Health Agency for Rural Populations

Health outcomes depend on a complex combination of determinants that range from access to resources, behavior, and social structures. In rural villages of India, poverty, patriarchy, caste, and vast distances have beget strained health ecosystems. Individuals have limited access to knowledge around healthy behaviors, access to resources, and the agency to link behaviors with outcomes. While there are systems in place to deliver last mile services and generate data,  This data is restricted to accounting for what actions or distributions an actor has taken. The crucial measure of outcomes and impacts for users are wholly missing. Full delivery of services is unknown, possible interventions and simple behaviors are rendered inaccessible,  utilized too late or totally underutilized, and there is a disproportionately negative effect on women and marginalized communities. These gaps exacerbate the existing realities for the rural poor, including severe hunger, intergenerational malnutrition, debt due to health care expenses, and preventable deaths.

Two of the key health outcomes that face these regions are malnutrition and rising non-communicable diseases. Malnutrition has long-term impacts on maternal and child health, including maternal mortality and stunting in children. Anemia is one of the leading indirect causes of maternal mortality and causes long-term negative impacts on children's development. According to the National Family Health Survey 5 for rural Bihar and Jharkhand 64.9% of women aged 15-49 are anemic. In children, this number rises to 67.8% and 43.1% are stunted.
Also, Over 160 million people in India suffer from diabetes. As per the latest National Family Health Survey 5 and International Diabetes Federation reports, the number of diabetes patients is growing every year. In India, nearly 11.8% of people suffer from diabetes.  
Both of these health challenges can be managed preventatively and locally through a Community Health Entrepreneur who can catalyze behavior change, facilitate health services and entitlements, and encourage user-generated health data. 

Villages in India have witnessed transformative behavior change and access through the work of more than 5,000 Community Health Entrepreneurs trained by Healing Fields Foundation.  The challenge of poor health outcomes sits at the intersection of lack of agency, knowledge, and access to resources. Community Health Entrepreneurs are uniquely suited to address these problems as they have already undergone a transformation from voiceless women to respected leaders. As embedded change agents, they can analyze patterns and solve problems at the village level. They act as nodal points for knowledge and resources that are otherwise limited. A platform approach is necessary to allow complex data outputs to drive individual agency and behavior change. Community Health Entrepreneurs (CHEs) can be anchors of a platform that links health behaviors and outcomes for individuals or regions.  This solution addresses the challenges of agency and ownership and facilitates access to knowledge, resources, and care that unlock positive outcomes.  

The foundational layer of the platform will be an infrastructure layer. Data lives here. A family can access the data to understand the relationship between their health behaviors and the outcomes captured through telehealth. Family profiles will be built through an initial community registry, and then updated with data from health solutions like telehealth and entitlements. Aggregated data will build dashboards accessible to key decision makers who can influence the delivery of health services. Linking data between individual action, education, and health outcomes will create opportunities for novel insights. 
The secondary layer holds solutions. In the initial stages of the platform ecosystem, these solutions will be facilitated by CHEs, including telehealth and entitlement access. Initial screenings, health indicators - like blood sugar, hemoglobin, and height and weight - and referrals will be captured within the telehealth application. Receipt and consumption of entitlements affecting nutrition will be captured through a digital repository, linked to telehealth to encourage screenings and follow-up or accessed through an IVRS line built with Gram Vaani. Entitlement eligibility and application will be captured through Haqdarshak.
The network includes last- mile users, catalysts like CHEs, and key decision-makers.  At the family level, individual outcomes and use tracking will allow ownership of behavior change. Individuals have access to personal health profiles and will build agency as their actions beget outcomes. Through the aggregated insights, CHE follow-up can be intensified in areas that do not show improvement in behavior change.  Institutions can understand at a population level how concrete health indicators shift concerning program implementation.

This solution is targeted at resource-poor, rural populations of India that have limited access to health knowledge and resources due to barriers of distance, cost or patriarchy. The direct beneficiaries and implementers of the solution are women who anchor education, facilitate health behavior change and access to services,  and catalyze platform access. They catalyze access for all members of the community. We specifically target Uttar Pradesh, Bihar, and Jharkhand due to comparatively lower indices in health and empowerment. For individuals, the platform will drive transformation in health behavior and increase agency and ownership around health outcomes in malnutrition and NCDs like diabetes. For institutional stakeholders, aggregate health insights and access to user level data will enable equitable service delivery and program design.

