HealthRAB - IHCB

Emergency departments plays a vital role to deliver care to patients with critical and unexpected fatal illnesses. The emergency care facilities in LMICs are scarce and there is a strong need to strengthen emergency care capacity of health systems in these countries. In 2015, 28.3 million deaths globally were attributed to emergency cases and this burden is 4.4 times higher in LMICs. (Maukhtar S etal) 

In Pakistan, a significant gap has been found in treating emergency care in primary health care settings due to insufficient allocation of resources, lack of emergency transport, worst conditions on the road, ill-trained physicians, and their unavailability which are considered some of the major problems. 

Although Pakistan has one of the best Public Health infrastructures in Asia, the poor health situation of the country point-out a strong lack of quality care and implementation of ‘standard’ principles. The deficiency of skilled health personnel is a major contributory factor and one of the reasons for this scarcity is not having a robust training system for health care workers which can bring a marked improvement in their knowledge and skills that could ultimately translate into improved primary health care outcomes.

Since the adoption of the Sustainable Development Goals in 2015, there have been calls for more integrated, high-value approaches to healthcare delivery in low-income and middle-income countries (LMICs). According to WHO, scaling up primary health care (PHC) interventions across low and middle-income countries could save 60 million lives and increase average life expectancy by 3.7 years by 2030. Achieving the targets for PHC requires an additional investment of around US$ 200 to US$ 370 billion a year for a more comprehensive package of health services (WHO fact-sheets). Public health interventions to improve primary healthcare to address emergency treatment may lower the death rate in LMICs, and treating emergency cases at PHC could be the most inclusive, equitable, cost-effective and efficient approach to improve clinical outcomes and reduce mortality rates.

Primary Health Care Units should have the ability to cater to those patients who arrive with any type of emergency like trauma injury, chocking child, myocardial infarction, acute attack of asthma, etc. which can only be possible when first contact care providers are fully trained and capable in attaining emergency care and then referred to the hospital which can even save patient lives or any negative health impact.

Keeping all these issues in mind that are usually encountered in primary health care settings, a solution is presented in the first step with aiming “capacity building of healthcare professionals of Primary Healthcare facilities to equip them with Basic Resuscitation Course through EMS experts in prevention, assessment, and management and assisting them through Telehealth and Telemedicine. In the second step Primary Health Care Provider (PHCP) will be provided a mobile embedded “digital health care application” with decision support algorithm that allows the physician to manage emergency situations in more efficient and effective ways. This health care digital application will also capture the vital information of the patient.

Having this integrated health care bundle “consisting of knowledge with procedural skills and clinical decision support system (CDSS) equipped mobile” will enable primary health care providers (PHCP) not only to provide optimal care and manage some of the emergencies but also will be helpful to save patients’ life and lessen the burden on emergency departments and tertiary care hospitals. This bundle is likely to be helpful in mitigating pressure on the entire health system generally and coping with the probable fatal issues of the patient specifically.

This study is a two-arm control randomized trial. At baseline, primary health care facilities in rural areas of Sindh will be selected on a random basis to decide either to be intervention or control arms. The selected catchment area will be having same dynamics and homogeneous population. Knowledge assessment will be done to PHCP through a well-structured assessment tool i.e. called KAP (knowledge, attitude and practice) tool. To understand the intervention strategy and to get a better understanding, a qualitative study will be planned in the community and health facility. An intervention of integrated health care bundle (capacity strengthening of PHCP + Mobile based Digital health care Application) in collaboration with the Digital Care (pvt) Ltd. and Emergency Department of Emergency Liaqat National Hospital. The intervention consists of training of PHCP in basic resuscitation courses facilitating through EMS experts in prevention, assessment, and management and assisting them through Telehealth and Telemedicine. All primary and secondary indicators will be again assessed at the end-line after a year. This study will be managed through a dedicated research team comprised of a project manager, clinician, EMS expert, field supervisors and data collectors, data analyst etc.  

