Integrated Primary Healthcare for Women

Access to Sexual and Reproductive Health (SRH) services of sufficient quality is a challenge in India. Most hospital Obstetrics/Gynaecology departments provide a narrow range of services focused around childbirth. Comprehensive pregnancy care that involves holistic ante-natal care, post-delivery follow up, breastfeeding support, contraception/sterilisation and immunization etc. is lacking, especially outside of major cities. Access is further compromised during extreme weather events and exceptional situations such as COVID-19. 

We provide year-round access to essential SRH services, medicines and menstrual hygiene products, by community nurses and climate-resilient primary health units. Gatekeeping function ensures that all patients receive the care they need, and only the care they need. This improves trust levels between healthcare providers and the community. This brings in more people to the formal healthcare system. Hospital revenues improve, even though per capita health care costs decrease. Our work potentially integrates thousands of private hospitals in India via unitfied primary healthcare.

Life-saving medical interventions related to Maternal and Newborn health are not available to those who need it, at the same as being over-supplied to others in India. World Health Organization (WHO) recommends a 10% to 15% benchmark of Caesarean Section (C.S.) rates as 'normal'. Accordingly, there is a yearly deficit of 0.5 million C.S. in India (surgery not done where indicated). At the same time, there is an estimated annual excess is 1.8 million C.S. in India (surgery done where not indicated medically), with more rapid increase of C.S. rates seen among affluent social groups and regions  (both in India as well as parts of middle east and latin america). 

Stigma, lack of privacy, lack of time, direct and indirect costs of visiting Gynecologists are all reasons why hospital-based family planning has poor uptake in the community. Satisfying unmet need for contraception could prevent 104,000 additional maternal deaths per year (29% reduction) by 2008 figures. The 'Three Delays' that contribute to poor maternal and child health are addressed by effective community-based primary healthcare. Access to good quality perinatal care for mothers in time can significantly reduce pre-term delivery, asphyxia or sepsis; all of which are linked to adverse neonatal outcomes.

Trained Nurse/Midwives and General Practitioners (GP) provide essential Reproductive Healthcare services in the community. Health Centers (HC) are located strategically to provide all-year access, even during extreme weather events. Our GPs and nurses team up with Gynaecologists and other Specialists placed with partnering hospitals. Digital health records integrate between activities undertaken in different care settings. Specialist telemedicine consultations are possible via mobile application or by visiting a PHU in person. GPs make home visits to follow up on tele-consultations as indicated. Nurses ensure year-round delivery of pharmaceuticals and hygiene products. 

Our intervention removes key bottlenecks preventing access to hospital-based SRH. These include physical reasons (flooding, lack of transport), social reasons (stigma, lack of privacy), financial cost (direct cost of hospital-based care or indirect costs of prolonged inpatient stay) or (currently) fear of contracting COVID-19. Specialist outpatient services will shift from hospitals to HC, as hospitals try to mitigate risk of closure due to COVID-19 transmission. Digital technologies and home based care will facilitate non-intensive care provision at home. GPs perform ‘gatekeeping’ function, avoiding either extremes of too much or too little of specialty care.

We target two demographics: those living in rural areas as well as the urban and peri-urban poor. Our services are of value to gender minorities who continue to face various obstacles to access respectful SRH services. We help hospitals to continue serving the community while reducing risk of COVID transmission. We also help civil government to ensure continued access to healthcare during extreme weather events. We can also potentially help international humanitarian situations.

We are currently speaking to GPs and nurses, in addition to the general population, to understand their expectations and priorities. Hospitals  foresee benefit from more patients coming into the formal care system, and new revenue streams from telehealthcare and domiciliary care. As a rights-based organisation, we guarantee respectful care to all women and couples, irrespective of marital status, sexual orientation or gender identification. Our pilot is planned in Kuttanadu wetlands, a below sea-level farming region in Kerala that saw massive flood-related displacement of people in 2018 and 2019. We engage credible local NGOs to capture the perceived quality of care received by patients. Our use of WHO-recommended Robson audit to objectively assess that C.S. rates help improve trust levels between the community and private healthcare system.

