17 March 2011
Nurses instead of doctors, software solutions instead of human judgement. This is the ex–banker’s radical premise to reconfigure primary healthcare in rural areas. M Rajshekhar checks out a pilot in a Tamil Nadu village.
Karambayam is the site for one of the two healthcare clinics set up by Mor and his 30–member team to reconfigure primary–healthcare delivery in rural areas. It’s far removed from his life four years ago, when he was tipped to succeed KV Kamath at ICICI Bank. On leaving the bank in 2007, he moved to the ICICI Foundation to work on rural development. Last September, he left the foundation to take charge of ‘SughaVazhvu’ (happy life in Tamil).
SughaVazhvu is testing a radical idea: can technology replace doctors with nurses, human judgement with software solutions? "It is difficult to expect doctors to stay in villages," explains Mor. "So, we are asking if a combination of technology and a reasonable amount of training (to local nurses), under the supervision of a doctor, can deliver superior outcomes."
SughaVazhvu bears the imprimatur of Mor in its conception and design. By the end of his ICICI Bank stint, says a former colleague, Mor was seen as an "idea factory" without the ability to execute. "He once wanted to open 15,000 vocational training centres. We opened none," says the ex–colleague.
The clinic in Karambayam is a two roomsand–a–porch affair. On the porch lie three benches and some potted plants. The first of the two cream–coloured rooms inside is rimmed with paraphernalia for diagnostic tests. The second room is where the nurse and doctor meet patients.
As primary health centres (PHCs) go, it’s well–stocked. Most government PHCs remain dysfunctional, crippled by an absence of doctors, medicines, equipment and medical records. "Doctors make their diagnosis more on the basis of judgement than data," says Zeena Johar, president of ICICI Knowledge Park’s Centre for Technologies in Public Health (ICTPH).
Then, while chronic diseases like diabetes are widespread, the equipment for spotting and treating them is missing at the PHCs. As are essentials like eye–care and dental. Mor, who is a member on the Planning Commission’s National Commission for Universal Healthcare, says 95% of healthcare needs can be met at PHCs.
"The PHC should deliver ‘managed healthcare’ – tracking an individual’s health indicators over her life – and direct her to secondary, tertiary and home care as needed." He thinks technology, arranged and harnessed intelligently, can be the answer. So, SughaVazhvu monitors the health of the people of Karambayam and Alakkudi – the other village where it has a centre. At the outset, it asks villagers extensively about their medical history, through a standard questionnaire.
The objective is two–fold: one, when a patient makes a repeat visit, their symptoms can be seen in conjunction with their medical history. Two, a person’s health can be tracked continuously.
SughaVazhvu is also testing if technology can help address the shortage of doctors. It is testing a nurse–managed, doctor–supervised model, pumped by technology and protocols. "Medicine is driven by rules," says Johar, a PhD in molecular diagnostics and biochemistry.
SughaVazhvu relies on three sets of protocols. The first captures a patient’s medical information. The second codifies how the tests are to be conducted. The third helps with diagnosis of 20 common ailments, including upper respiratory infections, gastro–intestinal problems, diabetes and hypertension.
When a patient comes to SughaVazhvu, the nurse feeds the person’s symptoms into the computer. The software views the symptoms in conjunction with the patient’s medical history, and recommends diagnostic tests. If the diagnosis is confirmed, the treatment recommended is validated by a doctor and administered. If not, the nurse refers the patient to a doctor.
This model, claims Mor, reduces the need for a doctor. The Medical Council of India mandates one doctor for every PHC. SughaVazhvu has asked the council to allow one doctor to supervise 5–20 centres.
"80% of diseases can be dealt through protocols," says Johar. Dr T Sundararaman, who runs the National State Health Resource Centre, which advises the Central and state governments on the National Rural Health Mission, is unsure. "At a couple of levels, this (SughaVazhvu) is very simplistic," he says. "Diagnosis involves pattern recognition.
I’m not sure you can replace judgement with a database." He doesn’t think technology will make the difference. "Trained nurses will."
Sundararaman also warns about the power and politics in healthcare. "When you are doing pilots, everything is fine. The opposition starts when you try to scale up," he says. "Political boundaries have to be scaled."
These are still early days for SughaVazhvu. It doesn’t have concrete answers on the model or its funding. Each centre entails a capital cost of 5.5 lakh and a running cost of 70,000 per month. ICTPH is funding the entire amount. When it was free, the Alakkudi centre was seeing 120 patients a day. When it started charging 50 per visit, hardly anyone came. It has since reduced the fee to 15, and now sees about 10 patients a day. What makes finding answers tougher is the state chosen for the pilots – Tamil Nadu.
Mor says Tamil Nadu was chosen because its healthcare set–up is good enough to experiment with next–generation questions. But it also means SughaVazhvu is competing with a good, and free public health system. Further, villagers have not grasped SughaVazhvu’s USP: healthcare management.
At the Alakkudi centre, Dr Chitra Ramaswamy says the below–poverty–line (BPL) households first go to the government PHC, but come to SughaVazhvu if they are not cured. The rich come to SughaVazhvu first, but go to Thanjavur if dissatisfied. SughaVazhvu resembles the rural banking pilots of Kshetriya Gramin Financial Services (KGFS), another pilot mentored by Mor. Both seek to replace, to some extent, tacit knowledge with protocols.
Says an industry peer who has seen Mor from close: "Nachiket has managed to create a team that complements him better. That was not the case in ICICI." Also, he says, Mor is spending more time in the field – that too in a limited geography thinking about a limited set of issues. "I see a lot more grounded ideas."
Unlike KGFS, Mor doesn’t see SughaVazhvu being scaled up. "We just want to try different permutations and combinations," he says. The plan is to set up five clinics, all funded by ICTPH, and leave it at that, but discover, perhaps, answers that help reconfigure how primary healthcare is delivered to rural India.
Public Health Models
Since Independence, India has seen myriad attempts to crack the primary healthcare conundrum.
- LOCALS AS BAREFOOT DOCTORS:
Programmes like Chhattisgarh’s Mitanin train local women as community health workers who can treat common ailments and mobilise villagers to demand better services from the government. It has catalysed improvements in the state’s public health system.
- LOCALS AS OUTREACH AGENTS FOR THE PUBLIC HEALTH SYSTEM:
Loosely based on Mitanin, the National Rural Health Mission’s Accredited Social Health Activists (ASHAs) take the ailing to the primary health centres (PHCs). Works only if the PHCs are functional.
- CREATING NON–PROFIT REPLACEMENTS FOR THE PUBLIC HEALTH SYSTEM:
Such projects have been working in rural India for decades now. Take Raj and Mabelle Arole in Jamkhed. Between 1972 and 1992, this doctor couple famously brought infant mortality down from 176/ 1000 to 20. Not a model that scales up.
- CREATE A NEW CADRE OF RURAL DOCTORS:
Assam and Chhattisgarh started a three–year course to produce rural ‘doctors’ who can practice only at the primary level. The Medical Council is evaluating this approach.
- RURAL AMBULANCE SERVICE:
Models like EMRI ferry patients who need secondary or tertiary care to larger hospitals. Works only if the primary centre is functional.
- USING TECHNOLOGY TO SUPPLANT FIELD–LEVEL MEDICAL KNOWHOW:
Sugha Vazhvu’s protocols seek to partly replace doctors with nurses, judgement with technology. Then, there are telemedicine pilots, which involve remote diagnosis.