Building trust between citizens and public health systems at the grassroots in India
Trust is one of the most crucial and oftentimes also the most overlooked value in public health practice. We at Remidio believe that for the success of a large-scale public health programme, trust sits at the very core.
Ronnie Dutta, Remidio’s Vice President for Sales and Marketing, shares his candid learnings on how technology can increase public trust in public healthcare. Meanwhile, we continue working with the government of Kerala towards addressing their need for retinal screening at the grassroots of India to tackle the spread of needless blindness.
“In 2016, 33% of our state citizens visited public hospitals. Today, 50% of them are visiting public hospitals.” said Shailaja Teacher, former Health Minister for the Government of Kerala to Remidio.
While health systems worldwide are working towards researching and addressing the trust deficit, the government of Kerala has already worked on bridging the gap. Remidio is proud to have played a part through the Nayanamritham project — a pilot study to conduct retinal screenings among patients with diabetes for referable Diabetic Retinopathy in 16 Family Health Centres (FHCs) across the Thiruvananthapuram district. The impact of the pilot project subsequently led to the government expanding the program across the state of Kerala.
For the unaware, Diabetic Retinopathy (DR) is one of the most dreaded complications of diabetes. It is an eye condition that causes vision loss and blindness. DR affects ~16.9% of patients with diabetes and 3.6% of whom are most likely to lose their vision because of sight-threatening DR (STDR).
India is home to roughly 75 million patients with diabetes as of today. If one can quickly do the math — there is an estimated 12.5 million people with diabetes who are likely suffering from DR in 2022!
Read on to know how technology aided retinal screening while building trust for all stakeholders’ inch by inch or should we say image by image!
A) Trust between technology and the public health system
“Previously, there was no DR screening happening at the primary care level. An ophthalmologist at the tertiary care unit used an indirect ophthalmoscope to screen. The process then required dilating the eyes of the patient with diabetes, a bystander, and an ophthalmologist. Remidio’s technology helped the health system bring in a futuristic mode of treatment to eye care and that too at the primary care level.” said Dr. Bipin K Gopal, Assistant Director, Directorate of Health Services, Thiruvananthapuram.
At the outset, the retinal screening was to focus on identifying referable DR. However, oftentimes the images were ungradable due to the prevalence of cataract. The study subsequently led to cataract screenings and cataract surgeries.
“In addition to DR — cataract, glaucoma and other retinal conditions were screened. In a way it is win-win for the program.” said Dr. Sobha Sivaprasad, the brain behind the Nayanamritham project and Professor and Consultant Ophthalmologist at Moorfields Eye Hospital, London, UK.
And this is how Remidio’s integrated solution — a Fundus on Phone, the world’s first non-mydriatic smartphone-based portable fundus camera, powered with the world’s first offline Medios DR AI brought retinal screening to the primary care level in Kerala.
The pilot study was conducted at 16 FHCs in 2019. Today the government of Kerala has expanded the retinal screening program to 172 FHCs across the state.
Now one must be curious to know the impact on the patients; but we take a moment to highlight another often-ignored aspect of the public health system, which is…
B) Trust between primary care providers and the State’s public health system
When the Nayanamritham project was kickstarted in 2019, the FHCs’ staff were already working on other initiatives by the state government. Adding dedicated technicians to the government’s payroll to operate the retinal screening was out of the question. The staff nurses were identified to be the first point of contact. Hence, for the Nayanamritham program to succeed, the staff nurses needed to be equipped with technology that was easy to train and use. Remidio delivered exactly this and more.
As the program expanded in the state, it was noted that the confidence levels of the staff nurses using the FOP increased while their skills improved. Towards this, Remidio conducted extensive training (~200 trainings) throughout Kerala with help of a dedicated engineer for the state. In fact, continuous training is the only way to counter the high turnaround of government staff nurses, who are often shuffled within the FHCs in Kerala.
In addition to continuous trainings, the dedicated service engineer also ensures periodic preventive maintenances are conducted across the 200 FHCs in Kerala.
“I feel like I am adding value to the patient by showing them the image of their eye and showing them the affected areas and guiding them to go for further treatment at the district hospital.” said a sister (name withheld) with a twinkle in her eye in Malayalam.
All of this led to an empowered set of health workers who selflessly got involved in dispensing the program’s agenda — to prevent blindness due to retinal conditions.
C) Trust between the patients and care providers
Patient education is imperative towards ensuring care gap closure for any program. Kudos to the government of Kerala for maintaining an NCD database and tactfully deploying ASHA workers to create the initial awareness, particularly among patients with diabetes for more than 5 years and citizens above the age of 40.
At the FHCs, if anyone was detected with referable DR, the next step was to direct them to the district hospital for further treatment.
Remidio’s Medios DR AI generated a visual report in less than 10 seconds. This allowed the staff nurses to engage the 1 out 3 patients with diabetes detected with DR immediately after the retinal screening. There and then, the staff nurse directly educates the patient about the potential risk of blindness. This effort led to 8.3% of patients detected with referable DR to the district hospitals or the tertiary hospitals.
Without the on-the-spot diagnosis of referable DR, informing the patients after a few days only meant an unforgiving kink in closing the care gap.
D) Trust between the patients and the public health system
The pilot project at Thiruvananthapuram also identified that 38% of the patients detected with DR were in the 41–60 age group. One can only imagine the economic burden on the family if any of them were undetected and not treated on time. Especially when more than 99% of the overall patients detected with DR were unaware that they had DR.
However, when these patients were detected and treated, the information dissemination was faster within their respective communities. Notably, the walk-ins across all FHCs increased.
For those who were not detected, the ‘technology provided visual proof’ about their eye health excited them and the message was passed on to the community. This is indeed a powerful moment for the program when the patients became the messengers. Leading to a greater number of citizens visiting the FHCs when they saw the value offered by the public health system. Does this not indicate the trust the citizens placed on the system.
Today, Remidio is pleased with the continuing impact of the program which has led several towards treatment. However, we are even more pleased with the role that technology played in building trust among all the stakeholders of the public system at the primary care level.
The on-ground impact at Kerala has led the governments of Tamil Nadu and Orissa to work alongside towards preventing blindness due to eye conditions such as DR, Glaucoma, Cataract, and refractive errors.
“I do not think I would have ever got my eyes screened if this program was not happening at my nearby FHC.” — said a 58-year-old female patient detected with DR (name withheld to protect identity)
Remidio’s Ronnie Dutta shares his thoughts further, “Reaching the unreached is the key towards needless prevention of blindness due to Cataract, Refractive errors, Diabetic Retinopathy and Glaucoma. Today Remidio is well prepared to offer a “Turn-Key” solution towards screening of all four conditions quiet simply and intuitively in the remotest corners of India.”
India is home to a third of the world’s blind population. The country has around 12 million individuals with visual impairment against the global total of 39 million. Cataract, Glaucoma, DR, and Refractive errors are the major causes contributing to India’s weak visual state of affair. Strengthened with our experience of driving impact at the remotest of locations, Remidio is an ideal partner for projects paving the way for technology adoption and its continuous usage through periodic trainings till gauging the impact of the project. Do write to us at impact@remidio.com to understand more on about preventing needless blindness.
