A healing touch

Poverty and the lack of resources prevent most people in rural India from accessing primary healthcare.

But there is hope in the form of Arogya Ghar, a self-sustainable social venture by Dr Bhagwati P Agrawal. Sachin Joshi writes on how it computerised medical protocols for common and preventable ailments to make medical knowledge and primary healthcare accessible to many.

Poverty prevents most people from accessing primary healthcare for common ailments and preventable diseases such as respiratory infection, reproductive tract infection, measles, malaria, pneumonia, minor injuries and diarrhoea. Though the government has instituted several healthcare programmes, these programmes have proved to be inadequate due to a chronic shortage of trained medical staff and the lack of standardised treatment protocols for preventable diseases.

Medical professionals find treating patients in villages economically unrewarding because the villagers don’t have the money to pay competitive fees for healthcare services. At many places, there are no standardised protocols for treating common ailments. This adds to the problems of an acute shortage of trained health professionals.

One of the ways to solve the problem is to leverage IT, train local community in basic healthcare skills that also generates self-employment, and effectively deliver low-cost healthcare services.

Along with his seed money provider and entrepreneur Atul Jain, Dr Bhagwati P Agrawal used science, engineering and entrepreneurship to build self-sustainable social enterprises that would deliver low-cost healthcare service in the rural areas of Rajasthan. Agrawal got a $200,000 (about Rs 90 lakh) grant from the World Bank for Arogya, and help for computerisation from Atul Jain at TEOCO in Fairfax, Virginia.

Dr Agrawal is the founder and executive director of Sustainable Innovations. In 2006 he had won the World Bank Development Marketplace Award for domestic rainwater harvesting. In 2007, he bagged the same award for Arogya Ghar. An alumnus of the University of South Florida, where he received his PhD in engineering science, and of MIT Sloan School’s Executive Management Programme, Dr Agrawal was named the Purpose Prize Fellow by Civic Ventures in 2009.

Arogya’s approach is simple — to make medical knowledge accessible to the rural population. This is achieved by computerising medical protocols for common ailments and preventable diseases. Generically, the best medical practices are reduced to simple interactive algorithms.

The objective of Arogya Ghar is to reduce the incidence of common ailments and preventable diseases through the establishment of kiosk-based, self-sustainable clinics in rural Rajasthan to provide affordable healthcare to the poor.

Arogya Ghar delivers primary care for an average cost of $0.25 per visit — a price affordable even for the poorest. The cost saving is the result of an innovative method of delivering diagnostic information and training to health workers.

A system of computerised protocols shortens the training time for health workers and overcomes absenteeism to increase the pool of available healthcare workers. The innovative computer kiosk system provides simplified best practices and computerised disease protocols, and it captures clinical demographic data. The kiosk assigns every child a secure and unique health identifier number. A patient’s medical history can be retrieved using this number. Mothers can seldom recall the vaccination dates of their children. They often associate dates with events in family or festivals. With the kiosks, children have a longitudinal history of immunisation.

Arogya is equipped with a protocol for child immunisation, be it for measles, mumps, rubella, hepatitis B, TB, diphtheria, or tetanus. Dr Agrawal’s friends, including doctors S P Sudrania, Suman Kapur, and Alok Tyagi, computerised medical protocols for 15-20 prevailing common and preventable ailments such as diarrhoea, anaemia, tuberculosis, asthma, respiratory infection, reproductive tract infection, malaria, and also vaccinations.

The unique health identifier number or the UHI of each child would maintain a health maintenance report and help track the child’s progress. For chronic diseases such as asthma and diabetes, Arogya may create a daily diary for each child or adolescent and this will record lung capacity or sugar levels.

These diaries are to be reviewed by paediatricians in a nearby town or at Indian Institute of Health Management Research (IIHMR). In case of non-preventable diseases, Arogya would send the clinical data to specialists for a simple form of telemedicine.

The growth in capacity entails replication of Arogya from one village to another in a region or from one region to another. The IIHMR has the management facilities and training facilities to train up to 1,000 health professionals per year.

Arogya can be implemented along with the National Rural Health Mission, a health programme sponsored by the Indian government. The government has the qualified staff to modify the medical protocols required while replicating the Arogya model in other areas.

Many companies sell products or services in a rural community through sales events or through door-to-door campaigns. Arogya does this through social entrepreneurs. Under the system community members own and operate health kiosks. Armed with proper training and equipment, community members are empowered to become the owners of their own micro-businesses.

The social entrepreneurs created as part of Arogya Ghar are governed by a policy set by an advisory board consisting of social workers, local governance and accredited social health activists on issues like subsidised care for people below the poverty line. Villages contribute to a revolving fund to replenish medicine stocks.

The kiosks are owned and operated by these high school-and college-educated social entrepreneurs, who have been given several weeks' training at IIHMR to run for-profit ventures. There is control in the sense that physicians track the performance of the local health workers from captured data and take remedial measures, if required.The kiosks provide instructions in multiple languages to cater to multi-lingual and multi-cultural populations, but the graphically-driven kiosk requires minimal language proficiency for health workers to enter the data — demographics, chief complaints, symptoms, etc.

Arogya has the ability to grow both in capability, as in the number of ailments addressed, and capacity, that is, the number of patients. Capabilities may be along several dimensions such as child development and immunisation, telemedicine, and chronic disease treatment.

Building and managing a micro-distribution network can be labour-intensive, but reaching out to the local population may be easier because it involves the services of local women that have a higher acceptability.

Arogya Ghar has the potential to benefit 40,000 villages with a vulnerable population exceeding 27 million inhabitants.

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