My leg feeds me, please save my leg

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Most of us are content with our regular 9 to 5 jobs, which provide relatively stable benefits and some form of financial security. These jobs also provide security in case of any unforeseen medical conditions or even injuries; and most of us are entitled to sick leave with full salary credited into our accounts. 

Now, imagine a scenario where your hands are either permanently fractured or disabled and ask yourself this question: “How am I able to earn money and contribute to the society?” These were the words of Mr. Venkat *, a 26-year-old youth, a driver by profession, who was suffering from a severe bone infection called Osteomyelitis in his right leg. The disease had hampered his daily life  as he could not drive and eventually took a toll on his livelihood.

To add to his problems, Venkat realized that the government health insurance scheme that he is entitled to did not cover his particular medical condition. He was devastated and was contemplating suicide, when providence brought him to Dakshas. Following our protocol, an initial preliminary screening was conducted, and an appointment for surgical intervention was fixed at no cost. 

 Venkat is currently recuperating from the successful surgery and is hoping to get back to his professional life. His traumatic journey offers a glimpse into the plight of  the underprivileged societies of India and their apparent disenfranchisement. It also reveals how innovative healthcare delivery models like Dakshas’ can save the lives of the poor and create hope for a better future.

* Name of the person changed to keep his identity confidential

Vivekananda Health Centre: Where complexities are simple

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The need for Dakshas was felt rather early, probably three years before the solution emerged. Eight different institutions have been engaged with Dakshas — the settings ranging from NGO clinics for the poor to high-end corporate hospitals. Among this, one engagement has stood out above the rest. 

Vivekananda Health Centre (VHC), Ramakrishna Mission (RMK), Hyderabad is a polyclinic that sees approximately 500 to 600 patients per day between 9am and 5pm. Over 50 doctors, including superspecialists, provide free consultation.  The clinic charges Rs.20 as registration fee and Rs.10 as user fee. Facilities for diagnostics, minor surgical and dental procedures, pharmacy and physiotherapy services are provided at highly subsidized rates. It is probably one of the best-managed healthcare facilities in Hyderabad, within the limitations of its service profile. 

Dakshas started its operations at VHC as a weekly orthopaedic clinic, seeing 30 patients a week. Gradually, it grew to three sessions a week, and then into a multi-speciality pain clinic. Today, Dakshas sees approximately 660 patients a week. Dakshas’ growth here was not only in terms of numbers, but our whole scope and service design was developed in this unique crucible. 

There are some characteristics that make Vivekananda Health Centre the ideal Healthcare Delivery Incubator. VHC has a single guiding principle: ‘the Patient’s Interest’. And it is willing to do whatever is possible to attain that goal. Authority and responsibility are delegated, human resources are managed with empathy, service design is constantly tweaked and tested, standards are higher than any other facility and all other hurdles are removed. What is even more intriguing is that RMK doesn’t view this as charity. One of the most important things Dakshas learnt at VHC is how everything and everyone’s interests are interconnected. We realized that it is our own interests that we serve through Dakshas, and that our interests can only be served by serving others. It is surprising how this brings together all the medicine, medical research and management skills that went into designing Dakshas. 

Reaching rural communities through their own

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For the last four years, Dakshas has been looking for a way to regularly reach out to rural communities. We felt that weekly, or more often monthly, interventions do not make the cut. Not only do we become sporadic and incidental, rural communities just see these camps as a way to obtain symptomatic medication. 

However, the recent intake of General Bedside Assistants from Pratham may just be what the doctor ordered! General Nurse Assistants are candidates from nearby villages, who are given three months of residential training under the Healthcare Sector Skill Council, National Skill Development Corporation. They are taught to provide hospital grade support in patient hygiene, nutrition, basic investigations and medication. 

Five such bedside assistants will be rotated through Dakshas’ partner hospitals and old age homes this year. They will be further trained in basic pain relief, care of immobilized persons and exercise therapy by a Dakshas physiotherapist. At these old age homes, as part of the training, the trainee will be assigned four abandoned and destitute elderly persons under supervision. They will also be rotated through partner hospitals to further hone their skills.

SEWA (http://sewa.ngo) has graciously sponsored these assistants for Emergency Medical Training under Emergency Management and Research Institute’s (EMRI) First Responder (FR) training programme. This is important as these General Bedside Assistants would be called to attend emergencies in old-age-home and urban settings before the ambulance arrives. 

