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array_files[0]=new Array(0,1,"./paper-8-addressing-the-issue.html","2009-10-09","11K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Addressing the issue Understanding the prevalence of mental illness as well as details of the existing systems in India, we will now review the strategies that have been taken to treat mental illness in the population, and how each initiative has been successful or has failed. � Previous Section: Conclusions about disorders in specific populations Next Section: Government initiatives � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[1]=new Array(0,1,"./paper-8-appendix.html","2009-10-09","11K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Appendix (Page 1 of 2) Appendix A DSM-IV Axes Appendix B DSM-IV Diagnoses Appendix C ICD-10 Classifications � Previous Section: Conclusion and recommendations Next Section: Appendix (2 of 2) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[2]=new Array(0,1,"./paper-8-appendix-2.html","2009-10-09","22K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Appendix (Page 2 of 2) Appendix D The Banyan Formed in 1993, the organization’s main purpose is to rescue and rehabilitate homeless, mentally ill women, offering them treatment, therapy, vocational training, and community support. Women are rescued from the streets and brought to the rehabilitation center, Adaikalam, which in Tamil means “shelter.” There, they go through stages of rehabilitation until they are prepared to enter society again. The Banyan helps to reunite these women with their families, fully educating the family members about the patient’s condition and how to care for her. When this is not possible, the women are moved to a different center in Kovalam. The women sent there from Adaikalam continue treatment, and also become part of the community. They participate in additional vocational training, making crafts that the center sells, and earning a small wage. The Banyan Village program in Kovalam is a small community living center for the patients, with a few caretakers. They are encouraged to take care of themselves and live as independently as possible. The directors of this program note that even chronically ill women who were not fit to re-enter society have shown enormous improvement from the experience of living in The Banyan Village. The Banyan center in Kovalam does not only treat the mentally ill; it is also a clinic, modeled after a PHC with a mental health care component. It caters to around 400 patients, most of whom are outpatients. The center has a very unique set up, located in close proximity to a Dargah and some faith healers. Usually the mentally ill are brought to either center for spiritual healing. When treatment fails in these places, families will be more likely to come to Banyan for additional help. The Banyan coordinators note that the traditional healing and prayer had a beneficial effect on the patients who come for treatment, and that those institutions were important to consider and incorporate. They also importantly note that at times these traditional methods sometimes produce results all by themselves. The patients that come often pay respects to all three centers, and between the three they get pharmacotreatment as well as a supportive community. In this way, the Banyan has succeeded in incorporating aspects of traditional healing with clinical therapy and treatment, and has been successful. The Banyan also makes excellent use of community health workers. They train their own community health workers to recognize mental illness, and to provide information to the families and patients about mental illness. The workers take on the responsibility of caring for the mentally ill without needing extensive psychiatric training, by working to ensure the patients receive proper care for their condition. For example, though Banyan does not house and rehabilitate mentally ill men they do provide support through their community health workers, who will work with the patient and the patient’s family to find suitable care in a hospital or other government program. They are also responsible for making house visits to previous Banyan patients, ensuring that the families are taking proper care of the patient, and that the patient is taking medications and has not relapsed. Offering just two days of training with a qualified psychiatrist, the Banyan has found an effective way to use community health workers to care for the mentally ill in their community. (Information from personal correspondence and The Banyan website, see references) Appendix E Schizophrenia Research Foundation In 1984, the Schizophrenia Research Foundation India (SCARF) was founded with Dr. M. Sarada Menon’s vision of a non-profit NGO that could address some of India’s pressing mental health problems. From the current headquarters in Chennai, India, SCARF focuses on furthering research in the field of mental health, providing rehabilitation, residential, and vocational training facilities for those inflicted with mental disorders, educating the public about the importance of mental health, offering mental health resources in urban slum and rural settings, and training members of the community to provide diagnostic and preventative mental health care within rural areas. Even though SCARF is involved in a multitude of projects, the organization has an underlying motive of helping to remove the stigma associated with mental disorders in India, setting it apart from other foundations. The facilities that are provided in Chennai itself are geared towards helping people with Schizophrenia and other mental disorders. SCARF has several residential sites that provide support for people with mental disorders who are not able to rely on their family members all of the time. At these residential centers, different activities are offered to keep the patients occupied, which has proven to be an effective rehabilitation method for people with Schizophrenia. These activities range from arts and crafts to producing goods to sell in the community. In SCARF’s day care center, patients are taught a trade as a part of vocational therapy, for which they are paid to produce. Both men and women receive care, which includes free medications and admittance to the rehabilitation program. Although SCARF is immensely involved in Chennai, many resources are provided in the rural and urban slum areas. SCARF’s research initiatives have included work in the field of Schizophrenia, treatment methods for different mental disorders, effects of mental disorders on family life, and community mental health. In all of these fields, SCARF has made significant progress, but it is through the field experience, community efforts, and rehabilitation programs that SCARF has truly made a difference. From making simple pamphlets, flyers and posters, to performing skits