1. Telemedicine as an Integrated Health Services Intervention Rural Uttar Pradesh, India Terry Lo Sept. 23, 2008

2. 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

3. 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

4. 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

5. 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

6. Other Options for Rural Medical Care Traditional healers, ayurvedic medicine, folk medicine

7. Other Options for Rural Medical Care (2) “Self-treatment” at the village pharmacy

8. 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

9. 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

10. 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

11. Female Health Seeking Behavior for Family Planning in UP Women not seeking family planning 43% of rural women who had unmet FP need sought healthcare Visited a health provider in the past 3 months 38% Sought medical treatment for themselves17% Sought treatment for children48% Sought family planning2%

12. 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

13. Telemedicine Provision Centers (TPCs) Real-time audio/visual consultation can work at dial-up connection speeds TPC in rural UP New Delhi-based doctor Central Medical Facility remotely connected

14. Neurosynaptic Diagnostic Attachments Serial/USB attachments thermometer, EKG, heart rate, stethoscope ultrasound (?)

16. 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

17. 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

18. TPC Entrepreneurs (2) High school educated women Computing experience beneficial, but not necessary Good standing in the community

19. Marketing of “Sky Health Centers” Promote Sky Health Centers as a franchise brand on fliers, banners, ads Also used to promote family planning

21. Entrepreneurs- record patient information request patient electronic medical records from server operate diagnostic equipment print out lab/clinic slips, prescriptions

22. 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

24. 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

26. 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

27. 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

28. Consultation Fee (2) 50 Rs consultation fee breakdown

29. 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

30. “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

31. Underlying Ethical Concerns Standardized syndromic diagnosis and treatment in all likelihood improves patient care But… 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

32. 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

33. 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

34. 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

35. 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/