By implementing this model can change the limited primary health care services to high productivity to prepare primary healthcare providers in helping to save patients’ lives and from adverse events and protect EDs from overcrowding with such patients. After successful intervention with evidence-based results, this model will be projected to the country level.

As it is well known that primary health care providers are the frontline of all health systems. By strengthening this frontline a strong primary health care system can:

(i) reduce the burden on the health care system as a whole and alleviating the burden on ED

(ii) protect the patient against the threats of adverse health care issues during the encounter of any type of emergency in primary health care settings

(iii) increase the knowledge and skills by strengthening primary health care providers and be additive to the broader health ecosystems

(iv) increase access to technology, appropriate facilities, and specialized staff

(v) rise the well-being of the community and as well as physician

Health Research Advisory Board (HealthRAB) has been working since 2012 and is trying to develop a health research ecosystem in Pakistan by paving its way through an organized and strong research network. This is our first time entering this type of challenging opportunity, with its independent problem-solving abilities, robust infrastructure, and a team of highly qualified and experienced professionals not only working in their own areas as senior clinicians, researchers, and well know academicians from all around Pakistan but also have an international advisory council of an ingenious panel of experts who are affiliated with renowned institutions from different regions of the world.

HealthRAB is striving with its limited resources and working efficiently to play its role in developing the health research ecosystem in Pakistan through the following core activities/projects:

• Research Award: In order to keep all the valuable institutes, researchers and healthcare professionals in a connectivity chain; the Research Award is a unique yet challenging arena created to stimulate the spark of ingenuity, authenticity and critical thinking. The Research award allows the contemporaries from Postgraduate to Assistant Professor Level to compete at the National level and produce standardized research work.
• Diseases Registry: One of the most renowned and innovative initiatives of HealthRAB is creating a “Disease Registries Database (DRD) of the patient that is not only useful for patient care but also for research purposes as in near future those organizations would be highly recognized and valued who gather huge amount of such database and then utilize it efficiently.
• Right now HealtRAB has developed databases of 9 registries of the defined patient population in all over the country i.e. Pakistan National Joint registry (PNJR), Cardiac Registry of Pakistan (CRoP), Diabetic Registry of Pakistan (DRoP), Hepatitis Registry of Pakistan (HRoP), Gynae Registry of Pakistan (GRoP), Stroke Registry of Pakistan (SRoP), Pediatric Orthopedic Registry of Pakistan (PORoP), Hip Fracture Registry of Pakistan (HFRoP), Spine Registry of Pakistan (SPRoP).
• International Medical Research Conference (IMRC): Coming across the highly professional and experienced Leadership and International Advisory council of the institute, it can be rightly said that HealthRAB has comprehensive potential and strength to become the Paramount National Institute to lead and be the driving force behind high quality, authentic Research work.  As a matter of fact, the institute has successfully conducted two International Medical Research Conferences in the last decade, proving its credibility and imminent potential for the upcoming years. These events are a source of capacity building as they provide opportunities for the new researchers to get inspiration as well as experience base knowledge which could encompass their personal growth to turn into productive Researchers of the future.

Other than all above said activities HealthRAB has a continuous educational system in term of Capacity building workshops, Online Research Courses and Research webinars.

HealthRAB has a strong network around the country that provide a great lead for managing, implementing, and scaling up this solution all over the country in a sustainable order. As HealthRAB already developed Clinical Research Centers (CRC) in different regions of the country and also conducted the workshop with the help of donors and collaborators that help for implementing this solution in the future.

The design process will cover the following approach:

* Setting Goals and Objectives with sets of key performance indicators defined through logical framework.

* Governance and regular program coordination

* Qualitative and Quantitative Research

* Sustainability and scaling up

* Monitoring, evaluation, and lesson learning

* Collaboration and coordination with communities and other development factors

HealthRAB is a non-profit organization and is running its project with the help of donors and partners. This is the first-time HealthRAB is applying for this grant to run this pilot study as an initiator. This solution requires some basic inputs and processes including human resources, finances, governance and leadership, information technology, infrastructure, procurement, logistics, and supplies. 