about mental health in rural communities, SCARF has been active in providing the community with resources about mental health. Through immense work experience in the field, SCARF has noted that the stigma surrounding mental illnesses has reduced over the years, but the discrimination against those who have a mental disorder still persists to this day. The organization believes that this can be attributed to the fact that there is a lack of awareness about the causes and the proper methods of treating mental illnesses. To tackle this, SCARF has been involved in training Community Health Workers (CHWs), and has acknowledged that it is an effective method of outreach and providing resources to the mentally ill in less developed communities. SCARF, in collaboration with other field organizations, has trained teams of CHWs to diagnose different mental disorders. In SCARF’s program, CHWs are trained for at the most three days, which is built upon by monthly workshops that provide the CHW with in-depth knowledge about mental disorders. Training is done by a psychiatrist, and depending on the training there could be intermediaries of coordinators or field level coordinators, who use audio-visual and observational personal interaction supplemented by Power Point and written manuals as training mediums. These CHWs play an integral role in the community, as they are able to recognize disorders, make referrals for patients, deliver medications, provide supportive care to families and patients, and raise awareness within the communities. As a part of SCARF’s community outreach efforts, the organization has created a series of clinics that have taken place in Kanchipuram, Tambaram, and Chetput in Tamil Nadu. At these clinics, well-trained professionals write prescriptions, and the field workers are in charge of dispensing the medicine properly. SCARF has adopted the concept of community clinics that are run fortnightly or monthly to provide medicines for mental disorders and to perform follow-ups for the patients who have been diagnosed with mental disorders. This has proved to be an effective way of community outreach and has become one of SCARF’s methods of providing health care at the primary level. (Information from personal correspondence and SCARF website, see references) Appendix F Sangath A large number of the interventions done by Sangath involve training lay people in raising awareness and outreach to the community, but also in providing treatment. Community outreach workers are also trained to work with people living with HIV, in the area of mental health. School health counselors are trained to deliver health education to adolescents in schools, and anganwadi workers are trained to promote early development among preschoolers. Their program called ‘Saathi’ is involved in promoting mental health among children with disabilities. The aim was to train the staff of a school for children with special needs to work with the parents and families of the children, and help the children while they are in the developmental phase. Currently they have developed the program in three schools, and are continuing to collect feedback on these programs. The program MANAS is currently being implemented by Sangath, with the purpose of integrating care for common mental disorders with primary care. Using evidential research from published trials, and intervention was planned that integrated a number of mental health care services with primary care, including psychoeducation, dispensing of antidepressants, and group interpersonal therapy. To involve the PHCs in the area, they conducted brief informational meetings as well as consultation with stakeholders and formative research to evaluate each specific intervention. After obtaining agreement, the program was able to obtain support from a number of general physicians, and also developed training programs for the physicians as well as for lay workers. The training manuals are all available freely on the Sangath website. MANAS was piloted in 12 PHCs in Goa, treating 2,000 patients that were diagnosed with a common mental disorder, over the course of one year. Currently the evaluation study is being done by a partner NGO, to ensure that results are interpreted without a bias. Sangath has received the McArthur Foundation International Award in 2008, for all of the valuable work the organization has done. With the effective use of resources to spread awareness and provide care for the community, this program is a successful model for any service organization. (Information from personal correspondence and Sangath website, see references) � Previous Section: Appendix (1 of 2) Next Section: References � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[3]=new Array(0,1,"./paper-8-classification-and-diagnosis.html","2009-10-09","15K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Classification and diagnosis of mental illness There are two principal methods used to classify mental illnesses. The Diagnostic Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) is published by the American Psychiatric Association and is the main source of psychiatric diagnosis in the United States as well as many other countries. It covers all mental disorders and includes information about causes of the disorders, gender statistics, age at onset, prognosis, and current research being done. The DSM-IV organizes the diagnosis process in the form of broad Axes, as summarized in Appendix Figure A. Under Axis I, diagnosis, is a list of specific mental disorders, included in Appendix Figure B, along with general summaries of each. The International Classification of Diseases, Version 10 (ICD-10), published by the World Health Organization is a comprehensive classification of disease, with a chapter (Chapter V) devoted to mental and behavioral disorders. Appendix Figure C shows the organization of topics under ICD-10, and the general descriptions of the mental disorders listed in the DSM-IV Appendix Figure B can be applied to the ICD-10 categories as well. The two systems have many similarities, as well as important differences. They share many similarities in diagnosis of diseases such as depression, dysthymia, substance dependence, and generalized anxiety disorder. However, there are lower concordance levels for a number of other diseases. For example, according to one study by Andrews et al. (1999), the ICD-10 system of diagnosis tended to indicate a larger percentage of social phobias, panic disorder, and post-traumatic stress disorder. The opposite was true for agoraphobia and obsessive-compulsive disorder, for which the DSM-IV indicated a higher prevalence. In general, the ICD-10 was shown to have a lower threshold for diagnosing mental disorder than the DSM-IV (Andrews et al. 1999). There have been arguments that the ICD-10 structure is inflexible, and does not provide the full range of choices for doctors