Uday - Health for a Billion

Nearly 30% of India’s population live without access to primary healthcare and functioning public health systems (about 50% globally). 100 million people around the world choose between food and medicine every day; over 30 million people in India fall below the poverty line every year. Measured in terms of DALYs (Disability adjusted life-years) lost per 100000 population, India, large parts of Africa and certain other parts of the world still hover between 40000 & 80000, 2-4 times higher than developed parts of the world. 63% of this is contributed to by non-communicable diseases (NCD) – Cardio-vascular diseases being the top contributor at 393.11 million; Diabetes a significant factor at 112.73 million (2019). When correlated with economic status, it is seen that all countries with a DALYs rate higher than 30000/100000 population have a GNI (Gross National Income) of less than $5000(2019). At 77 mn, India has the second largest number of diabetic population in the world. Nigeria alone is the home to 20% of diabetics in Africa. There is increasing prevalence among the rural population and increase in comorbidities such as End-stage Renal Disease (ESRD); 5-25% of family income is spent on managing diabetes and it’s complications making it a significant contributor to health poverty. It is a public health emergency. This is a collective failure – lack of access to primary care contributed to by shortage of doctors and health professionals and lack of appropriate health technologies that function in resource-constrained environments; absence of adequate and contextual public health policies and their implementation resulting from data-thin nature of the sector and underfunding. Current sources do not provide real-time, reliable data on clinical services, risk factors that are specific to the context of the at-risk population for key public health problems, or performance of public health interventions. Existing sources of information rely on infrequent ad hoc monitoring visits to health facilities or expensive occasional surveys such as Demographic Health Surveys. The dynamic nature of health challenges and risk factors render these survey findings out of date before intervention decisions are made. 

In this proposal, our objective is to address the data gap. By integrating primary care and epidemiological data (health-facing), combined with robust analytical tooling, we will enable dynamic measurement of performance of both primary care and public health policy effectiveness. Additionally, it will enforce public health policymakers to identify and address priority health problems in their populations more effectively and efficiently. We will specifically focus on Diabetes initially to measure the effectiveness of the solution, but the framework created will be agnostic and multiple health problems that are of public health importance can later be configured to fit into this comprehensive data & analysis-driven framework.

Through earlier collaborative efforts we have developed a unique clinical algorithm-driven software (Uday) that is triggered by the patient’s medical problem; and guides a community health worker to obtain structured, sequential health information, including limited physical examination of the patient and diagnostic testing. This information, transmitted real-time to real but ‘remote’ doctors in an Electronic Health Record (EHR) format, enables the doctor to make appropriate evidence-based medical decisions. This operates even in low band-width areas offering upto 12-15 kbps speed. By significantly eliminating the time per patient for the doctor (almost 70%) through task-shifting to a trained health worker from the local community and reducing the doctor’s need to travel to remote areas, this hybrid telemedicine model is an ideal mechanism for resource-poor, doctor-deficient geographies. This is a major improvement on the existing telemedicine model which is dependent on higher band-width & infrastructure, comes without reduction in doctor’s time/patient, depends on incomplete documentation of health data perpetuating data-thin environment, linguistic disconnect between patient and doctor, and no possibility of clinical examination of the patient. 

Our software has been deployed across 47 clinics in deep rural underserved areas in multiple states in India and Nigeria, both fixed (250 sft rooms) and mobile bicycle-based units. It has been operational for over 2 years; 174 trained and certified community health workers from among local rural youth (mainly women) are employed; 13 doctors (GP and Specialists) are engaged; and finally, over 12000 patients have received primary healthcare, including genuine medicines and diagnostic tests through frugal innovative easy-to-use devices. 

We now want to further develop the Uday software at three levels: i) inclusion of health-facing epidemiological data-points from the patient and integration with primary healthcare data, ii) generate insights by building a data analytic model around the integrated data that will enable measurement, monitoring and predictive analysis on a dynamic basis, and iii) develop intelligence based on the machine-learning algorithms that will guide doctors in their decision making process.

