Call4Svasth - Telecaring for the vulnerable

Despite significant progress in the domain of healthcare, access to quality, affordable, and timely healthcare services remains a significant challenge, especially for the poor and vulnerable populations in India. According to the Gender Gap Report 2022, India has performed the worst in the health and survival indicator and has ranked last, i.e. at 146th position, out of 146 countries. The most vulnerable and marginalised populations continue to suffer from the consequences of ill health due to a limited understanding of their health concerns, low health-seeking behaviour, and lack of access to efficient and affordable public health services. The Covid-19 pandemic has further exacerbated marginalised populations' vulnerabilities toward poor health outcomes. 

Marginalized communities have poor access to healthcare due to several reasons, such as cost and time of travel (convenience), long wait times, lost wages, stigma, or perceived stigma. These communities are also at the highest risk of communicable and non-communicable diseases and nutritional deficiencies, together referred to as the Triple Burden of Disease. The inability to access timely care leads to delayed presentation for treatment leading to poor health outcomes in vulnerable communities. Additionally, the overburdened primary healthcare systems with high patient workloads lead to long turnaround times, causing critical delays in care. These delays are even more pervasive in disadvantaged communities, and together coupled with a burden of both acute illnesses and chronic diseases, social determinants, and limited access to health care that is affordable and acceptable, they end up seeking health care only when they are seriously unwell or faced with catastrophic illness increasing preventable morbidity and mortality.

Moreover, healthcare cannot be addressed in a void without supporting access to basic amenities and government entitlements. Identifying families in need and providing holistic support, including mental health care, access to government entitlements, and referral to support services for women and children experiencing severe GBV is the need of the hour to improve overall well-being. 

One of the tools adopted to solve the above problem is ‘Telemedicine’, which has the potential to plug numerous gaps in India’s public healthcare system; from the lack of infrastructure to the lack of human resources, telemedicine makes healthcare accessible, convenient, and ‘greens’ the healthcare systems by reducing the need for travel. But, telemedicine by itself through the presence of helplines does not make healthcare accessible to the most marginalized. The digital divide, as well as the social and emotional determinants of health, make telemedicine merely a stop-gap solution in the care continuum for low-income communities. For the vulnerable, social and emotional determinants of health are often overlooked by traditional telemedicine providers.

C4S is a Phygital care platform whose primary focus is to improve the holistic health of communities living in ultra-poor households with an income of less than 1.90$ a day. It is a scalable and cost-effective model replicated across 10+ locations in India and Bangladesh. The program has reached over 100,000+ members, predominantly from the slum dwellers community, the hard-to-reach areas, migrants, and tribal communities. 

It is an integrated digital platform, with hyper-localized, community-led, cost-effective helplines run by trained nurses, nurse aide callers, front-line counselors, and social protection officers. Call for Svasth - C4S differs from traditional telemedicine helplines by virtue of its hybrid nature, the range of services it offers, and the depth of its intervention.

Our Solution: Onground+Online presence of care teams

1. The program's key focus is to employ and train members from the communities we serve to be the on-ground champions of the program. The champions leverage their social capital, navigate the on-ground realities, go door-to-door, screen, and connect members with the care required over the helpline. 

2. The care teams are the digital presence of the program. They are located across India and connect to the members through a strong tech backbone of CRM and EHR. 

Our In-house technology and digital solution: The digital care platform of C4S is a combination of Telemedicine, Tele counseling, and Tele help

Call for Svasth - C4S = Tele-health + Tele-help + Tele-share

1. Tele-Health: Triage & primary care provided by trained nurses. Protocols overseen/certified by Teledoctors serve as guides for advising over-the-counter medications.

2. Tele-Share: Professional & experienced counselors support mental health issues like stress, anxiety, depression, gender-based violence & child sexual abuse.

3. Tele-Help: Facilitation of social protection schemes & services. 

C4S improves health access, breaking geographical barriers, and bridging the digital divide

Telecare can save time and money for vulnerable communities by reducing the need for travel to receive care. Additionally, instead of depending on vulnerable populations to reach out to healthcare providers, healthcare providers can stay in touch with such populations without depending solely on smartphones. While many of the care and counseling services are available through teleconsultation, the core of telecare is the feet on the ground, which generate demand and provide localized delivery. Differing from any other teleconsultation and information service, Call4Svasth goes beyond a traditional helpline service that answers queries. Call4Svasth addresses health inequities and substantially bridges the access gap in low-resource and harder-to-reach communities by providing personalized health information and holistic health care. 