To implement this solution HealthRAB will be in dire need of strong financial assistance that could directly influence outputs and indirectly to the project outcomes. Implementing this model requires larger investments of time and resources for supervision and development of the needed applications and managing the Project.

Since the adoption of the Sustainable Development Goals in 2015, there have been calls for more integrated, high-value approaches to healthcare delivery in low-income and middle-income countries (LMICs). According to WHO, scaling up primary health care (PHC) interventions across low and middle-income countries could save 60 million lives and increase average life expectancy by 3.7 years by 2030. (2) Achieving the targets for PHC requires an additional investment of around US$ 200 to US$ 370 billion a year for a more comprehensive package of health services. (2) Public health interventions to improve primary healthcare to address emergency treatment, may lower the death rate in LMICs, and treating emergency cases at PHC could be the most inclusive, equitable, cost-effective and efficient approach to improve clinical outcomes and reduce mortality rates.

The strength of this SOLUTION lies in its innovation. Whereby, HealthRAB will work as a hub-spoke model and implement this intervention model through partners (Digital Care and Emergency Departments). This model will also give us an indirect connection with various communities across country.

Another important aspect of innovation is that from our experience we believe that there is a need to address issues pertinent to PHCP training outcomes and impact. This refers to job satisfaction and lives averted from the process. Since the HealthRAB will work in close coordination with partner organizations and health care sectors, we shall be able to maintain focus on project deliverables and track the progress of proposed beneficiaries.

A key component of the proposed SOLUTION is the Digital technology of CDSS embedded mobile that refer to a cross-cutting theme of the latest technology of machine learning, this research will add significant value to the knowledge base of the health sector in Pakistan.

Impact goals for the solution are explained here for the first next year:

(i) reduce the burden on the health care system as a whole and alleviating the burden on ED

(ii) protect the patient against the threats of adverse health care through effective management  minimizing the possible errors in clinical diagnosis

(iii) Strengthen the knowledge and skills of primary health care providers and be additive to the broader health ecosystems

(iv) increase access and effective utilization  of digital health technology, appropriate facilities,

(v) rise the well-being of the community and as well as physician

Every impact goal has a specific purpose followed by the performance indicators that are assessed by the related outputs through desired activities and process.

An example is taken from the LFA (logical frame analysis) developed by HealthRAB for the SOLUTION:

Impact Goal: Strengthen the knowledge and skills of primary health care providers and be additive to the broader health ecosystems

Purpose: Establish hub of key trainers

Performance Indicators: Numbers of Doctors received specialized training program, Number of Healthcare Management Professionals hired

Outputs: Existing capacity and knowledge of the physician, improvement in knowledge of the physicians, number of specialized training, health system assessment

Activity/Process: Arranging training session, selection of primary health care units

Assumptions (to be verified): Increase # of trained physicians, increase skills and satisfaction level, increase efficient working environment, increase the well-being of physician 

MoV (Means of Verifications): Training program test score, satisfaction survey to the physician

Following are the some measurable indicators:

Knowledge of physician, clinical outcomes including mortality, number of patients arrived with an emergency and treated successfully, satisfaction level of the physician, Qualitative outcomes

The growing demand for emergency services, combined with the priority sorting due to patient’s acuity, results in long waiting times for patients. Waiting times have a significant impact on patient mortality, morbidity with readmission in less than 30 days, number of pre-Intensive Care Units (ICU) resuscitation, length of stay (LOS), patient satisfaction and costs. The outcome of patients’ medical treatment is time-sensitive, therefore the sooner the treatment is rendered, the better the outcome.

Diagnosis is one of the crucial tasks performed by primary care physicians; however, primary care is at high risk of diagnostic errors due to the characteristics and uncertainties associated with the field. There may be critical patients presenting symptoms not easily recognized as indicators of criticality. If not identified in due time, these patients have to wait for a long time for medical observation, which results in an increased risk of morbidity. Therefore, the need for an efficient system to assist the health professional in taking a timely and correct decision becomes of vital importance.