to diagnose certain illnesses. For example, among the F2 disorders listed, the diagnosis is based strongly on duration of symptoms. A diagnosis may change depending on persistence of symptoms, and often the time of remission required can delay a diagnosis, or the change in diagnosis after treatment can cause the patient to stop taking proper medications and relapse (Bertelsen 1998). The Axis structure of the DSM-IV often allows more flexibility in diagnosis, which in some cases makes it a better option. The World Health Organization uses the ICD-10 system for diagnosis. This review will compile data from studies that use both, and will specify which system was used. Many studies also use more specific surveys or diagnostic methods for research as well. These are questionnaires or criteria specifically tailored to a certain disease. Often, they offer a more in-depth diagnostic criteria or a way to quantify the extent or severity of a certain disease. Common examples in the literature include the Hamilton Rating Scale of Depression, The Panic Disorder Severity Scale, The Positive and Negative Symptoms Scale, The Beck Depression Inventory, and The WHO Quality of Life Assessment (Wiley-Exley 2007, Manjula et al. 2009). The term Common Mental Disorders (CMDs) is commonly used by mental health professionals. CMD was a term coined by Goldberg and Huxley (1992) to describe “disorders which are commonly encountered in community settings, and whose occurrence signals a breakdown in normal functioning” (Patel et al., 1999). Depressive and anxiety disorders are classified as separate diagnostic categories in the ICD 10. The concept of CMDs, which are basically depressive and anxiety disorders, is valid in community settings because of the high degree of comorbidity between these categories and the similarity in their epidemiological profiles and treatment responsiveness (Patel et al., 2006). � Previous Section: Etiology of mental disorders Next Section: Global burden of mental illness � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[4]=new Array(0,1,"./paper-8-community-mental-health.html","2009-10-09","19K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Community Mental Health Adopting a model of care based around the community is being seen as an increasingly “appropriate method of care for mentally ill individuals” (Wiley-Exley 2007). A community- based model moves the care out of an institutional setting and onto the ground floor (Chisolm et al. 2007). While many government programs are floundering in the face of dealing with mental health, a renewed approach based on community psychiatry could offer an exciting opportunity in the developing world. Jacob (2001) identifies important issues to consider in a move towards community mental health. The shift in focus to a local context that focuses on achievable goals surrounding identification and treatment of priority disease is essential. Only after these initial priorities are reached should future, more progressive, goals be set. Also, building up skills and partnerships with community health workers and other health professionals in the community, be they modern or traditionally based, is critical. In a review of the literature, Wiley-Exley (2007) sees the drive towards community mental health as the result of “a human right approach to mental illness, an international effort to integrate community and primary care methods of health services into mental health care and research that has provided evidence of community mental health services facilitating more clinically cost-effective care.” All but one of twenty studies covering fourteen developing nations, four major illness categories and a number of varied community based interventions showed positive effects on at least one outcome including positive cost-outcome results. Only three studies noted any negative outcomes from the interventions. This paper also emphasized the importance of adapting any of these techniques to the local context and not simply replicating them without modification. Many developing countries are beginning to use these community-based models for mental health with varying degrees of success. In Kenya, 1994 marked a switch of decentralisation of mental health care to all levels of the health care system along with an emphasis of treatment by a health staff rather than simply mental health specialists. Muga and Jenkins (2008) compare the attitudes of district health workers on mental health three years after the switch in policy. The study found an interesting contrast in responses. 146 of the 148 participants agreed with the underlying philosophy of a decentralised mental health policy. They admitted the importance of non-health professionals as well as lay people; however, they also emphasized specialist care, a focus on technology and pharmacology as well as some disdain for the difficulty of diagnosing and caring for the mentally ill. The workers largely wanted to adhere to a medical model of care rather than the biopsychosocial model the government tried to implement. This disconnect compromised the primary health care concept of the health policy and made it difficult to perform effectively. Nigeria had more success with their grass-roots awareness program in increasing use of community-based mental health services (Eaton and Agomoh 2008). Nigeria has large levels of stigma and magico-religious belief and treatment surrounding mental illness, the largest population in Africa and a shortage of mental health professionals. Mental health was adapted as a part of the local care structure in 1991 but this has led to little action. Through the efforts of the Amaudo Itumbauzo, an NGO, and the government, 57 community psychiatric nurses have been placed throughout three southern states in recent years. These nurses conduct home visits, basic prescribing, referral, and other treatments. Continuing this type of outreach, 2310 village-based health workers (VHWs, simliar to community health workers) from three states were trained over four years to conduct mental health promotion, monitoring and education. The result of this grass-roots community campaign was a statistically significant increase in the number of patients attending psychiatric clinics in the two months following the campaign with sustained results through the following year. Nigeria offers a great example of how a community-based intervention can be successful in face of the many problems of the developing world. The structure of the Nigerian health system, its large population and lack of mental health resources invoke many parallels to the Indian situation. The Nigerian results offer hope for success of similar models in an Indian context. The literature surrounding community- based interventions supports this as well. Chatterjee et al. (2003) worked with an NGO, Ashagram, in the Barwani district of Madhya Pradesh, to