Cost & time for travel, stigma in accessing care, and lack of qualified resources are factors that effect all the marginalized communities. Telemedicine has the potential to solve for this by connecting qualified resources with the members over phone. Traditional telemedicine platforms leave behind communities with high digital divide, low digital literacy, and mistrust in digital technologies. These are usually the most vulnerable communities which can benefit greatly from teleservices. Call4Svasth has been designed for marginalised and vulnerable communities.

The platform through its on-ground workers earns trust among thethe members, changing their health-seeking behavior and solving digital illiteracy and the digital divide which were the pivotal factors for the failure of telemedicine models. 

So far the program has successfully reached over 100,000 vulnerable people, across the urban and rural areas including slum dwellers, migrant workers, small farmers, fishers, street vendors, at-risk adolescents, women in sex work, garment workers, transpeople across India and Bangladesh

The cost of delivering one quality medical case was estimated at INR 96 ($1.1), similar quality consultations are priced over INR 1500 ($18.2) in tier 2 cities. The tech-integrated telecare solution will strengthen the livelihood and build resilient healthy communities. Call4Svasth improves the health outcomes of the community and especially for populations who are susceptible to triple-burden disease who are far away from quality and timely healthcare services. 

Call4Svasth will directly impact the communities and improve their overall health outcomes and build resilient support systems: 

• To improve health-seeking behavior among community members by enabling access to primary health care services through teleconsultations and continuum of care

• To provide and facilitate counseling support for incidences related to stress, GBV, depression and cases of abuse among community members

• To improve health education knowledge and awareness among community members on social protection schemes and services 

• To increase the health agency of the community members by providing dignified care

• To empower the communities with health promotion along with the continuum of care.

Call4Svasth is a hyper-localized program. The core of the program who are its community health workers are always hired and trained from the communities we serve to be the feet of the program. This is particularly done to ensure the program is rooted in ground realities and navigates the local context. They provide inputs on day-to-day activities and needs of the communities based on which the action plan for the week is created. In addition, by training the community members in basic digital skills, community monitoring, and mapping local health networks we also ensure the communities are more become resilient. 

In addition to the on-ground care team, the care teams are also a reflection of the communities we serve. All our agents speak the respective languages of the communities served. Our triage agents are all from vulnerable communities (PWD, LGBTQ+ ). While serving special needs populations such as the transwomen community from Salem, India our traige agents and nurse were transwomen.

 The program has reached over 100,000+ members, predominantly from the LGBTQ, slum dwellers community, hard-to-reach areas, migrants, and tribal communities. The program is operational in India and Bangladesh. 

As C4S is scaling we are looking for mentorship opportunities particularly in terms of product fit. Additionally, we need technology and market partners to help grow the program across geographies. As we enter new markets we need support in navigating the legal and regulatory landscape of our new geographies.

Call4Svasth as program differs from existing telemedicine models as it focuses on providing last mile - holistic health access to vulnerable and marginalized populations. The inception of idea came into being at the onset of the COVID-19 pandemic where the Indian public health systems left behind vulnerable populations. The uniqueness of the solution comes from its design and technology and the development of community-centric and offering patient-centric care. There are many super apps, unicorns, and other digital solutions what sets Call4Svasth apart is the purpose of making healthcare accessible - we have been working with populations who don’t prioritize their health as they view “health as a fundamental right not for them to avail”. Call4Svasth is building trust in these vulnerable populations to revolutionize change in their health-seeking behavior and empower health agencies. 

• Last mile health access 

Telemedicine models fail in low-resourced settings because they don't take the local context into account and they don't factor in the lack of trust in digital health models existing in rural communities. Through our CHWs (Community health workers) who are from the same community, we are able to solve for the local context. Factors such as digital illiteracy are addressed as our CHWs facilitate the calls when necessary. Through leveraging their social capital in the communities lack of trust in digital health is overcome. 