Ashoka Fellow Muktishwari Bosco, Gayathri Prashanth and Dr Bimal Charles have been trailblazers, dedicating their careers to tackling the nearly insurmountable twin issues of health and empowerment.  With their leadership and community feedback, Healing Fields Foundation has evolved over 20 years from building one of the first micro-health insurance programs in the country to preventative health education and now telehealth and entitlements. Community input generated the need for service delivery and facilitation at the village level, and the drive for users to make their experiences visible. This evolution has always been a reflection of community needs and feedback on implementation and design, which is possible due to the embedded nature of the program and the prioritization of distributing the ability to solve.  Healing Fields has always chosen to work in India's poorest and most challenging districts. In these places, cultural norms strip women of their agency and health care has meant basic treatment through unqualified providers. Introducing a holistic program that focussed on empowerment, preventative education, behaviour change, and access to quality providers demanded vision and commitment. A vibrant health ecosystem requires qualified providers and internal staff for training and quality monitoring. These are difficult to find where Healing Fields seeds programs. An agile implementing organisation like Healing Fields Foundation is best suited to enabling local staff and community catalysts, incorporating digital solutions that bring resources into the community and finding dedicated partners. Healing Fields has been been recognized for innovative impact as the winner of the 2022 Roux Prize for evidence-based public health achievement by the Institute of Health Metrics and Evaluation,  One of India’s Top 50 Last Mile Responders to Covid-19 by the World Economic Forum, and as a +1 Global Fund Awardee by the Roddenberry Foundation. 

Building the additional technology infrastructure that will unlock the potential of artificial intelligence, big data, and interrelated insights beyond what the team can currency curate is necessary to reach the potential of the platform. The power of the solution towards health behavior change, access to services, and user interest has been validated through the prototype. The challenge will be a crucial step in bringing the solution from individual implementation by Healing Fields, to building and enabling an ecosystem for scale. 

Because Healing Fields engages the community to shape programming, innovation happens organically. Healing Fields has pioneered building and utilizing digital tools that are accessible to remote rural and digitally illiterate communities. Healing Fields seeks not to replicate current health structures but to support citizens through the democratization of knowledge and referrals. Further, the availability of services and entitlements does not guarantee utilization or improved outcomes. Behavior change and nutrition status improvement take time, understanding of local challenges and reinforcement. Accessing government entitlements requires health-seeking behavior by the individual, and this is where a CHE will work alongside existing solutions. Alternatives to telehealth and maternal and child health tracking exist but are not developed for the rural landscape, catalyzed by embedded change agents, ownership transfer to the citizen, and prioritization of follow-up. Involving community leadership is critical to sustaining impact.  Alternative programs focus on single indicator outcomes instead of a holistic approach to agency and bringing health outcome data to the rural end user.  The platform can be leveraged by any community-level catalyst, as the lack of user-generated data and population aggregated health outcomes can be utilized by diverse implementers. Since presently data tends to measure delivery, users have limited voice, and the delivery partners have no access to the data they send up the pyramid- the innovative impact of user-generated health data can be applied to any other implementer in the space. The structure will be modular and open source for diverse programs. Access to user-generated data can unlock equitable delivery of government entitlements, telehealth in urban scenarios, or even use in agriculture. 

• First year, building platform from minimum valuable prototype 

  • Anemia and Malnourishment modules deployed and iterated

  • Partnerships and collaborations with decision makers for co-creation of platform and use of generated insights 

  • Initial dashboards for outcome generated

• Five Years

  • Platform prototype deployed in 2500 villages  and 2500 CHEs trained in the use of platform, reaching 1.25 million families 

  • Behavior tracking and family profiles available for 6.25 million people 

  • Big data insights and dashboards for outcomes  available on data generated 

• 1. No Poverty

  • Income to CHEs 

  • Access to entitlements around financial services

  • Reduction in healthcare costs 

• 2. Zero Hunger

  • Utilization of entitlement programs around nutrition (anganwadi center for supplementary nutrition)

  • No of ration cards supplied through facilitated access

  • Kitchen gardens built

  • Nutrition demonstrations held

• 3. Good Health and Well-being

  • No of screenings by CHEs for NCDs and malnutrition 

  • No of patient consultations by doctors and nurses

  • No of health products sold 

  • No educations sessions held by CHEs

  • No of people reached through education

  • No of women and girls with anemia screened and referred

• 5. Gender Equality

  • No of women trained as CHEs

• 6. Clean Water and Sanitation

  • Handwash and sanination education by CHEs

  • Village sanitation activities anchored by CHE

Input will be women from resource poor communities who are trained as change agents of health and enabled to utilize the platform. 

As outcome, CHEs will ensure access to entitlements, health education, and counseling.  Families from 5000 villages will be onboarded to the citizen registry. CHEs will conduct screening for anemia, malnutrition and NCDs through camps, collaboration with government health systems, and telehealth consultations.
Outcomes will include access to remote consultation with qualified doctors for conditions like malnutrition, anemia, diabetes, and hypertension. Village-level camps and activities will be convergence points for services to families . High-risk cases will be identified, with medical consultation through telehealth, referral to government systems and regular follow-up by CHEs. Access to and utilization will be ensured for key entitlement like IFA supplements, nutritional supplements and nutritional counseling, alongside nutrition demonstrations and kitchen gardens. Users will have improved access to health knowledge and outcome tracking. 
Outcomes for other stakeholders will include improved access to information and services from users on health and nutrition to achieve better health outcomes.  Aggregated and interrelated data will allow for shifts in implementation and understanding of gaps. 
Community ownership, agency, and behaviour change leads to improved health outcomes and improved data available to stakeholders for decision making. 
Priority long-term impacts are reduction in under 5 malnutrition and stunting, reduction in anemia for women and girls, and improved management of diabetes and hypertension. 