Primary Healthcare that integrates medical specialties, humanities and nursing sciences represents the optimal balance between healthcare access, quality and cost to pregnant women and newborns. While India's urban poor and those in rural areas benefit more, the ability to provide last mile connectivity during situations such as COVID and extreme weather events make it relevant to entire population (hence this application also fits under the 'health security and pandemics' challenge). Our approach to maternal health within rights-based SRH paradigm addresses unmet need for family planning, itself a major cause of poor maternal and neonatal outcomes. 

Our innovation uses digital technologies to strengthen the primary healthcare system, unlike most others who seek to extend reach of tertiary care centers bypassing GPs. We do this by leveraging the potential of cloud-based electronic patient management systems to integrate between care delivered at different physical locations by multiple providers. Telemedicine provides opportunity for improved access to care during COVID-19 and extreme weather events. Most healthcare in India continues to be centralised, focused around tertiary care hospitals (with equity implications for those from rural or poorer backgrounds). Digital health companies are mostly led by persons with IT background, who sometimes have an incomplete understanding of quality considerations in healthcare. We combine academic rigour, deep understanding of clinical medicine as well as the potential of digital healthcare to strike the optimum balance of access, quality and cost to patients.

Our organisation is built from the ground-up to be dynamic and tech-friendly within a people-centric culture. Our employees and associates provide broad spectrum of high quality Sexual and Reproductive Healthcare to all, irrespective of marital status, gender identification or sexual orientation etc. We hire locally, particularly from among gender minorities and other vulnerable social groups, generating livelihoods. We partner with local governments/NGOs to independently audit perceived quality of care as well as to create pooled payment mechanisms that make our services free at point of delivery. Our health units are designed to be carbon neutral, and we partner with urban mobility providers to operate a fully electric fleet, including mobile clinics. 

Electronic Patient Management systems, such as the Microsoft Cloud-for-Healthcare enable coordination and integration between activities and processes carried out across different sites. The SaaS platform allows patients and healthcare providers at various levels and locations to collaborate in treatment-related decisions. AI-integration enables more personalised healthcare recommendations, as our dataset grows over time. Telehealthcare integrated with health information captured from wearable devices at home enables better chronic disease management. Guttmacher-Lancet Commission Report (Accelerate progress—sexual and reproductive health and rights for all) have defined evidence-based package of high impact Sexual and Reproductive Healthcare (SRH) services. We define training programs for GPs, nurses and Gynaecologists on providing rights-based SRH, with a mix of in-person and online training. Our organisation is conceived as dynamic and nimble, to fully utilise the technological possibilities of integrated care in a way that current tertiary care-centred paradigm struggles to leverage. We move away from traditional 'value shop' approach to participatory 'value networks' in healthcare, in the process addressing crucial gaps in current health services delivery.

Cloud-based patient managment systems, such as the Microsofy Cloud-for-Healthcare, have developed over the past decade into robust platforms that are inter-operable with existing hospital EMR. During COVID, most healthcare organisations have sharply pivoted to telemedicine, to avoid risk to themselves as well as community at large. However, evidence shows that digital health should be 'blended' with in-person care for best results (eVita Study, Talboom-Kamp et al). Tertiary care hospitals in India, such as Narayana Health (where I worked previously) have been at the forefront of adopting digital health, and the public health system in Kerala have piloted the 'e-Sanjeevani' initiative for digital health. Both of these are not integrated to routine in-person care, unlike our intervention. With digitally integration to hospital-based care, and guided by evidence by treatment protocols, our GPs are able to provide effective gatekeeping function for access to healthcare services. My own research in the subject points to the importance of pooled payment mechanisms in ensuring Universal Health Coverage. Our services are brought under pooled payment mechanisms guaranteed by local governments, digital health records enabling transparent audit of surgical rates and quality of care.

T. Ahlin, M. Nichter, and G. Pillai, ‘Health Insurance in India: What Do We Know and Why Is Ethnographic Research Needed’, Anthropology and Medicine, 23.1 (2016)

Trained Nurse/Midwives and General Practitioners (GP) provide essential care in the community. We begin with women's health as a, before moving to other high gap areas such as Cancer Care or Dementia.  Primary health units (PHU) are located strategically to remain open and accessible during extreme weather events. Our GPs and nurses team up with Gynaecologists and other Specialists placed with partnering hospitals. Digital health records integrate between activities undertaken in different care settings. Specialist telemedicine consultations are possible via mobile application or by visiting a PHU in person. GPs make home visits to follow up on tele-consultations as indicated. Nurses ensure year-round delivery of pharmaceuticals and hygiene products.

