Opinion: Understanding effective service delivery for rural health care

A community health worker enters data into the Wireless Health Incident Monitoring System installed on her mobile phone, developed by iKure. Photo by: iKure

What differentiates a high performing health service delivery model from an ordinary service delivery system? Over the years, with the exponential rise in health care spending, health practitioners are increasingly looking for affordable and value-added service models as the key ingredient for delivering effective care.

However, there are number of factors that explain why a strategic delivery model works while some lag behind. Is it the culture, leadership of the organization, or the unique community it serves? Identifying the key approaches that underpin the success of a delivery model is essential to ensuring that similar models can be developed elsewhere to deliver high-quality and affordable care.

Care in rural India continues to face myriad challenges related to accessibility, affordability and quality of services. With the rapid growth of India’s health industry, over half a billion people (50 percent of India’s total population) are served by only 30 percent of the combined medical force. More than 66 percent remain deprived of basic primary care and over 50 percent travel 20-30 kilometers to reach distant hospitals.

Despite deployment of an innovative health care model, the health needs of rural communities are still not adequately served. With long distances to access care and an ongoing rise in health care costs, rural residents continue to show poor health outcomes. While traditional health care delivery systems focus on treatment and curative services, the root cause of diseases are greatly influenced by rural determinants that remain poorly addressed.

Given the diversity of rural communities, evidence suggests that no single model can adequately serve the health needs of the community members. In contrast, rural communities require alternative approaches to health care and models of service delivery must take into account geographical, economic, social and cultural factors that varies between communities across the rural population.

The focus of a service model should be on ensuring that community needs are met and positive health outcomes achieved.

The use of technology is bringing with it changes to rural health service delivery. With numerous applications, technologies such as telemedicine offer greater access and affordability of services, particularly among rural population. However, evidence suggests despite significant government efforts, telemedicine has not reached scale and fulfilled its potential for huge impact if applied in a disruptive fashion.

In this context, it is important not to view the adoption of technology as a desirable outcome of innovation; rather a disruptive approach that addresses the old traditional system in a cost-effective manner is the key to measure effectiveness of service delivery model.

In designing health care innovation, the focus should be shifted to transformative change with a bottom-up approach. As we need technological advances to cure diseases, disruptive innovation is all about empowering community members to provide treatment that usually requires a doctor’s intervention.

Similarly, we need innovation for diagnostic and therapeutic care that can enable procedures to be cost-effective and can be done in convenient settings which otherwise require a hospital visits. Implementation of such technological solution will mobilize grass-roots members to provide care within their community, induce empowerment, reduce frequent interventions by doctors and enable practitioners to focus on patients that require critical care.

Health care innovations in practice

iKure Techsoft, together with the University of Michigan and the Deshpande Foundation, has developed an interactive tool for maternal and child health care monitoring and routine assessment used by iKure community health workers in the states of West Bengal and Karnataka, India. This mobile application identifies women at high risk of pregnancy complications in particular (anemia and preeclampsia) to ensure referral and institutional delivery, and screens children the age of 12-24 months with a validated screening tool to identify early symptoms and patterns concerning developmental delays that can be referred to specialists for further management. The application records the interactions of the community health workers administering the questionnaires and tests for the efficiency of conducting questionnaires digitally.

Another example includes the SMARThealth program of the George Institute for Global Health India, developed in collaboration with the Institute of Biomedical Engineering at the University of Oxford, and implemented in rural Andhra Pradesh. This program identifies patients at the risk of developing cardiovascular disease(s) and enables the choice of optimal treatments, using standardized, evidence-based approaches with the help of a simple decision-support algorithm — referring high-risk patients to medical practitioners at the nearest primary health center.

Closing the gap in rural health status and improving distribution and equitable access to services calls for the adoption of preventive approaches. Health inequalities are closely associated to social, economic and cultural behavior that can be greatly reduced through preventive and health promotion approaches.

During a field survey conducted by iKure in 15 villages of Haveri district in Karnataka state, pregnant women were reported to be highly anemic and underweight. The reason was women avoided taking folic acid and iron tablets fearing their babies would bear a big head. As a result, they ate less and avoided taking any nutritional supplements.

However, the situation after one year’s intervention has changed: “Through Communication for Behavior Change,” iKure’s community health workers are advocating behavior change, promoting need of institutional deliveries and importance of seeking neonatal and postnatal care. This cadre of health workers are selected from the community and trained to motivate and provide enabling information around pregnancy and child health development.

Thus, in the quest for an effective delivery model for rural and remote communities, the focus of health services should be on ensuring how community needs are met and how transformative changes can be inculcated within the system.

While engaging the community is a transformative move where they themselves becomes the driver of change, any other structural changes should also be encouraged. It is necessary to ensure that service delivery model should relate to contexts in which health needs arise and health practitioners operate.

For example, in seeking to maximize rural health outcomes, health practitioners could offer real opportunities to establish more integrated and focused patient care.

New models, technology implications and integrated approaches should be a part of well thought out plan that responds to local needs, addresses key determinants of health, and focuses on promotion of health rather than curative treatment alone.

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