conduct a community-based rehabilitation program for schizophrenic patients. The model consisted of “first tier” out-patient clinical services with monthly follow-ups that reviewed drug treatment, educated the family and offered rehabilitation strategies. The control received just out-patient care while the intervention group received out-patient as well as second and third tier interventions. The second tier consisted of locally selected mental health workers who provided services to patients in the community setting. The third-tier included family members and key community members who were made to form local village health groups to address proper rehabilitation and stigma reduction practices. After 12 months, participants in the intervention group were more compliant with their medications (63% v. 46%), had better clinical and disability outcomes. This engagement of the community leads to better outcomes but also takes up considerably more resources. The MANAS intervention in Goa, India, conducted by Chatterjee et al. (2008) also showed the success a community-based program can have in India. This intervention was geared towards addressing common mental disorders in low and middle income countries. The interventions used my MANAS were all based on published, evidence-based research and included psychoeducation, pharmacotherapy and group interpersonal therapy. Essentially the intervention was a reconfiguration of the human resources and the principles of treatment delivery at the primary care level. An emphasis was made on individualizing treatment. Details of the program were worked out through consultation with local, national and international stakeholders (ex: education must be kept short, drugs must be free, evening meetings, inclusion of yoga, etc.). The intervention was refined and fixed through multiple phases and issues like addressing non-adherence and shifting responsibilities amongst staff were undertaken. Health outcomes were not assessed in this study but rather the feasibility of the model. Though there were problems with adherence and the group therapy sessions, yoga classes and provision of drugs were both successful. The best lesson learned from this study, however, was the effectiveness of evaluation, flexibility, adaptability and an open mind to the community you are serving. These studies show the effectiveness, but also the potential obstacles to implementing community-based care. A constantly evolving model is needed to address unforeseen problems in the system. If a model fails to adapt, those within the system will also fail to fully adhere to the desired goals. The MANAS program is based on this constant input of feedback and an open evaluation. The situation in Kenya offers the opposite side. A directive was broadly proclaimed but not followed up. Because of this, no one truly changed in practice and the old system persisted. For the mental health programs to be successful in India it is key to incorporate the community model. It is within this community scope that rest of the paper should be viewed. � Previous Section: Government initiatives Next Section: NGO initiatives � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[5]=new Array(0,1,"./paper-8-conclusion-and-recommendations.html","2009-10-09","14K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Conclusion and recommendations Mental illness is a problem in low and middle-income countries. In India, there is no established system for addressing mental illness at the community level, with the exception of private or civil society initiatives that have sought to address specific populations. Considering the cases presented in this review, there is reasonable justification to implement an affordable and accessible system of mental health care at the primary level that cooperates with the existing health care infrastructure. In order to work towards building a system of community mental health care, there are a series of steps that need to be taken. First and foremost, IKP Centre for Technologies in Public Health (ICTPH) needs to recruit mental health professionals, such as psychiatrists, psychologists, and social workers. These professionals will contribute towards designing a preliminary research study, which investigates the needs of specific communities in Thanjavur District. A proper and scientific needs assessment of the community is an integral part of understanding the prevalence of mental health concerns. This research method should incorporate observation, focus group discussions, surveys, and in-depth interviews with the different stakeholders, which include doctors, faith healers, community leaders, etc. Based on the results of the needs assessment, appropriate interventions need to be planned. These interventions must start with targeted issues in order to be most effective. Interventions should include raising awareness at the community level to further preventive health care. This venture will sensitize the community towards individuals with mental disorders, which will subsequently help reduce stigma and discrimination. In order to achieve the long-term goal of providing community mental health care, it is imperative to build a team of community health workers who are trained to specifically work in the field of mental health. Community health workers will be trained to diagnose disorders, carry out appropriate referral, and provide supportive counseling to the patients and their families. They will also be involved in raising awareness and educating the community through the use of media, all in the interest of integrating mental health care. Another effective intervention could be collaborating with schools. This will not only help raise awareness, but it will also help in diagnosing mental disorders in children and adolescents. By involving the students, teachers, and parents in this process and inviting counselors to visit schools, the community will be more sensitized towards mental disorders. There are obvious gaps in the mental health system in developing countries. However, by formulating context- specific and culturally sensitive programs designed for effective care at the community level, equal access and resources can be provided to all individuals. � Previous Section: Conclusions about treatment options Next Section: Appendix � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[6]=new Array(0,1,"./paper-8-conclusions-about-addressing-the-issue.html","2009-10-09","11K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Conclusions about addressing the issue Government initiatives and private initiatives have both striven to treat mental illness in the population. The government programs were not successful, primarily because of overreliance on pharmacotreatment, and lack of resources being allocated to effectively provide treatment to the population. Private organizations have been effective