Our intervention removes key bottlenecks preventing access to hospital-based SRH services. These include physical reasons (flooding, lack of transport), social reasons (stigma, lack of privacy), financial cost (direct cost of hospital-based care or indirect costs of prolonged inpatient stay) or (currently) fear of contracting COVID-19. Specialist outpatient services will shift from hospitals to HC, as hospitals try to mitigate risk of closure due to COVID-19 transmission. Digital technologies and home based care will facilitate non-intensive care provision at home, with equity implications beyond SRH. GPs perform ‘gatekeeping’ function, avoiding extremes of too much or too less of specialty care.

All this will lead to improved access to care, free at the point of delivery to patient. Hospitals benefit from more patients coming into the formal care system, and new revenue streams from telehealth. In the long run, ‘Women’s Health’ that is much broader in scope than hospital-based Gynecology services will become the norm in communities we serve. Trust levels between community and health system will improve, leading to reduction in litigation and violent incidents in hospitals in case of adverse outcomes. Healthcare becomes a decentralized system, networked PHC teams engaged in co-creation of value with intended beneficiaries, all the while integrated to hospital-based care. By doing so we shall ‘mainstream’ respectful rights-based SRH care in India.

4. Starrs, A. M.et al. Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission. Lancet 391, 2642–2692 (2018).

Project is in advanced ideation stage, we intent to serve 1000 patients by end of 12 months of pilot program in Kuttanadu Wetlands, a below sea-level ecosystem in Kerala, India that experiences significant burden of climate-change related risks. In 5 years we will have presence in other parts of Kerala and three South Indian cities (Chennai, Coimbatore, Bangalore) with a combined population upwards of 20 million. We will also start work in Fiji, in collaboration with Medical Services Pacific.

Access to Sexual and Reproductive Health (SRH) services of sufficient quality is a challenge in India. Most hospital Obstetrics/Gynecology departments provide a narrow-range of services focused around childbirth. Comprehensive pregnancy care that involves holistic ante-natal care, post-delivery follow up, breastfeeding support, immunization etc. is not widely available in the country. Other aspects of SRH (including sexual health, contraception and abortion, screening for gynecological cancers etc have much lower coverage as well). 

Nearly half the respondents in an online survey of 500 middle class women conducted by the market research firm IPSOS in 2018 reported that they visited or consulted with an Obstetrician/Gynecologist once a year or less. India has an estimated shortfall of 500,000 C.S. yearly, at the same time as 1.8 million surgeries done without medical indication. Access is further compromised during extreme weather events and exceptional situations such as COVID-19. Kerala state has experienced back to back massive floods over the past couple of years. Cumulatively, almost a million people were displaced and infrastructure losses of nearly 3 Billion USD have been attributed to flood-related damages. 

India has announced massive health insurance program 'Ayushman Bharat', which is also expected to cover telemedicine services. Our organisation enables that these funds are utilised in a way that strengthens the primary healthcare system, and does not lead to further fragmentation of the health system. We hope to achieve the goal of integrated people-centered health systems promoted by the joint WHO-UNICEF vision for primary health care in the 21st century. 

Gynecologists provide most primary women's healthcare in India, as such we expect sceptisism towards quality of care that is delivered via non-specialist doctors and nurses. Compared to rest of India, Kerala has many more hospitals and better road connectivity, which may further reduce uptake. The public health system is well functioning, many primary health clinics have been recently upgraded as family health clinics with basic specialties available. The state is also early adopter of digital health technologies. Culturally, there is likely to be some resistance to respectful sexual and reproductive healthcare to all persons irrespective of marital status. Many of our own employees are likely to internalise these values, and digress from the core mission of participatory, rights-based healthcare. Our most immediate challenge is accessing seed funds to pilot the intervention, considering that state government is under massive financial strain due to COVID and rebuilding after extreme weather events.

We focus on addressing crucial gaps in healthcare delivery during COVID-19 and extreme weather events. We develop a well-trained workforce that can exceed expectations of quality, at substantially lower costs and easier to access. We will seek that our services be covered under state-supported community health insurance, such that our services are free at point of care. We will provide a level of integration between different care settings and between in-person care and telehealthcare, that is not hitherto provided by either the public sector or the private sector. We clearly communicate the organisational mission and guiding values prior to selection to all our employees. Through a mix of training and third-party evaluation of quality of care, we ensure that our organisation adheres to these values at each step. Thus we not only counter sterotypes of what constitutes 'good' care, but also work towards a new vision of healthcare that is based on dignity of every individual.  Kerala state government is committed to protecting the rights and dignity of gender minorities, we form broad alliance with NGOs operating in this space. We engage with the communities we serve in a way that either the public health system or the corporate private sector is unable to.