70% of the health infrastructure in India is concentrated in major cities where only 25-30% of the population lives. Even comprehensive primary healthcare is not available to the vast rural population who remain underserved. The public health programs that are, in any case archaic and unresponsive to the need (not being data-driven), remain patchily and poorly implemented. People continue to suffer, DALYs continue to rise, disease burden piles up, people die unnecessarily – these are the people our solution will serve.    

The trained community health workers, through the Uday software, will monitor existing cohorts of patients with diabetes across wide geographies, in addition to delivering primary healthcare. This intervention will improve monitoring of glycaemic control, earlier detection of complications of diabetes, control of progress of adverse effects on renal/cardiac/eye systems and change in health-seeking behaviour (diet, exercise, BMI,  concomitant risk-factor adjustments etc.) from a community perspective. This integrated approach will reduce their out-of-pocket expenditure, improve health indices, prevent late-stage complications and overall, lead to a decrease in lost DALYs. 

With 650 Endocrinologists and 1200 Nephrologists in India, such a digital approach that combines primary care & public health, along with data-driven monitoring is the only answer.

The specialist doctor founders and leaders of our team, on return from the UK after higher medical training, established 4 peripheral hospitals in West Bengal to deliver curative healthcare services to the rural population. In January 2011, our team was engaged by an Indian corporate house to design and implement a rural primary care delivery mechanism for the villagers (about 10000) across 28 villages at Salboni, West Bengal, as part of their Corporate Social Responsibility (CSR). The abject poverty that overrode humanity and civilisation as people struggled searching for the next meal, the total disenfranchisement that made people meaningless in their very existence and the lack of any health infrastructure painted a very dismal picture. We began to realise that lack of access to healthcare increases disease burden that then requires expensive treatment at hospitals, thus perpetuating the poverty cycle. 

In 2013 we started training rural poor youth as allied health workers, and trained over 4500 youth (1750 as community health workers; 60% women), certified nationally, across multiple states in India. In 2016, we started developing the software tool (the data-driven communication between frontline workers and remote doctors). We lived in villages for years, worked with the health workers, understood language and communication barriers; all of which contributed to the ethnographic understanding of how this highly complex clinical algorithm-driven software should be structured and presented. With a nuanced understanding of economic, behavioural and gender dimensions that define the rural communities, we engaged the trained community health workers in delivery of digital healthcare through setting up multiple clinics over a wide geography. Their performance overwhelmed us with humility; and we now know that human capacity can be stretched beyond dominant logic characteristics. This defines us. 

Our team includes - specialists from Public health education and background, intercultural program implementation experts and data-science specialists. The team, drawn from multiple countries (India, Mexico, Ireland, UK and Nigeria), works together on a continuous basis; reflects a balanced mix of age and gender and is from some of the finest academic institutions in the world. Current work locations include India and Nigeria, with plans for expansion across Mexico.

We are applying to this challenge primarily because of two reasons:

Financial – The grant, if awarded to us, will be used towards further development of the Uday software. It will be spent on capital purchases (computer etc.); salaries of development team; engagement with health workers in its design and training; undertaking specific surveillance work on diabetes across new clinics to be established.

Market barriers – Our solution is currently in use in two countries – India and Nigeria. We would like to expand across other countries that have similar health inequities. This is an area where the support from BMGF will be of great value in overcoming entry-level barriers.

Clinical algorithm-driven hybrid telemedicine software solution (Uday) that allows elucidation of a patient’s clinical problem exactly in the same way a doctor would do; while being easy to use by a community health worker operating in a low band-width environment. 

Integrated platform with primary care and epidemiological data, powered by machine learning algorithms and data analytics that creates decision-guiding algorithms, heat maps of specific diseases and measures effectiveness through dynamic changes on real-time. 

Continuous learning and improvement at the core, driving (cost-)effective and efficient provision of care. 

It is configurable so that the variations in different ethnic/geographic groups can be accommodated in its algorithm to reach specific public health solutions; and avoid ‘one size fits all’ approach. 