in many states, and have successfully provided treatments and access to community support to many patients in disadvantaged areas. However, while numerous and motivated to provide aid, private organizations cannot cater to large populations effectively, without a partnership with government organizations. � Previous Section: NGO initiatives Next Section: Treatment options � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[7]=new Array(0,1,"./paper-8-conclusions-about-disorders-in-specific-populations.html","2009-10-09","11K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Conclusions about disorders in specific populations The review of these populations serves to illustrate the ubiquitous nature of mental illnesses in the Indian population. The prevalence of mental disorders in children illustrates the need for early intervention and preventive strategies, particularly for substance abuse and suicide prevention. For women, social poverty is an important factor in mental health, as well as living in patriarchal societies. The geriatric population is often ignored and mental illness is mostly not recognized in the first place. In all three populations, it is important to address the problems of stigma and discrimination. Mental illness is by no means a ‘disease of the affluent,’ but rather affects all demographics within a population, as has been discussed. � Previous Section: Geriatric disorders Next Section: Addressing the issue � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[8]=new Array(0,1,"./paper-8-conclusions-about-treatment-options.html","2009-10-09","14K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Conclusions about treatment options Whether treating a patient by means of traditional methods, psychotherapy, pharmacotherapy or some combination of the above, the goals are always the same: a healthy patient. Magico-religious treatments present an interesting quagmire for the treatment of mental health. While clear human rights violations such as the Erwadi incident need to be stopped, there are a plenty of traditional healers who have nothing but the best interest of the patient in mind. The potential impact these healers can have on a successful recovery cannot also be overlooked. Providing proper facilities where people know they can get good mental health care would protect against the use of Erwadi-like asylums. Also, by educating the community and performing outreach to the traditional practitioners, these modern and ancient techniques can work hand in hand as complements towards a healthy patient. Though an over-reliance on medication may be a problem in the Indian national mental health structure, it would be crass to devalue the importance medication does have in the treatment of mental health. Ideally access to medicine would remain high and medications would be delivered correctly and with a high adherence while at the same time being complemented by other treatments. Alone medications might not always work, but they often do and often even better when combined with other forms of therapy. No treatment is perfect and problems, of course, exist with both forms of treatment. Limited time and mental health resources can make even the shortest psychotherapeutic interventions simply unmanageable for both the Indian patient and therapist. A therapist properly trained in any of the therapeutic techniques mentioned here is a rarity in places like India. It is therefore important to be generally familiar with the therapies and try to locally adopt the best practices of each to fit the situation needed. Often times, many of the components of supportive or cognitive behavioral therapy will make their way into the most basic of therapeutic interventions. Facets of these interventions could fit well into community-based treatment and outreach models as well as adapted to group settings and support groups. The utility that these therapies can offer the community when integrated correctly is vast. Another concern that needs to be addressed is that many of the psychotherapy studies listed above are not from India or even the developing world even though they are being used in or considered for the Indian context. It is an unfortunate reality that in many cases little research is available for many of these interventions in any developing country, let alone just India. This is a trend that is changing however and the future should show promising developments in these fields. It would take time, determination and likely a fair amount of funds for any organization to be able to provide the proper training, conduct research and roll out effective mental health care, but as much of the above research shows, the tools are there; they just need to be wielded responsibly by competent hands. � Previous Section: Psychotherapy (2 of 2) Next Section: Conclusion and recommendations � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[9]=new Array(0,1,"./paper-8-disorders-in-specific-populations.html","2009-10-09","12K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Disorders in specific populations Mental illness is present in all demographics of any population. The next sections will discuss the prevalence of mental illnesses organized by three key demographic groups: children, women, and the elderly. Children’s mental health is an area that has not been deeply researched, but is important to consider, particularly as a major preventative care opportunity. Women’s mental health has been an important issue, one that has also been overlooked. The WHO Global Burden of Disease reports that unipolar depressive disorder in women accounts for 4% of all DALYs in low income countries, whereas for men it accounts for only 2% (WHO Global Burden of Disease 2004). Similarly, the geriatric population suffers high rates of illness, in the population over 70 it was found that more than 50% suffer from chronic conditions (Ingle 2008), and mental illnesses also place a heavy burden on the geriatric population. The following paragraphs will expand on the details for each demographic, discussing the prevalences of mental illnesses and presenting studies targeted to each population. � Previous Section: An Indian perspective (2 of 2) Next Section: Pediatric disorders � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[10]=new Array(0,1,"./paper-8-etiology.html","2009-10-09","15K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Etiology of mental disorders Causes of health and disease are generally a product of the interaction between biological, psychological, and socio-cultural factors. Stressful life events, affect (mood and level of arousal), personality, and gender are prominent psychological influences. Social influences include parents, socioeconomic status, racial, cultural, and religious background, and interpersonal relationships. Genetic factors Schizophrenia is linked strongly to genetic