Monday, September 03, 2007

How do we improve healthcare services for the poor in urban slums ?

The dismal state of healthcare delivery in rural India has been documented many times, but comparatively little attention has been paid to the plight of the urban poor. Even though Bombay is India's medical capital, healthcare services for the poor here are even worse than they would be in a remote village. It is true that there is no shortage of doctors and hospitals in Bombay, but most of these are in the private sector, which means they are simply unaffordable for the poor - a tragic example of famine amongst plenty.

The poor mostly live in overcrowded slums where they are afflicted by a double whammy. Not only do they fall prey to the common infectious diseases which are the bane of poor countries, they are also increasingly afflicted by the chronic diseases usually associated with richer nations, because of urban stress, pollution and an unhealthy lifestyle.

While the government does provide free medical care, this care is often of poor quality. Government clinics are under-staffed and are always short of supplies. This means that a poor slum-dweller may have to spend the better part of the day waiting in line to see a doctor at a government clinic. While the doctor's consultation is "notionally" free, the patient still has to spend money on buying drugs and medicines. Even worse, because the system is so inefficient ( lines in the OPD ( outpatient department) of hospitals are extremely long and the wait to see a doctor can be interminable), most people simply cannot afford to take a day off in order to seek medical attention. Since they are daily wages earners and live from hand to mouth, making a trip to the hospital to get "free medical care" exacts a huge financial toll in the form of lost income.

This means that they are forced to put off going to the doctor and they often live in the hope that the problem will improve on its own. However , because of inadequate and delayed medical attention, simple medical problems become complicated and minor illnesses become major diseases. When matters get out of hand and they are finally forced to go to the free hospitals, insult is added to injury, because the doctors criticise them for not having come earlier ! Not only are healthcare workers at these hospitals rude, they are often burntout themselves, because of their huge workloads, as a result of which a bad situation just becomes worse. Many poor patients prefer going to private hospitals, because they are looking for "value for money" and are willing to pay for it, even though they cannot afford it !

So, what is the solution ?

The knee-jerk reflex has been - Provide them with more hospitals or subsidised medical care. This is not an effective long-term solution, and is simply a form of " band-aid medicine".
The only effective solution will be to rely on the one resource which is almost inexhaustible—the people themselves. It is within these millions that we can tap India’s greatest resource for combating diseases. The principle is simple - educate them so they can manage their own problems.

Of course, this is easier said than done. This is a daunting task, and the challenges are enormous. However, the biggest mistake we make is to assume that the poor are incapable of tackling their own problems. We forget to give them credit for the fact that they have the street-smarts to survive in conditions in which most of us would not be able to last even one week ! Surely they are capable of looking after their own health if we give them the right tools to help themselves .

That's the rub - we need to adapt what we provide, so that it makes sense to them and is useful for them - and this is something we have failed miserably at, because we do not respect them enough to ask them for their opinion or feedback.

The barriers are numerous and these include:

  • The fact that literacy skills are limited
  • Time is at a premium for most of the men
  • There are very few educational materials designed for their wants
  • They have a very limited ability to pay

On the other hand , there are a number of hidden resources we can tap into
  • The numbers are huge, and women , children and the elders who stay at home will have plenty of time
  • Even though they may be illiterate, they are street-smart
  • They are easier to reach, because they are concentrated in small localities - slums have extremely high population densities
  • Labour can be extremely inexpensive, which allows us to implement solutions which can never be cost effective anywhere else !
  • The potential ROI ( return on investment) is huge, because we can affect such a large number of people.
We need to change our focus. Instead of trying to provide healthcare services which need specialists and doctors, we need to tap the people themselves. The poor are smart and motivated , and are very capable of solving their own problems, if we give them the right tools and teach them how to use them.

An excellent example of this is the revolution which has occurred in the area of microfinancing.
When given money and the freedom to use it as they see fit , poor people come up with remarkably innovative ideas which could never have been planned, designed or anticipated by outsiders !

Information Therapy - the right information at the right time for the right person - can be powerful medicine ! The key is to develop materials which are right for them - and the right information is information which they will want to watch and can learn from. People prefer watching graphics, so we need to develop materials which are graphic intensive - either in the form of animations; or videos.

The good news is that modern technology has made creating and sharing graphics extremely easy, so patient educators ( from the community itself) can build their own customised health video libraries with ease ! A simple example would be to find an articulate doctor with excellent communication skills, and to record a doctor-patient consultation with her about the top ten common clinical problems. These videos could then be watched on cable TVs, which many slums do have . If the programs were entertaining, they would be a very valuable means of educating people and could be used over and over again. Patients would find them much easier to relate to, since the videos are in their own language; deal with their immediate personal concerns; use local characters they can identify with; and provide local solutions which they are familiar with .

Chronic diseases such as diabetes, cancer and heart disease are now becoming an increasing problem in urban slums. Each slum is likely to have an "expert patient" who has learnt to live well with their chronic disease. We need to find these success stories - and this patient can then be interviewed on video, so others can learn from his experience.

Videos could also be created on how to talk to doctors and how to navigate the healthcare system if hospital care is needed.

Another simple example would be to publish a series of animated graphics and cartoons about common health problems and how to treat them.
An example of this is at One way of looking at this would be to think of it as a video version of the classic text - Where There Is No Doctor . A modular library of such graphics could then be published online as "open source content" ; and patient educators could download and dub these in local languages . This version can then again be uploaded to google video - and shared with other patients from all over the world. In fact, these could even be adapted for each slum's local living conditions. As the technology improves, it will soon be possible to deliver this graphic educational content on the third screen which is quickly becoming universal even in slums - the mobile phone.

Isn't all this too expensive ? In fact, it's too expensive not to do it ! Human capital is India's most precious resource and we cannot afford to squander it ! Patient education, if done properly, can provide a terrific return on investment. We have the technology , the tools and the manpower - let's do it !

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