It is modular in that as newer public health problems or disease forms emerge, the PHSS can be adjusted to meet the new challenges. 

Process innovation - We have demonstrated through our ongoing project that digitally trained community health workers from among rural youth are perfectly able to deliver healthcare when supported by technology and doctors.

The primary care workflows and the public health program implementation are integrated into a single process, making healthcare delivery, health education and awareness creation and public health program as a continuum by the same workforce. This avoids resource duplication, engages the community workers better with community thus enhancing acceptance. Their ability to handle diagnostic technologies also allows the model to deliver 360 degrees health services.

Frugal solution. Our infrastructure cost is minimal; it can also be co-owned with the health worker entrepreneurs/local population. The diagnostic devices are highly affordable and purpose-built for resource-poor environments. 

We believe this has the potential to transform the way public health research, policy formulation and monitoring of implementation are being done now.

SMART GOALS

Measurement and achievement of impact goals

Theory of change

'Uday’ is a comprehensive software which reproduces the doctor’s clinical decision-making algorithm, and assists a trained community health worker in extracting structured medical history from a patient and conduct a limited physical examination through its minimalist UI (mostly checkboxes and drop-down) and picture/gif-guided module. The software covers 43 commonly reported problems in primary care and has 77 picture/gif assisted physical examination. 

It is developed using open source tech stack and developed in a federated and enterprise architecture. The software adheres to recommended security protocols and HIPAA auditing is going on. The application is available on android and online. This software is continuously fed by data and evolves to become a more adaptive and dynamic clinical decision support system. The modular API helps to integrate low-cost innovative point of care systems and methods with the app. The front-end is language-agnostic and can be modified based on requirement, the clinical algorithms are easily modifiable. Its low bandwidth operability is further enhanced by the adoption of LoRaWAN technology, enabling operation even in low or no bandwidth areas. 

We are also working on several low-cost, frugal, disruptive point-of-care diagnostic devices and IoT based solutions such as paper-based plasma glucose detection, hemoglobin detection, renal function tests, Albumin-Creatinine ratio etc. in collaboration with IITs. The one time and recurring cost reduction will be more than 50% which will make these services affordable to the rural population. 

Essentially, the technologies we are/will be using are developed with the beneficiaries and users taking into account linguistic, cultural, infrastructural and other practical constraints and use-cases. Ethnographic understanding holds the key.

Women and men from middle school background and living in remote rural areas are selected and enrolled into a training program of 6 months duration. The program includes classroom and skill lab training for 4 months and hospital-based internship of 2 months. At the end of the program, they appeared for an examination conducted by the National Skill Development Corporation (Government of India) and were certified to a national standard. The course trains them to become community health workers, with additional knowledge of computational skills, manage the functionality of Uday software, conduct basic diagnostic tests, soft skills and understanding the context of data-driven primary health care to their communities.

The health workers are then placed in the fixed Digital Health Centres or in the mobile units to reach and deliver high-quality health care to the last-mile-population. They use a tablet computer to log into the Uday software platform and collect the health data from the patients who approach them for treatment. This data is then reviewed real-time by our doctors who provide clinical management plans to the patients, including medicines and tests. Medicines are administered to the patients by the health workers. They receive a monthly stipend for this work. Revenue stream is generated from consultation, medicines and tests.

Diversity, inclusion and equity have been pillars of our enduring values since inception. In our organization, women hold ranks from the frontlines to the top-rung. Six out of every ten employees, and two out of three Directors are women. Further, three out of the five key administrative and operational decision-makers positions are held by women. The educational backgrounds of our core staff ranges from middle school graduates (Community health workers from rural areas) to PhD holders (from premier universities) all of whom belong to all the major religions in India. We recruit employees from various backgrounds and geographical locations, ranging from our community health workers, who are recruited locally, to our head office staff, who originate from five different States in India. We ensure buy-in from all project staff for all our key decisions, which allows us to maintain a flat organizational structure. We maintain a safe and constructive environment for all our people by upholding a zero-tolerance policy for marginalization, discrimination or preferential treatment within the company.

