September 2007

e-Choupal – Delivering Rural Healthcare Services : Dr Pankaj Trivedi and Mukti Bapna

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Lack of health services is one of the main impediments for improving the quality of life in rural India and the same has been reiterated by the e-choupal initiative of ITC. e-Choupal is a starting point for reflecting on key challenges in achieving ” Health-For-All” and developing effective response system. It tries to provide primary, secondary and tertiary health care as well as consultancy services. The paper focuses on providing health services in rural areas and also about its innovative policy. It also shows an innovative model used in healthcare services.

Let’s begin with some fundamental questions on the state of public health situation in India –

Why there is a child mortality rate of 1 death every 30 seconds in India?

Why does a mother die each passing minute?

Why do thousands of people fall prey to malaria and bird flu every year in the country?

Even a minimal understanding of current public health scenario in the country will be enough to precisely point out the reasons, which are are none other than lack of proper medical facility and adequate healthcare infrastructure outside urban centers.

All along, rural areas have been miserably neglected when it comes to providing public healthcare. Further-more, when we discuss this problem in a little detail, some other crucial questions crop up, and these are  –

  • How to break our cultural taboos and change behaviours?
  • How to provide literacy about health among people?
  • How to provide high-quality care in low resource settings?
  • How to give access to health professionals such as to ensure right treatment for patients?
  • How do we design and implement affordable public healthcare system?
  • How to guarantee a ‘fair-for-all’ system of health?
  • How to educate people to plan ahead for potential health problems?

In order to make an attempt to address such questions and offer a solution for them,  a rural health service model has been designed, based on ITC’s  e-Choupal network.

(‘Choupal’ is a Hindi word, meaning an informal assembly or forum where villagers meet to share local news and information.

The e-Choupal initiative has been pioneered by Mr. S. Sivakumar, CEO, ITC  Agro-Business Division, started in 2005)

OPERATIONAL MODEL

In general, the e-choupal project constitutes a network of rural kiosks, providing a number of information and communication related services for rural population.

In terms of health services, e-Choupal provides preventive, primary, secondary and tertiary healthcare services.

Primary care practices provide health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of healthcare settings, for instance – office, inpatient, critical care, long-term care, home care, day care, etc.

Secondary and tertiary healthcare services are provided by reputed doctors and specialists, made available to the populace through telemedicine services arranged at proximal distance. In addition, e-choupal also provides consultancy services, diagnostics and pharmacy services.

In providing these products and services, e-choupal used a three tier model as given below :

Tier 1: Choupal  level health (paramedic) centers
Tier 2: Hub/Mall level ‘choupal sagar’ health centers, pathology centers and pharmacy
Tier 3: Specialist doctors, diagnostic centers & specialty centers of partner hospitals

Tier 1 includes dissemination of health advice and information at the choupal premises and arranging the necessary infrastructure for free health camps in  villages. Activities at Tier 2 include providing the necessary infrastructure to the physician and provision of requisite space for lab and pharmacy, thus facilitating organized and quick service to patients. Tier 3 includes telemedicine services which help rural citizens to gain access to reputed specialists from top hospitals.
The model is a combination of technology (facilitated through e-choupal infrastructure) and community, interfaced through a ‘sanchalak’ (operator), who interacts with the local community and hence binds all members of the rural populace.

e-Choupal has partnership with reputed organisations in the healthcare segment, who bring their core expertise in medical care at both ends of the spectrum � starting from rural initiatives to super-specialty hospitals.

State government agencies help in the improvement of local regions by participating in pulse polio drives, Sakshartha (Literacy) Mission, tuberculosis prevention mission, HIV/AIDS awareness camp, family planning mission etc. The partnership is very strategic since core aspects of healthcare are managed and provided by the partner, who also take care of the last mile connectivity and delivery factors.

FINANCIAL MODEL

Patient fees and subscriptions/donations from partners and government primarily provide the required inflow of cash to run the program. Fees charged to patients availing the services are only Rs. 25 ($ 0.6) for consultancy, with a validity of one week, irrespective of number of times a patient avails the service in that week.

A cost benefit analysis of the business model indicates that the project is financially viable & sustainable. e-choupal initiative results in marginal additional fixed cost, which can be recovered easily by scaling up operations.

Following figures may be useful to understand the commercial viability of the program:

The average population covered by a choupal is approximately 6500 (constituting approximately 1200 household). The yearly average expenditure per rural house-hold  on healthcare is nearly Rs. 4400 (approx. $ 105). Hence, potential revenue from each choupal through healthcare service alone is Rs. 5.3 million (approx. $ 126,000).

The number of choupal in a typical state like Madhya Pradesh is 1700. Thus, the total market potential in a state is approximately Rs 9200 million ($ 220 million). The total potential for all 8 states to which the project has been extended comes to around Rs 75,000 million (approx. $ 1786 million).