• Holistic care 

Telecare focuses on providing and interlinking the following services. By doing so we are able to provide a holistic solution for the community well being 

• Telemedicine 

Qualified medical team (Nurses & Doctors) who provide non-judgmental, qualified medical consultations and send prescriptions over the phone

• Tele counseling

Qualified counselors carry out multiple mental health counseling sessions

• Tele help 

Facilitation of social welfare protection schemes and services

• Continuum of care 

Owing to the lack of agency among the vulnerable and marginalized population we recognize that a  single medical consultation will not create a health impact. Telecare provides a continuum of care, where the members are regularly followed up (both - in person and over the call) till their conditions are cured or adequately managed.

The entire program targets the vulnerable and rural communities, making them the primary customers. However, since these are resource-constrained settings we are looking at revenue generation through institutions bearing the responsibility for the well-being of these communities.

The program goal is to ensure every person has access to free and quality primary health care

The following are the key outcomes

• Reduced out of pocket expenses

• Increased access to primary health care services

• Improved health seeking behaviour

• Increased knowledge on preventive health

• Heathy days

Outcomes 

• 30 % improvement in health-seeking behavior in vulnerable communities

• 10 % reduction in undiagnosed triple-burden diseases

• 10 % personalized health information calls delivered 

• 10 % of community members availing the counseling services to address depression, anxiety, stress, abuse, and gender-based violence

Our tech backbone consists of an EHR platform designed with easy workflows for the nurses to ensure continum of care. A telephony system to ensure all call are made to members in a safe space. An on-ground app which is lite and works off-line for the community health workers to ensure they are able to enter member details and finally whatsaap channel for easy communication with the members. In addition to this a strong analytics platform to monitor the program activities and impact. All these have smoothly interlinked to form one solution for C4S. 

Swasti’s idea embraces the diversity of the communities and the populations we serve. We intend to reach a million healthy days through inclusive designs and community-centric solutions in order to achieve health equity for all. We have experience working with 14 different marginalized and vulnerable communities in 22 states of India and 25 countries across South Asia, East Asia, and Africa on over 100 projects and programs. We have gender-inclusive leadership and a team that translates into building knowledge systems. For example, our LGBTQ work in the ground, and the helplines are run by members of the community. Swasti's agenda is to change the way well-being pathways are achieved starting with primary healthcare and tackling social determinants that direct how we experience everyday well-being. Call4Svath’s work envisions expanding into other geographies and communities in need because of its inherent advantage of plug-and-play features, phygital strength, and linguistic capabilities.

Call4Svasth’s value proposition is its holistic and personalized approach to primary care. The key customers are the marginalized and vulnerable population who lack access to quality care and are struck in the poverty cycle due to health expenditures. The program focuses on providing medical consultations, health information, counseling services, and linkages with existing government schemes. These activities build health agency among members and make the communities resilient. The doorstep delivery of this program in communities that lack healthcare access ensures its successful uptake. 

Its phygital designs enable the qualified care team to be leveraged across geographies and be connected to community members from several remote locations. In addition, the technology solution required a one-time cost to be set up and support the delivery of the program. Hence the only cost is for the maintenance of the technology and supporting the centralized care team. These have drastically reduced operational costs and provided a high-quality service delivery at a minimal cost. The infrastructure in place can also offer consultations to clients from non-marginalized communities on a pay-for-service basis. This revenue could cover the expenses to keep the service running for the marginalized population.

Call4Svasth was set up and run on grants, however, the model has been designed to become financially sustainable through a combination of services while keeping it free of cost for the communities. A crucial aspect in making this possible is its ability to leverage care teams and connect them across geographies, enabling cost-sharing across all these communities and members served. Its financial operations will include 

• Free-for-service operations for the target population to ensure healthcare remains accessible to them. By sharing care teams across similar geographies operating costs are cut down and resource optimization increases.

• Pay-for-service operations for the non-marginalized community members with the ability to pay. The care teams and technology infrastructure remains the same as the one utilized for marginalized communities. 

• Market expertise support - Through Call4Svasth operation consistent expertise has been gained on topics such as “Digital technology in low resource settings”, “Community-based monitoring” etc. C4S can monetize this knowledge base to market entities working in similar fields. 

Overall though its multiple revenue streams, Call4Svasth will support its running cost and remain free for use to marginalized populations. 

Since 2020 the program has raised over 2 Million USD from philanthropic organizations to establish and run the program across India.