Under Ayushman Bharat, the Government has pledged to upgrade 1,50,000 sub-centres and primary health centres across India, transforming them into Health and Wellness Centers (HWC) to further its agenda of making comprehensive primary health services affordable and accessible to all. As numerous practitioners and policy-makers have already pointed out, pairing health insurance coverage with quality services on the ground is the key to delivering the full promise of Ayushman Bharat.
What’s the gap
Developing India is faced with a massive epidemiological transition. Back in the 1990s, non-communicable diseases (NCDs), including diabetes, cardiovascular diseases and chronic respiratory diseases, accounted for roughly 30% of the disease burden. Today, they account for over 50%. This drastic shift in the disease burden brings with it the need to reevaluate service delivery at the primary-level, and this is an opportune time to discuss how the HWC model can be leveraged to bring about this much needed transformation.
HWCs are specifically mandated to provide NCD related services, which according to the National Health Mission’s (NHM) operational guidelines specifically includes screening, prevention, control and management. However, so far all efforts towards addressing NCDs at the primary-level are directed towards population-level screening activities. While this is a step in the right direction, it is of little value unless followed-up by a clear and effective mandate for educating patients about prevention and management.
The NHM’s standard treatment guidelines for NCDs place a clear emphasis on promoting healthy behaviours to trigger lifestyle changes which are essential to preventing and controlling NCDs at a population-level. Medical Officers (MO) are responsible for prescribing medication and counselling patients in the clinic, while Multi-purpose Health Workers (MPW) are tasked with conducting follow-up visits to ensure adherence to treatment protocols. However, in reality these services are inadequately delivered; PHCs are often understaffed, and without specialized health counselors and MPWs aren’t equipped with visual or material aids needed to transform a generic set of guidelines into a compelling health intervention. Most importantly, the absence of individual-level lifestyle and behavioral data and sophisticated tracking mechanisms makes it impossible for MOs and policy-makers to track the impact of specific interventions on behaviors and health outcomes.
Enter mobile-based health interventions
MHealth interventions are uniquely positioned to address these persistent gaps in service delivery. Over the next five years, half a billion Indians are expected to become first time internet users thanks to increasing smartphone penetration. This is an excellent opportunity to re-design healthcare delivery in keeping with these trends. Mhealth interventions make it possible to disseminate standardized IEC materials at low-costs and large-scale, collect patient-level medical and behavioural data on meals, activities, medication, lab tests and blood sugar for instance, hyper-personalize treatment plans to better reflect individual lifestyles and deliver real-time support, empowering patients to better manage their chronic health conditions in the long-run.
The Government has experimented with digital platforms to deliver health education interventions in the past. However, consider the mDiabetes program: generic SMSes such as “reduce the intake of fatty and fried foods”, which neither respond to individual lifestyle trends, nor deliver actionable insights or engage with individuals are unable to drive behavioural change.
When intelligently designed, digital lifestyle interventions bring with it the promise of improving outcomes at a patient-level and reducing the burden of NCDs at a population-level. Moreover, artificial intelligence and gamification techniques can be leveraged through mobile platforms to increase patient engagement in-between visits to the PHC and enable MPWs and MOs to deliver continuous monitoring and treatment support remotely, track patient outcomes and medication adherence and schedule follow-up visits. Most importantly, longitudinal population-level data generated through such interventions can prove invaluable when designing new programs or testing innovative interventions for NCD control.
mHealth interventions around the world
There is ample evidence for integrating mHealth interventions within public health systems. The United Kingdom’s National Health System (NHS), for instance, is currently piloting a digital version of its flagship Diabetes Prevention Program (DPP) in eight pre-identified areas across the country. According to the NHS, “the on-line method of recording activity and mapping progress has the potential to have the same impact as face-to-face interventions”. The DPP identifies those at high risk and refers them to a behaviour change program. Under this program, the NHM is testing specific interventions such as wearable technologies that monitor levels of exercise, mobile phone applications which allow access to health coaches, on-line peer support groups and a platform to set and monitor goals electronically.
Admittedly, India is behind the UK in terms of technology adoption; smart-phone penetration is yet to reach its full potential in India and in areas where smartphones are widely used, it is yet to be seen if people will trust their devices beyond social networking and video streaming to access preventive health services. However, early evidence of the success of mHealth interventions which report significant reductions in HbA1c, the gold standard for measuring diabetes, weight loss and increased patient engagement, is encouraging and provides a compelling rationale to test alternative methods of service delivery.
Need of the hour
Ayushman Bharat is in danger of becoming another missed opportunity to reform the health sector in India unless policy-makers place an equal emphasis on both access and quality, and we need not look beyond the implementation of the Right to Education Act to appreciate the importance of both aspects of public service delivery. There is no better time to advocate for technology driven solutions to achieve universal health coverage. And why not capitalize on the digital revolution underway to bring high-quality and low-cost health interventions quite literally into the hands of the people?
Abhishek Shah is the co-founder and CEO of Wellthy Therapeutics.
Shaheen Madraswala is the Public Private Partnerships Lead at Wellthy Therapeutics.
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