Telemedicine%20as%20an%20Integrated%20Health%20Services%20Intervention%20Rural%20Uttar%20Pradesh,%20India

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Telemedicine as an Integrated Health Services
InterventionRural Uttar Pradesh, India
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• Terry Lo
• Sept. 23, 2008

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Uttar Pradesh, India

• 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

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Challenges of Rural Healthcare

• Overall shortage of trained medical personnel
• India- 1700 people to 1 doctor
• Little incentive to serve rural population
• dispersed, poor
• limited opportunities for physicians in rural
  areas
• Public sector can not provide sufficient coverage
  of services
• 54 have no government health facilities nearby

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Challenges of Rural Healthcare (2)

• Majority of rural residents go to private medical
  services
• perceived better quality of care
• Private sector has little incentive to provide
  public health services
• curative services are profitable

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Village Private Care Rural Medical Providers
(RMPs)

• Some formally trained, some not (quacks)
• wide variation in expertise
• Some highly regarded by the community
• live in the villages
• Usually prescribe medications with consultations

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Other Options for Rural Medical Care

• Traditional healers, ayurvedic medicine, folk
  medicine

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Other Options for Rural Medical Care (2)

• Self-treatment at the village pharmacy

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Other Options for Rural Medical Care (3)

• Take public transportation to the nearest town
• May only be 15km away, but could take half a day

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Unmet Family Planning Needs

• Women who are capable of having children, are
  sexually active, and-
• are not using birth control but report not
  wanting more children
• indicate current pregnancy unwanted
• indicate desire for spacing of children

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Unmet Family Planning Needs (2)

• Large unmet needs for family planning in UP
• 24 unmet need for family planning
• 40 rural women currently use contraception
• goal of 60 to stabilize population

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Female Health Seeking Behavior for Family
Planning in UP
Visited a health provider in the past 3 months 38
Sought medical treatment for themselves 17
Sought treatment for children 48
Sought family planning 2

• Women not seeking family planning
• 43 of rural women who had unmet FP need sought
  healthcare

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World Health Partners

• New Delhi based NGO
• Goal To establish telemedicine primary care
  intervention in rural UP villages
• integrate family planning services
• curative services as a carrot
• Large scale 1500 telemedicine provision centers
• 15,000 villages
• 30 million residents

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Telemedicine Provision Centers (TPCs)
TPC in rural UP

• New Delhi-based doctor
• Central Medical Facility
• remotely connected

• Real-time audio/visual consultation
• can work at dial-up connection speeds

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Neurosynaptic Diagnostic Attachments

• Serial/USB attachments
• thermometer, EKG, heart rate, stethoscope
• ultrasound (?)

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Location of Telemedicine Provision Centers (TPCs)

• 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

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TPC Entrepreneurs

• Field staff approach families about becoming
  entrepreneurs
• Entrepreneurs invest 3000
• WHP provides furniture, computer, satellite
  equipment, generator, promotional materials,
  technical support, and training
• Entrepreneurs operate TPCs as a business
• provide space, attend trainings, maintain and
  promote TPCs

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TPC Entrepreneurs (2)

• High school educated women
• Computing experience beneficial, but not
  necessary
• Good standing in the community

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Marketing of Sky Health Centers

• Promote Sky Health Centers as a franchise
• brand on fliers, banners, ads
• Also used to promote family planning

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• 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

• Medical assistants record medical intake
• Doctors-
• 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

Central Medical Facility, New Delhi
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Franchise Clinics and Village Pharmacies

• Franchise clinics
• WHP partnered with franchise clinics in main town
• also provide family planning
• Patients referred to franchise clinic for
• follow-up tests/physical examinations
• medical procedures
• Village pharmacies
• WHP would supply birth control

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Rural Health Provider (RHP) Referrals

• WHP developed partnerships with rural health
  providers
• Provides training for RHPs
• what conditions to refer patient to TPCs
• what emergency conditions to refer to town
• RHPs are paid for each patient referred

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TPC Consultation Fee

• First week, offered 1Rs (2.5 cents)consultations
• introduce villages to telemedicine concept
• First months, tried varying the consultation fee
• Settled on 50Rs (1.25)
• gives value to the service
• limits consultations to more serious illnesses

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Consultation Fee (2)
50 Rs consultation fee breakdown
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Initial Feedback From Villages

• Ok with telemedicine
• 50 Rs fee appropriate
• willing to pay more if it helps
• want medications, testing available at TPC
• do not trust local pharmacy
• do not want to go into town for tests

Informal interviews with patients and non-patients
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Practical Concerns

• RHPs charge 20Rs a consultation and give out
  medication
• Why would villagers pay 50Rs to only be referred
  to town for testing?
• TPCs initially set up to function purely as a
  diagnostic service

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Underlying Ethical Concerns

• Standardized syndromic diagnosis and treatment in
  all likelihood improves patient care
• But
• Dont 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
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Additional Challenges

• Monitoring and quality control
• TPC entrepreneurs
• RHP
• maintaining a high standard of medical care
• Proof of concept
• why not directly to family planning services?
• economic feasibility of system
• for WHP, for entrepreneurs, for franchise
  clinics, for RHPs
• Identifying/prioritizing areas in UP with need

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In General

• Interventions do not occur in a vacuum
• must consider context
• Interventions ideally fit into the bigger
  picture
• broader issues of development and ethical
  considerations

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Wealth Index (WI)

• 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
• WI can also be calculated for villages, regions
  used as a relative comparison
• Useful for evaluation purposes or identifying
  households/areas of need

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• 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/
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