factors. Since 1980, 11 major family studies of schizophrenia have been reported that used blind diagnoses, control groups, personalized interviews, and operationalized diagnostic criteria. Every study showed that the risk of schizophrenia was higher in first-degree relatives of schizophrenic patients than in matched controls. The mean risk for schizophrenia in these 11 studies was 0.5% in relatives of control and 5.9% in the relatives of schizophrenics. Modern studies suggest that, on average, parents, siblings, and offspring of individuals with schizophrenia have a risk of illness about 12 times greater than that of the general population (Evans, et al., 2005). But this does not mean that genetic factors completely fix the nature of the disorder and that psychological and social factors are unimportant. Social factors modify expression and outcome of disorders. Some mental disorders, such as post-traumatic stress disorder (PTSD), are clearly caused by exposure to an extremely stressful event, such as rape, combat, natural disaster, or concentration camp (Yehuda 1999). Yet not everyone develops PTSD after such exposure. On average, about 9 per cent do (Breslau et al., 1998), but estimates are higher for particular types of trauma. For women who are victims of crime, one study found the prevalence of PTSD in a representative sample of women to be 26 per cent (Resnick et al. 1993). The likelihood of developing PTSD is related to pretrauma vulnerability (in the form of genetic, biological, and personality factors), magnitude of the stressful event, preparedness for the event, and the quality of care after the event (Shalev, 1996). The relative roles of biological, psychological, or social factors also may vary across individuals and across stages of the life span. In some people, for example, depression arises primarily as a result of exposure to stressful life events, whereas in others the foremost cause of depression is genetic predisposition. Social factors Research in both developed and developing countries has shown the link between poverty and poor health status. Poverty and its associated psychosocial stressors, such as violence, unemployment, and insecurity, are correlated with the onset of adult mental disorder (GMH 2). Children born into poverty face various risk factors for mental and physical illness. Risk factors in poor children’s families and communities combine with scarcity of protective factors to increase the likelihood of mental health problems and developmental disabilities. A review of 11 community studies in six low income and middle-income countries in Africa, Asia, and Latin America, reported a consistent association between poor education and high rates of mental disorders. Sex is also an important determinant of mental disorders, help seeking, and the need for services. In many countries, more women than men meet criteria for common mental disorders such as anxiety and depression. Patel et al. (2006) showed that nearly half of the people who attended primary care in India had common mental disorders, and that disorders were associated with poverty and female sex, after controlling for other social and demographic variables. � Previous Section: Introduction Next Section: Classification and diagnosis of mental illness � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[11]=new Array(0,1,"./paper-8-geriatric-disorders.html","2009-10-09","21K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Geriatric disorders The increasing life expectancy and decline in mortality have led to an increase in the elderly population in India. The 1981 census reported that the elderly comprised 6.5% of the population, compared to 8% in 2001. With this demographic shift, it is becoming more important to properly treat the medical problems of the elderly. Prevalence of mental Illness in geriatric populations A variety of surveys have demonstrated that there is a high percentage of mental illness in the elderly population. One carried out by Ramachandran et al. (1980) in Poonamallee found that psychiatric disorders were present in 35% of the elderly population. Of this, the rate of depression was found to be 240 per 1000 population, and schizophrenia was 10 per 1000. Not only are psychiatric disorders highly prevalent among the elderly, but also they often contribute to the other somatic illnesses that the elderly face. These psychiatric comorbidities often go undiagnosed. Recently, a study by Sood et al. (2006) at the Government Medical College in Amritsar looked at the mental health of 528 non-psychiatric patients aged 65 years and above, using the psychogeriatric assessment scale (PAS), which is a standardized interview for dementia, depression, and related disorders in the geriatric population. They found that 49% of the patients interviewed had a psychiatric co-morbidity. Depression was the most common (25.9%), followed by adjustment disorders (11%), anxiety disorders (4.54%), dementias (3.6%), delirium (3%), bipolar disorders (0.8%), and substance-related disorders (0.4%). The high prevalence of psychiatric disorders that were undiagnosed and untreated prior to this study indicates tremendous gaps in the mental health care available to the geriatric population. Study: Community support The question is how to remedy this situation by providing geriatric patients with proper support for their illnesses. A 2006 study provides findings of examining an old age home, Mumukshu Bhavan in Varanasi as well as the psychiatric outpatients of the Institute of Medical Sciences (Tiple et al. 2006). Based on a DSM-IV diagnosis, the prevalence of mental illness in Mumukshu Bhavan was found to be 37.8%, with depressive disorders comprising about 35% of cases. For the psychiatric patients, depressive disorders comprised 21.42% of cases. Importantly, the study also measured the level of objective and perceived social support that patients received. The objective level of support was measured by surveying the number of close friends or relatives each patient felt they had. Those in the old age home perceived a greater level of good support than the objective survey reported (47.05% vs. 22.61%), while those in the outpatient clinics perceived a level of social support that was less than the objective level reported (2.38% vs. 35.9%) (Tiple et al. 2006). This indicates that the community aspect of Mumukshu Bhavan, where prayers and other spiritual discourses were a part of daily life, plays a role in providing support and care for the mentally ill, particularly the elderly. Dementias While senile dementia is not the most prominent of geriatric mental health disorders in India, it is estimated by research surveys that approximately 16 million people suffer from this memory behavior, and personality disorder in the low and middle-income countries around the world. According to Patel et al. (2001), dementia accounts for one-quarter