The infrastructure layer will incorporate family profiles within India's national health stack. The information for these profiles will first be collected through CHE surveys, and then built into a profile alongside entitlement utilization and health profiles through telehealth.  These cohesive sources of information will allow users to visualize the link between action and outcome, and generate aggregated insights. As the platform expands, big data will allow population insights to be generated and shared using dashboards for relevant stakeholders. 
The solution layer will rely on software and mobile applications that can be used by individuals with low digital literacy in order to deliver high impact programs like telehealth and entitlement facilitation. These two initial pieces of software are already in place for the prototype, but can be expanded as the platform grows. 
The network layer relies on crowd sourced engagement to establish network effects and bring more users into the platform and expand scope of use to new domains. 

Community Health Entrepreneurs and Users collect primary health data. CHEs collect this data in their role as health facilitators, and they earn an income for this work. The Community registry to collect initial data will be integrated with data generated by telehealth and family health profiles. Users are incentivized by a combination of access to information through family profile and entitlement repositories and incentives within telehealth that provides discounted services for users regularly inputting data to the entitlement repository. Over time, the agency that is built through the management of family-level health information and outcomes measured through telehealth provides strong continued interest. 

Solutions to agency and resources affecting health and nutrition cannot be one-size-fits-all. Since the ultra-poor who do not own land, it is not feasible to plant a kitchen garden to eat more vegetables. For low caste individuals, becoming empowered to request consistent delivery of entitlements requires overcoming marginalization, deprivation and loss of agency. For women to prioritize their well-being as equal to their family members, they must confront pushback from decision-makers in the household and patriarchal structures. The examples of marginalized identities and diverse challenges highlight the need for a local change agent who can counsel individuals based on their specific needs, engage with families or systems resistant to change on behalf of others, and push for incremental change over time. Community Health Entrepreneurs are trained on various solutions and are chosen from all caste and religious backgrounds. They work with all community members- regardless of economic status, religion or caste. Elements of their work, like whole village digital surveys, give them the opportunity to learn about each group's needs and introduce themselves to each group as a resource. The program breaks barriers of scarce resources, gender norms, patriarchy, and caste- for our Community Health Entrepreneurs and the communities they work in. 

• Key Activities

  • Community Health Entrepreneurs are trained as leaders, educators, onboard users and facilitators for telehealth and entitlements.

  • Users access family profiles and digital repositories for information on health and available resources.

  • Institutions access aggregated dashboards on health outcomes and access to services.

• Value Propositions

  • Services, specifically accessible, affordable, and quality care through telehealth and facilitate access to entitlements. 

  • Follow up and continuum of care 

  • Agency building to link health behaviours with health outcomes

  • Information and nudges around accessing regular entitlements and health screenings.

  • Population-level user-generated health information for stakeholders 

• Partners

  • Haqdarshak for entitlement eligibility screening 

  • Gramvaani for low digital data collection solutions

  • Pharmacies and Low-cost medicine providers for prescriptions

  • Government for the delivery of services

• Channels 

  • CHEs are physical anchors of the digital platform

  • IVRS for feedback and low-tech generated user data

  • Users utilize a digital repository to track the utilization of entitlements. Incentives within the telehealth solution encourage use of the digital repository at the early stages. 

  • Online dashboards for aggregated insights 

• Customer Segments 

  • Women from rural, resource-poor communities as health agents of change 

  • Community members in rural and resource-poor villages with limited access to health resources and knowledge 

  • Institutions with an interest in aggregated health data 

  • Government for aggregated data on entitlement delivery

• Key Resources

  • Capital to build and maintain the platform

  • Human resources for anchoring implementation (CHEs)

  • Technology and online domains

• Cost Structure

  • Training to CHEs 

  • Telehealth nurses and doctors

  • Tech platform building

  • Monitoring and program implementation 

• Revenue Stream

  • CHEs earn an average income of RS 6280 per month

  • Revenue to Healing Fields generated through services is Rs 4080 per month per CHE, which would support the costs of doctors, nurses and telehealth infrastructure.

  • In the long term, partners can pay licensing fees to bring the platform to new communities. 

Services directly to the community generate revenue while generating data insights, including telehealth, health products, and entitlement access. The platform will be financially sustainable to women through income earned through telehealth. In the short term, the platform will be sustainable through grants for training, platform development and back end implementation costs. In the long term, partnerships with other institutions, NGOs and the government programs interested in population health insights will contribute revenue needed to sustain the platform. 

So far, Healing Fields has successfully generated grant funding, CSR and award prizes to build the initial prototype for the platform. This has included the Roux Prize from the Institute for Health Metrics and Evaluation for evidence based health impact, funding for a randomized control trial with JPAL, and grant funding from GIZ  and other Indian and International donors to build health systems in the aftermath of the pandemic. Funding is needed to move the project into the next phase and enable it for scale.