In addition to this, the concept has been extended to other states like Uttar Pradesh, Maharastra, Rajasthan, Andhra Pradesh and Karnataka, and is working well as per cost-benefit analysis

SUSTAINABILITY STRATEGIES

For long term sustainability the following strategies are implemented:

  • Leveraging technology to reduce the cost of telemedicine.
  • Building volumes to increase profitability � (a) spread word of mouth publicity (b) organise awareness camps through kiosk operators (c) conduct health camps in villages.
  • Obtaining regular feedback and carrying out research to figure the medical needs.
  • Adopting market-based models as a scaling up strategy so as to reach large number of people in need.
  • Designing inclusive system in which healthcare facilities can be provided in low resource environment.
  • Creating trust among local communities, as well as introducing public incentives for encouraging better usage of new facilities at local level.
  • Encouraging readers to visit original website to learn multiple dimension of the concept.

FACILITIES

Choupals also provide some additional and value-added community services for ensuring capacity building and awareness generation

  • Choupal radio broadcasts preventive health measures and remedies for localized ailments.
  • Doctors compose and deliver engaging talks on radio.
  • e-choupal website makes available 24 hours query sessions.
    Telemedicine services allow villagers to interact directly with specialist through video conference mode and also at an economical rate.
  • Health camps are co-operated by kiosk operators to facilitate activities like free eye-checkup, free tuberculosis camp, free cataract cure camp etc.

Out of the total number of patients who avail the healthcare service of e-choupals, more than 75% qualify as “low income or marginalized”. This in itself is indicative of the fact that the rural health service model of e-choupal is ensuring that the weaker sections of the society gain access to quality and affordable healthcare.

RECOMMENDATIONS

In order to improve service delivery mechanism through e-Choupal network and maximise benefits for rural community, the following recommendations may be considered:

  • More courses for capacity building of existing paramedics in the village.
  • More programs on training and certification for healthcare service in rural areas.
  • Changes and modifications in the pharmacy regulation.
  • Certified training for rural citizens for enabling them to sell basic drugs in villages.
  • Create standards for health data exchange.
  • Proper regulation and protocol for leveraging modern technology like telemedicine etc.
  • Provide incentives on tax for capital equipment.
  • Provide concessions to players contributing in the rural healthcare segments.
  • Co-operating with the local paramedic through kiosk operators and focusing on their training and accreditation.

CONCLUSION

e-choupal provides the “last mile” complementary solution for rural communities by introducing high-tech and high quality services in low income settings. This has helped to push geographical barriers and overcome cost constraints.

Experiments have consistently demonstrated the importance of creating trust in local communities, as well as introducing incentives to start using these new facilities at the local level. e-choupals  are acting as change makers, and are well set to achieve the mission of “Health-For-All” within its macro agenda for transforming rural economy through innovative solutions and services.

REFERENCE

www.echoupal.com

  • Case study on ” How to improve health for all” by Stephanie Schmidt.
  • Case study on  ” Delivering healthcare services through the
    e-Choupal ” by S.Sivakumar.
  • Other related Websites.
  • About e- Choupal

    ITC’s International Business Division, one of India’s largest exporters of agricultural commodities,  conceived e-Choupal as a more efficient supply chain aimed at delivering value to its customers around the world on a sustainable basis.

    The e-Choupal model has been specifically designed to tackle the challenges posed by the unique features of Indian agriculture, characterised by fragmented farms, weak infrastructure and the involvement of numerous intermediaries, among others.

    ‘e-Choupal’ also unshackles the potential of Indian farmers who have been trapped in a vicious cycle of low risk taking ability – low investment – low productivity – weak market orientation – low value addition – low margin – low risk taking ability. This makes them and the Indian agribusiness sector globally uncompetitive, despite rich & abundant natural resources.

    The Model in Action

    Appreciating the imperative of intermediaries in the Indian context, ‘e-Choupal’ leverages Information Technology to virtually cluster all the value chain participants, delivering the same benefits as vertical integration does in mature agricultural economies like the USA.

    With a judicious blend of click & mortar capabilities, village internet kiosks managed by farmers � called sanchalaks � themselves, enable the agricultural community to access ready information in their local language on the weather & market prices, disseminate knowledge on scientific farm practices and risk management, facilitate the sale of farm inputs and purchase farm produce from the farmers’ doorsteps (decision making is now information-based).

    Real-time information and customised knowledge provided by ‘e-Choupal’ enhance the ability of farmers to take decisions and align their farm output with market demand and secure quality and productivity. The aggregation of the demand for farm inputs from individual farmers gives them access to high quality inputs from established and reputed manufacturers at fair prices. As a direct marketing channel, virtually linked to the ‘mandi’ system for price  discovery, ‘e-Choupal’ eliminates wasteful intermediation and multiple handling. Thereby it significantly reduces transaction costs.

    The Status of Execution

    Launched in June 2000, ‘e-Choupal’, has already become the largest initiative among all Internet-based interventions in rural India. ‘e-Choupal’ services today reach out to more than 3.5 million farmers growing a range of crops – soyabean, coffee, wheat, rice, pulses, shrimp – in over 31,000 villages through 5200 kiosks across six states (Madhya Pradesh, Karnataka, Andhra Pradesh, Uttar Pradesh, Maharashtra and Rajasthan) Source: www.echoupal.com

 

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