of the DALYs while depression accounts for one-sixth of the geriatric population around the world. Within India certain case studies have found that there might be over three million people with various types of dementia (Mishra 2009). However, a large number of the cases of dementia go unreported due to ignorance or stigma, thus an accurate figure has not been reached and numbers can only be derived from sample studies and surveys. Unfortunately, the stigma associated with the forms of dementia is one of the leading reasons why treatment for this senile personality and memory degenerative disease can be scarce in rural areas. The lack of education in these lower-income areas has allowed these populations to believe that cases of dementia are irrelevant or just a normal behavioral change related to the process of aging. In some cases, people with dementia will not consult a doctor at all. In fact, a study conducted in Kerala showed that when caregivers were consulted, they misinterpreted dementia as “deliberate misbehavior by the [elderly] person” (Prince et al. 2007). Furthermore, the unawareness about the causes and the symptoms of this mental illness encourages hospitals to dismiss cases or provide very minimal treatment. Despite this general lack of knowledge about dementia, the stigma placed with the disease has restricted the outreach of more education. While dementia and Alzheimer’s are widely recognized as social disorders, the public continues to regard them negatively. In Kerala, the word used to describe dementia, Chinnan, literally translates to “childishness”, and in other parts of India terms like “weak-brained” or “tired-brained” are given to elders who have this mental disorder (Prince et al. 2007). Perhaps this stigma is largely due to the fact that the families of the affected people feel embarrassed and ashamed to reveal any imperfections to the public. But the reality is that the stigma surrounding dementia can only be defeated through education of the public and strict government policies regarding the treatment of mental illnesses. Hence, a large responsibility has been placed on private organizations and research industries to understand the cases of dementia on a global scale as well as within India. In 1998, the 10/66 Dementia Research Group was founded in Cochin, India, and has since sought to further the epidemiological research and survey various developing countries about dementia in order to suggest practical healthcare methods for dealing with this geriatric mental issue. The name 10/66 is derived from the demographic information about dementia. It refers to the fact that only 10% or less of the population-based research on dementia has been carried out in low to middle-income nations when 66% of the world’s population of people with dementia live in those countries. In 26 centers located around the world, the 10/66 Dementia Research Group found that the Geriatric Mental State, the Community Screening Instrument for Dementia and the CERAD 10 were all viable education-fair diagnostic tests that could be used to detect dementia. The typical DSM-IV diagnostic criteria have a lower threshold than the 10/66 diagnostic criteria, due to cultural differences. After collecting data in seven different locations in India, the study showed that out of the 2,000 residents in each testing site (age 65 and over), a DSM-IV diagnosis showed a prevalence rate of 1% while the 10/66 diagnoses showed a rate of 10.6% (Prince 2009). The organization explains that there may be biases in the cognitive tests, inconsistencies in the number of people in the different testing locations, issues with the DSM-IV diagnostic criteria or other problems that may have caused the large range of percentages. While this is just one survey that the 10/66 Dementia Research Group has performed, there are hopes to improve the methodology and create a “multi-centric prevalence survey” in India that could prove to be a more thorough survey of the entire population (Prince 2009). A qualitative study was conducted by Patel and Prince (2001) in Goa, India, concerning geriatric mental health in developing countries. The study used focus group discussions (FGD) in which interviewers and researchers facilitated and recorded the proceedings of the discussions. Older persons were brought into one of the five groups of 37 people in the FGD. Each group was asked a series of questions related to the health problems and services their community provided. In regards to dementia, participants stated that it was typically associated with a stigma and that by educating family members about dementia, the affected could receive a higher level of care. Similarly, a participant mentioned that senile depression was fairly common. The participant assumed that about “five out of 10 families” had this “social” problem (Patel and Prince 2001). It was also found that primary health care doctors did not have adequate training in the field of mental health disorders, making it difficult for the elderly to find support. According to many sources, the lack of recognition of mental disorders, the stigma placed on these disorders, and the lack of awareness about mental health in general are some of the major dilemmas that the elderly continually face in rural India. But it is consoling that many private organizations and research foundations are seeking to assist in the process of bettering the outreach of information that is given to the public about mental health and providing more resources at the primary healthcare level for the treatment of geriatric mental health disorders. � Previous Section: Womens disorders Next Section: Conclusions about disorders in specific populations � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[12]=new Array(0,1,"./paper-8-global-burden.html","2009-10-09","15K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Global burden of mental illness Mental illness is a nontrivial contribution to the global burden of disease. The burden of illness is analyzed quantitatively by disability-adjusted life years (DALYs). It is the sum of the years of life lost (YLL) and the years lived with disability (YLD) due to the illness or injury. The YLL value is calculated by the number of deaths at each age multiplied by the global standard life expectancy for each age. The YLD value is calculated by multiplying the number of incident cases of a disease or injury in one year, by the average duration of the disease, and a weight factor between 0 (perfect health) and 1 (death), that reflects the severity of the disease. In this way, the DALY is a measurement that combines morbidity and mortality in one value, estimating the chronic effects of an illness not just by deaths that are caused but also by time spent disabled by the disease. Neuropsychiatric conditions comprise 13.1% of the total global DALYs. They also contribute to over a