Our ideology steers our efforts to serve underrepresented communities and rural populations who have been systemically denied basic primary care. Our work over the past 10 years has uncovered that such groups are more accepting of healthcare services if it is closer to home, and delivered by providers who belong to their own communities, particularly if they are women. Therefore, more than 60% of our community health workers are women, and more than 50% patients are women from marginalized communities. This has not only enabled local women to transition into capable health providers, but has demonstrated that women form the cornerstone of our health delivery model.

Our people are energetic and value-driven who persistently ideate innovative and personally rewarding healthcare solutions. Our health workers spiritedly try to improve the health of underserved communities, and our projects deliver relevant health prevention and promotion interventions at the community level, which forms the backbone of society. Together, we represent a well-oiled machine with equity and collaboration at its core.

As an organization, our business model is an integrated approach to solving dual problems – livelihood among rural youth and improved access to primary care and public health. We leveraged health sector opportunities in India for our strategic approach – large and growing, massive existing shortage of health human resources, more women employed in health sector, renewed understanding and emphasis on primary care and public health as the route to reducing societal burden of diseases, favourable policy environment for digital health and emphasis on translational frugal technology innovations. This led to hypothesizing the 3T approach – train large number of rural youth as health workers (both for hospitals and community workers); translational technology collaborations; and transform erstwhile telemedicine models (dependent on high infrastructure with limited scalability and replicability) to a digital health model that is driven by a clinical decision-support software. Each of the ‘T’s is revenue-generating, with different timelines to financial viability; but the cumulative financial results demonstrate sustainability to be achieved within 4 years.

Now, we will talk about the specifics of the digital clinic model, the subject of this application. The trained and nationally certified CHWs provide a range of services through the digital clinics (both fixed & mobile). These include – GP & Specialist consultation real-time, on-the-spot diagnostic tests using certified devices (Hb, Sugar, Albumin, ECG), medicines, other services (physiotherapy, nutritionist, IM injection etc.) and products (Oral Rehydration Solution, Sanitary Napkins etc.). The tariffs for these services are all below $1 except specialist doctor consultation at $1.2. It is an asset-light model, requiring very little capital; being inherently frugal and process-driven, the time to commissioning is very short and so widely scalable; internet dependence is very little; and finally, being run by local personnel (CHWs) the adoption is easier, with very little communication barrier and high trust. Each cluster of clinics (1 fixed and 4 mobile) breaks even at 16 patients/day. 

Our organization is undiluted and promoter-funded. However, our funding model, over and above promoter’s contribution, included – grants from various government bodies (Department of Science & Technology, Government of India & Indian Council of Medical Research), support from science & technology institutions (IIT Kharagpur and Guwahati), mandates from various governments (West Bengal Scheduled Caste Scheduled Tribe Other Backward Castes Development & Finance Corporation, Govt. of West Bengal; Ministry of Social Justice & Empowerment, Govt. of India) and CSR funds from large private organisations (Federation of Indian Chambers & Commerce, Aditya Bikram Birla Group). Government mandates include both for training a certain number of youth as paramedical/community health workers (fee paid by the government) and for establishing and operating number of digital clinics (where we are paid a management fee by the government). These sources, coupled with revenues from our operating model ensure our sustainability. Revenue sources include tuition fee paid by students as they learn at our paramedical technician training schools, and user-fee the patients pay at the digital clinics. Individual charges at the clinics are all highly affordable, including EKG which is done at $0.8 (12-lead EKG; reported by a cardiologist). Doctor’s consultation is charged at $0.4 (for a GP), $1.2 for a Specialist etc. The economy is on the scale. On a stand-alone basis, the training centres achieve financial break-even at 70 students/year (which all centres are doing); the digital clinic clusters do so at 16 patents/day (revenue inclusive of consultation, medicines and tests). We are expecting the digital clinics to reach stand-alone viability in the next 12 months; and that would be the time when we would look at raising diluting capital to undertake a large-scale expansion.

Profitability over last two years (2020-21 & 2021-22) (all figures are in USD):

Grants received: