produce desired outcomes. Taking this approach, we have rolled out a specific design in rural Thanjavur with the help of our on-field partner: Sughavazhvu Healthcare.

The design currently being implemented on the ground in Thanjavur seeks to serve a relatively “tiny” population of 200,000 individuals or approximately 50,000 families in a clearly defined geography. This version of the ICTPH Health Systems design has the following core components:

  1. Within the geography in which the 50,000 families live, identification of 20 distinct contiguous areas in each of which 2,500 families live.
  2. Working with a locally hired temporary team of Enrolment Officers, a GPS mapping of each dwelling and a one-time enrolment and Rapid Risk Assessment (RRA) of each individual residing within each dwelling, and issuance of bar-coded identity cards to every individual along with a selective issuance of High Risk Status cards to specific people found to be at risk for certain non-communicable diseases. These High Risk Status cards entitle them to free treatment within the local health centre for that specific disease. The RRA measures five markers for each individual (height, weight, blood pressure, tobacco consumption, and waist and hip circumference) and based on internally developed automated algorithms risk grades each person. The entire enrolment and RRA process is implemented using low-cost Android based mobile devices which synchronise real-time with Sughavazhvu’s central database. The cost of this one time effort is estimated at $800 for each location.
  3. Establishment of one Rural Micro Health Centre (RMHC) to serve the enrolled and risk graded population of 2,500 families. Each RMHC is sought to be located a point such that it represents no more than a twenty minute walk for the household living at the furthest point of the catchment. The architecture of the RMHC is such that it is a welcoming and colourful place with a lot of light and air but with an adequate degree of privacy. Each fully equipped RMHC on average costs about $6,000 to construct and fit out. It has a monthly operating cost of about $120 including rent, electricity, and internet charges. For every five RMHCs there is a fully equipped diagnostic centre which costs about $10,000.
  4. Each RMHC is staffed by a locally hired physician with an undergraduate degree in Ayurveda, Unani, or Siddha systems of medicine. This physician is legally permitted to prescribe allopathic medicines and is completely retrained and recertified using ICTPH’s internally developed, year long, training programme. This physician is trained to use technology; work with clearly developed protocols; and is multi-skilled to treat infectious diseases, non-communicable diseases, offer dental treatments including scaling and fillings, conduct a comprehensive eye exam as well as prescribe and dispense glasses, mental health counselling and treatment (under development), and cervical screening including cervical cancer screening and treatment using Cryotherapy. On average it is possible to get a very large number of such physicians at a salary of about $250 per month.
  5. Each physician is supported by a locally hired and heavily trained health extension worker who is paid about $50 per month.
  6. An internally developed Health Management Information System(HMIS) and a central team of auditors ensures that each RMHC follows all processes and protocols exactly as laid down centrally. A new Clinical Decision Support System (CDSS) will also assist the physician in reaching an appropriate diagnosis and arriving at the best treatment plan.
  7. Each RMHC is able to serve about 40 patients in a day and spends about $1 per patient on drugs and diagnostics. It is our estimate that the full suite of primary care offered by the RMHC including medicines and diagnostics can be offered to each individual at approximately $14 per capita per year including all costs.
  8. Secondary and Tertiary care health insurance can be provided to each individual at approximately $6 per year assuming tight gatekeeping at the primary care level and a great deal of proactive work to ensure that the high risk individuals identified in the RRA are able to bring their risk levels down to moderate levels. The insurance will pay for care at a clearly identified preferred network of providers.
  9. Therefore a comprehensive Managed Care plan (with no deductible or co-pay) can be put together in our view at approximately $20 per capita or $100 per family per year. However, with the government willing to spend only $10 per capita, additional resources would have to be found from within the $40 being spent by the people themselves taking care to ensure that equity considerations are kept at the forefront. For starters we have defined health-poverty as having a high-risk status on the RRA thus entitling the individual to completely free care for that condition until they reach a moderate risk status.

Our early work with the 12,500 households that we currently serve through our 5 RMHCs persuades us that many of these ideas may actually find some traction in the field. These are preliminary ideas that we have been working on and a great deal of work remains ahead, particularly in completing the development of our Primary Care HMIS, our in-depth certified physician training curriculum, our mental health treatment and counselling protocols, and in thinking through various health financing mechanisms. Over the next two or three years we hope to explore some of these ideas more carefully and if indeed we can successfully offer this as a Managed Care programme to our target population of 50,000 families and work towards building a disease free future for them. If we are indeed able to do so successfully then we hope to be able to take these ideas to both the government as well as the private sector so that they may be taken to scale across the country.

1 Nachiket Mor (nachiket@nachiketmor.net) is an Independent Board Member of the IKP Centre for Technologies in Public Health (ICTPH) and is the corresponding author. Karthik Tiruvarur is a senior member of the ICTPH team as well as the Chief Operating Officer of Sughavazhvu Healthcare in Thanjavur. This note was first delivered as a speech by Nachiket Mor at the Massachusetts Institute of Technology (Cambridge, Massachusetts) on February 23rd, 2012.

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