In the clinical setting, clinical decision support systems (CDSS) provide clinicians, staff, and patients with knowledge, patient-specific information and recommendations. CDSS are usually used for addressing clinical needs, such as ensuring accurate diagnoses, screening in a timely manner for preventable diseases, and averting adverse drug events or pain management. However, CDSS can also potentially improve efficiency, and reduce costs and patient inconvenience. The aim of such systems is not to replace the decision-makers – clinicians, patients and health organizations – but to provide relevant knowledge and support in their decision-making. CDSS is not intended to replace a clinician’s assessment, but rather to facilitate the clinician’s correct assessment and reasoning through suggestions and alerts. CDSS performs various functions, including giving reminders, alerting users of prescription interactions and test results, interpreting tests, predicting mortality based on epidemiological data, assisting in diagnosis, and calculating drug doses etc.

Use of CDSS in Primary Healthcare settings for the treatment of emergency cases could lead to improvement in the health professionals' decision-making and better clinical management and patients' outcomes.

HealthRAB is a nonprofit organization.  Based on its mission of “improving the health research ecosystem and its vision of “improving health globally by developing a relevant and efficient research ecosystem”, the members of HealthRAB

•             Provide leadership for developing the health research ecosystem

•             Create synergy among the existing stake holders and bring them together.

•             Build capacity of the human resource involved in conducting research

•             Collaborate and network locally as well as globally to initiate research activities.

•             Facilitate the development of a national research policy and strategy.

The beneficiaries of HealthRAB include Clinicians, Health Researchers, Academicians, Faculty members, Healthcare leaders, medical societies, hospitals, medical universities, and medical students etc.

HealthRAB offers various services to its beneficiaries including

National disease registries: Disease registries play an important part in improving health outcomes. They also reduce the costs of health care. Using such registries, health-care providers can compare, identify, and adopt best practices for patients. Developing national disease registries is one of the flagship project of HealthRAB,

The development of national disease registries isdone through the collaboration of HealthRAB with the particular medical society/associations. Once the MoU is signed between both parties, HealthRAB then provide support in terms of Registry database designing, development of online registry software, organizing capacity building workshops and trainings for the registry members and publication of annual registry reports.

Research Awards: In order to foster the development of health research ecosystem,  HealthRAB regularly conducts research awards (in various field of medicine and surgery) that provides a platform to the young aspiring researchers to present their research work (in the form of podter presentation) and compete with their peers at a national level. These awards are conducted during the annual conferences of various medical societies/associations. The winners are awarded research grants from HealthRAB In order to motivate them to continue doing research.

Capacity building workshops: To enhance the skills and competencies of health researchers, HealthRAB regularly conducts certified capacity building and training workshops on various aspects of research including research methodology, conducting effective peer review, qualitative and quantitative research etc.

Development of Health research policy document: HealthRAB is a member of the Research Steering Committee formed by the Ministry of Health, Pakistan and has an an active MoU with Pakistan Health Research Council (PHRC). Developing policies and strategy for health research is a part of the mandate of HealthRAB. In this regard HealthRAB and National Institutes of Health (NIH) Pakistan are jointly working to develop strategies for conducting health research in Pakistan. This document defines

•             Defines the infrastructure needed for quality research and researchers; allowing them to do their work as a primary vocation and to disseminate the research.

•             Contains suggestions for enhancing research quality and for setting standards.

•             Seeks to facilitate translation of available research into actionable information by defining actions on part of researchers, a group of specialists that produce information products, that extract pertinent messages from research and to present them in a language and by means that resonate with specific end users of health information.

•             Defines who these end users would be and how they may be trained to become better users of the information being presented.

•             Includes discussion of the main priority areas for research in Pakistan.

HealthRAB has successfully developed partnerships with Pharma industries and local donor agencies to run their projects like Research Awards, Clinical Research Centers, Developing of Disease Registries etc. HealthRAB engages different pharma companies via offering relevant proposals in their interest and making MOUS if both parties agreed.