No permanent team at the moment other than co-founders.

I am an experienced Palliative Care physician, with experience of designing and leading telehealthcare project for major corporate group in India. Currently I am finishing the International Course in Health Development at KIT Royal Tropical Institute Amsterdam, a WHO-collaborating center on Gender and Health System Strengthening. My co-founder is a practicing Obstetrician/Gynecologist working in India.

We are working closely with NGOs, such as the M.S.Swaminathan Research Foundation in Kerala and KIT Royal Tropical Institute (formerly known as the Colonial Institute) Amsterdam. Guided by the Sustainable Development Goals (SDGs) of the United Nations, KIT focuses on health care, gender, economic development and intercultural cooperation (kit.nl). The Amsterdam Health and Technology Institute (ahti.nl) was founded in 2014 by the City of Amsterdam, with a mission to ‘improve urban health and healthcare by connecting people, technology and medical knowledge through innovation and entrepreneurship’. AHTI’s expertise on urban health is important to Kerala, which undergoing rapid urbanisation, much of it unplanned. We are also in talks with the Obstetrics/Gynecology society of India (FOGSI) to endorse the project.

We work with local governments to cover our services under tax-backed community health insurance, such that there are no user fees for access to essential services. These include pregnancy care that involves holistic ante-natal care, post-delivery follow up, breastfeeding support and immunization. We charge patients for value-added services, such as GP home visits and inpatient care at home. Nurses sell feminine hygiene products and contraceptives. We also charge user fees for extended post-pregnancy care based on indigenous knowledge practices.

Initially we work as a B2B, enabling hospitals to develop primary health/digital capabilities. We will need viability gap funding to recruit and train GPs and nurses, as well as to offer our services at competitive price point. Our path to sustainability depends on being acknowledged as a valuable gate-keeping primary healthcare provider that saves money for the government. Our basic benefits should be covered under pooled payment mechanisms guaranteed by the goverment, such that there are no user fees at point of service delivery. At this point, we adopt a primarily B2C business model.

Solve could give us the headstart to go into business this fall. Our business model requires support from government by coverage under pooled payment mechanisms, which will receive a boost if Solve were to support us. We wish to partner with established corporates, particularly those with technological capability in Electric Vehicles and SaaS for healthcare. Solve has the unique ability to put us in touch with people and resources from across the world, from whose experience we might learn and refine our own business model. This is important because our experience in entrepreneurship is limited at this point.

We wish to reach out to Microsoft, as an official partner. We can provide a perfect use case that demonstrates the capabilities of Cloud for Healthcare SaaS platform. Similarly, we wish to reach out to captains of Indian industry, particularly those with expertise in electric vehicles. We wish to receive support and guidance to refine our business model, from advisors who have entrepreneurial experience. 

Microsoft for cloud, for SaaS.

Anand Mahindra, for partnership with Mahindra for fleet maintainance. We have particular interest in EV segment and mobile clinics that the company have developed.

Kiran Mazumdar Shaw: As a potential lead investor and technical partner for pharmaceutical supply chain management.

Our intervention is directed to improve access to respectful healthcare for girls and women of all ages. We also create sustainable livelihoods for nurses and many female General Practitioners currently out of work due to life course related events. We do this by providing training and a flexible way back into the workforce.

We train and upskill nurses and General Practitioners such that they are able to provide value in primary healthcare, not simply triage and refer patients to referral centres. Continuing education is built into our organisational processes, including humanities and law. We do this by a mix of in-house and online training that we provide in house. Further, we advise and facilitate distance learning from a range of accredited educational institutions. We allow for steady career progression based on skills gained, both for doctors and nurses. 

We will deepen our linkages with the community, by investing in a sustained advocacy campaign on the value of primary healthcare, and why it is superior to narrow hospital-based gynecology services. We will establish a mobile clinic focusing on the urban poor in Kochi, parallel to the health centres in Kuttanadu.