After 6-12 months of training, they will return to serve their villages, while receiving an honorarium. Dakshas will continue to monitor their interventions in real time. 

The aim is to  establish a permanent link with rural communities, so that  care can be provided on a daily basis under remote surveillance. Also, further medical interventions can be initiated promptly in real time or at weekly intervals. First-aid and proper transportation to referral facilities can be ensured. 

And most importantly rural communities will not lose skilled personnel to urban areas

Dakshas’ future trajectory

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Over the course of the last 20 months, Dakshas has grown six times. And this seems impressive. However, when we pause to examine Dakshas’ impact in the context of  the problems faced by the health sector today, we fall short. Approximately 55 million Indians become poor every year due to healthcare expenses. Dissatisfaction and conflict has reached alarming levels. So much so that some medical students now opt for non-clinical careers to avoid patient contact — something unheard of when we were medical students.

On mulling over the problem, we realised that the solution lay in ‘growing the idea, not the organization.’ For, ideas scale faster; can turn viral; and achieve the impact an individual organization may only dream of.

To fuel exponential growth, we made three fundamental changes in our orientation:

1. We inverted the organogram

This resulted in the frontline team members, who actually deliver the services,  residing at the top of the chain. Those they report to only act as resources to enable frontline performance.

2. We adopted fractal-based growth

Within our service arm, every individual and resource will be encouraged to replicate itself. Growth will no longer be considered additive or linear, but mutliplicative and exponential.

3. Most importantly, we also envisaged that Dakshas will become a product

A product that can connect a marginalized patient to a healthcare provider who has free time or a resource. This will allow Dakshas to link NGOs with healthcare providers who can spare free capacity. It will open up the health system for poor patients who cannot afford care. It will allow healthcare partners to earn variable cost against their free capacity. However, as a policy, it would not reinvent resources.

 Dakshas has set in motion a process that has the strength to encourage stakeholders to realign from competition to collaboration, ensuring that Universal Healthcare is within our grasp.

Ready, STEADI, go

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Three weeks ago a patient walked into the Dakshas clinic at the Vivekananda Health Centre. She had been referred to us by a partner NGO She was 80 years old and had a fracture. She had fallen in the bathroom and fractured her hip. She was in tremendous pain and anxious  It would have been so much better if she had never fallen and fractured her hip. 

With 8.6% of India’s population being categorised as geriatric, prevention of falls can save considerable health expenditure. Around 20−30% of the injuries among the elderly can be attributed to falls and, in fact, they are one of the leading causes of death among them. And the truth is that no fall is harmless. Every time, it leads to a loss of confidence in carrying out one’s daily activities and could result in breakage of bones, head injury and hospital stay. Hip fractures are the most common in falls and can make a senior/elder patient bed-ridden for the rest of her/his life. 

Since May 2019, Dakshas has been working with old age homes to implement a fall prevention programme called STEADI (Stopping Elderly Accidents, Deaths and Injuries). STEADI, which is the Centre for Disease Control and Prevention’s (CDC) programme to prevent the elderly from falling. STEADI offers us just the programme we need  to prevent falls among the elderly. We identify elders who could fall and mark them as either ‘high’, or ‘moderate’ or ‘low risk’ through various checklists. We then conduct interventions like providing inmates at old age homes (how many) with regular strengthening, balance, and gait training programmes. All elders with high and moderate risk are referred to the physician and provided with walking aids. All osteoporotic patients are given vitamin D supplements. 

Over the last five months, Dakshas has screened approximately 691 seniors, 508 of whom where in various old age homes. Among them, 119 reported a fall in the last one year, and over 300 used furniture to support themselves. Various medical, orthopaedic, neurological and ophthalmological measures have been introduced to prevent falls. Ambient risk factors have been also discussed with the old age homes. 

Risk of fall pie chart

Post our intervention, no further falls have been  reported in the old age homes, which Dakshas now visits regularly. 

A survey six months later reveals that the absence of the following precautions contribute to   a high risk of falling:

  • grab bars in toilets; 
  • non-slip rubber mats in washrooms; and
  • mats in corridors leading to bathrooms

Dakshas hopes to rectify the situation over the coming weeks.