Transcript Telemedicine Clinics in Rural Uttar Pradesh, India

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Telemedicine as an
Integrated Health
Services Intervention
Rural Uttar Pradesh, India
Terry Lo
Sept. 23, 2008
Uttar Pradesh, India
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Most populous state in India (~190 million)
 75% in rural areas
Low rates of infrastructure and economic development
 per capita income of $290
 72% of households in rural areas do not have electricity
Challenges of Rural Healthcare
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Overall shortage of trained medical personnel
• India- 1700 people to 1 doctor
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Little incentive to serve rural population
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dispersed, poor
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limited opportunities for physicians in rural areas
Public sector can not provide sufficient
coverage of services
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54% have no government health facilities nearby
Challenges of Rural Healthcare (2)
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Majority of rural residents go to private medical
services
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perceived better quality of care
Private sector has little incentive to provide
public health services
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curative services are profitable
Village “Private” Care: Rural Medical
Providers (RMPs)
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Some formally trained, some
not (“quacks”)
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Some highly regarded by the
community
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wide variation in expertise
live in the villages
Usually prescribe
medications with
consultations
Other Options for Rural Medical Care
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Traditional healers, ayurvedic medicine, folk
medicine
Other Options for Rural Medical Care (2)
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“Self-treatment” at the village pharmacy
Other Options for Rural Medical Care (3)
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Take public transportation to the nearest town
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May only be 15km away, but could take half a day
Unmet Family Planning Needs
Women who are capable of having children, are
sexually active, and
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are not using birth control but report not wanting
more children
indicate current pregnancy unwanted
indicate desire for spacing of children
Unmet Family Planning Needs (2)
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Large unmet needs for
family planning in UP
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24% unmet need for family
planning
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40% rural women currently
use contraception
• ~ goal of 60% to stabilize
population
Female Health Seeking Behavior for Family
Planning in UP
Visited a health provider in the
past 3 months
Sought medical treatment for
themselves
17%
Sought treatment for children
48%
Sought family planning
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38%
2%
Women not seeking family planning
43% of rural women who had unmet FP need sought
healthcare
World Health Partners
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New Delhi based NGO
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Goal: To establish telemedicine primary care
intervention in rural UP villages
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integrate family planning services
curative services as a “carrot”
Large scale: 1500 telemedicine provision
centers
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~15,000 villages
~ 30 million residents
Telemedicine Provision Centers (TPCs)
TPC in rural UP
New Delhi-based doctor
• Central Medical Facility
• remotely connected
Real-time audio/visual consultation
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can work at dial-up connection speeds
Neurosynaptic Diagnostic Attachments
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Serial/USB attachments
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thermometer, EKG, heart rate, stethoscope
ultrasound (?)
Location of Telemedicine Provision
Centers (TPCs)
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Relatively near a main road
to town
 for logistics and supplies
Lack of clinics/hospitals
nearby
 RHPs, pharmacies
present in village
Sufficient population to
support a TPC
1 TPC to ~10 villages
TPC Entrepreneurs
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Field staff approach families about becoming
entrepreneurs
Entrepreneurs invest $3000
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WHP provides furniture, computer, satellite
equipment, generator, promotional materials,
technical support, and training
Entrepreneurs operate TPCs as a business
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provide space, attend trainings, maintain and
promote TPCs
TPC Entrepreneurs (2)
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High school
educated women
Computing
experience
beneficial, but not
necessary
Good standing in
the community
Marketing of “Sky Health Centers”
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Promote Sky Health Centers as a franchise
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brand on fliers, banners, ads
Also used to promote family planning
Entrepreneurs
record patient information
• request patient electronic
medical records from server
operate diagnostic
equipment
 print out lab/clinic slips,
prescriptions
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Patient Consultations
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Medical assistants record
medical intake
Doctors
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Central Medical Facility, New Delhi
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review electronic medical
history
“examine” patients
electronically record notes
prescribe medication
software incorporates
diagnosis/treatment algorithms
refer to clinic for follow-up
must offer family planning
Franchise Clinics and Village Pharmacies
Franchise clinics
 WHP partnered with franchise clinics in main
town
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also provide family planning
Patients referred to franchise clinic for:
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follow-up tests/physical examinations
medical procedures
Village pharmacies
 WHP would supply birth control
Rural Health Provider (RHP) Referrals
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WHP developed partnerships with rural health
providers
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Provides training for RHPs
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what conditions to refer patient to TPCs
what emergency conditions to refer to town
RHPs are paid for each patient referred
TPC Consultation Fee
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First week, offered 1Rs
(2.5 cents)consultations
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introduce villages to
telemedicine concept
First months, tried varying
the consultation fee
Settled on 50Rs ($1.25)
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gives value to the service
limits consultations to more
serious illnesses
Consultation Fee (2)
50 Rs consultation fee breakdown
Initial Feedback From Villages
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Ok with telemedicine
50 Rs fee appropriate
willing to pay more if it
helps
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want medications,
testing available at TPC
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do not trust local
pharmacy
 do not want to go into
town for tests
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Informal interviews with patients
and non-patients
“Practical” Concerns
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RHPs charge 20Rs a consultation and give
out medication
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Why would villagers pay 50Rs to only be
referred to town for testing?
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TPCs initially set up to function purely as a
diagnostic service
Underlying Ethical Concerns
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Standardized syndromic diagnosis and
treatment in all likelihood improves patient care
But…
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Don’t UP villagers have the right to have access to
medical tests?
What about treatment?
What is the “medical care standard”?
WHP establishing testing capabilities and offer
common medications at TPCs
Additional Challenges
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Monitoring and quality control
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TPC entrepreneurs
RHP
maintaining a high standard of medical care
Proof of concept
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why not $ directly to family planning services?
economic feasibility of system
• for WHP, for entrepreneurs, for franchise clinics, for RHPs
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Identifying/prioritizing areas in UP with need
In General
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Interventions do not occur in a vacuum
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must consider context
Interventions ideally fit into the “bigger picture”
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broader issues of development and ethical
considerations
Wealth Index (WI)
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In other countries, impractical to use household
income as measurement of wealth
Instead create a composite measurement based
on household possessions
WI is put into quintiles from poor households to
rich
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WI can also be calculated for villages, regions; used
as a relative comparison
Useful for evaluation purposes or identifying
households/areas of need
• Surveys typically also ask about
drinking water source, type of toilet,
housing material
• Can access Demographic Health
Surveys and country specific data
from:
http://www.measuredhs.com/