quarter of the DALYs due to non-communicable diseases, both globally and for low income countries. Currently, unipolar depressive disorders are the third leading cause of burden of disease, and it is projected that by 2030, they will be the leading cause of burden of disease, comprising 6.2% of the total DALYs(Global Burden of Disease Report 2004). How does mental illness compare with other global health concerns? For developing countries, particularly, the prevalence of infectious diseases and maternal health gaps seem like more pressing issues, and in the face of these issues how important can a topic like mental health really be? It is true that infectious disease, and maternal, child, and reproductive illnesses are issues that account for a large portion of the years of life lost (YLL). Lower respiratory infections were the number one cause of YLL in low-income countries, according to the WHO Global Burden of Disease Report (2005). Neglected, however, are the conditions that produce the most years lost due to disability (YLD), such as mental disorders, dementia, and stroke (Prince et al. 2007). Neuropsychiatric conditions make up one third of all YLD for adults aged 15 years and over, and unipolar depressive disorders alone are the leading cause of YLD in low and middle-income countries, as well as in high-income countries (GBD Report 2004). The argument that mental illnesses are more prevalent in developed countries has been shown to be invalid; mental illness is a global concern that is prevalent in developing countries as well as in developed countries, and is a problem that is often not well addressed in developing countries (Das et al. 2005, Saxena et al. 2007). In addition, studies have shown a correlation between mental illness and comorbidities with other physical illnesses. An article entitled “No Health Without Mental Health”, published in 2007 by the Lancet as part of a series on global mental health, reviews comorbidities of mental illness and many other illnesses. These include non-communicable diseases such as cardiovascular diseases and diabetes, as well as communicable diseases such as HIV/AIDS, tuberculosis, and malaria (Prince et al. 2007, Coehlo et al. 2009, Lacovides and Siamouli 2008). A study of a rural population in Tamil Nadu found that body pains were the most frequently reported symptoms of the mentally ill, representing a major somatic manifestation of mental illness (Badrakalimuthu 2009). A mental illness can make it more difficult for a person to recover from a somatic illness; for example a depressed person may show lower adherence to a treatment plan than a mentally healthy person, as has been seen with adherence to HIV and tuberculosis (Prince et al. 2007). With all of these factors to consider, it is evident that mental illness is a pressing global issue, for developed and developing countries alike. The next section will review the burden of mental illness in India. � Previous Section: Classification and diagnosis of mental illness Next Section: An Indian perspective � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
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Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Government initiatives The National Mental Health Program During the 1970s and 1980s, numerous national studies of mental illness evaluated the systems that existed in India as well as gathered epidemiological data. The influx of data also brought to light the cultural considerations of mental illness, The National Mental Health program was launched in 1982 with the following objectives: To ensure availability and accessibility of minimum mental health care for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of population. To encourage application of mental health knowledge in general health care and in social development. To promote community participation in the mental health services development and to stimulate efforts towards self-help in the community. The NMHP hoped to integrate mental health with primary care, as well as secondary and tertiary care. The program has directed state level programs as well as workshops for mental health professionals and voluntary organizations. The NMHP developed the model for the District Mental Health Program, and embarked to create better mental health care facilities in every state. In the years since the program was launched, there has been improvement: the number of psychiatrists tripled from 1,000 to nearly 3,000 within the last twenty years. A number of legislations were passed to bring mental healthcare into primary care, such as the Narcotic Drugs and Psychotropic Substances (NDPS) Act of 1985, the Mental Health Act of 1987, and the Persons with Disability Act 1995. For the first time, mental illness was included as one of the disabilities in the Persons with Disability Act of 1995 (Murthy 2003). These acts, particularly the Mental Health Act, were progressive in nature, providing definitions and nomenclature for a psychiatrist, a psychiatric nursing home, and a psychiatric hospital. The term “asylum” was eliminated, aiming for more progressive terminology. The acts also gave the patients more rights, for example preventing them from being detained in a mental facility without consent or a commitment order (Ganju 2000). A number of other changes have improved mental health care significantly over the past twenty years. Second generation drugs became cheaper and more easily available, families of caregivers have increased their support for the mentally ill in a growing number of community-based self-help groups, the growing number of voluntary organizations has found effective ways of community-based rehabilitation in many areas of the country, and stigma and discrimination of the mentally ill have been recognized by medical professionals (Murthy 2003). The NMHP does have shortcomings. The main tenants and goals of the NMHP are on primary care, with little emphasis on rehabilitation or preventive-promotive care. Also, although the NMHP encourages proper community care along with its recommended medical care, it does not actually give a description of what is “proper.” Therapies such as Electro-Convulsive therapy (ECT) have become more popular within the past twenty years, though this has been a controversial form of treatment, and though the NMHP encourages non-invasive therapy it is silent on specific recommendations. Additionally, a criticism of the NMHP has been that it prioritizes only severe mental illnesses, of mental retardation, epilepsy, and psychoses, when the majority of mental illnesses include a much wider range of psychological problems (Davar 1996). The NMHP nominally encourages community-based non-invasive therapy, but very rarely is this reflected in its programs. The Ministry of Health blames the shortcomings of the program on the lack of well defined models to be put into place (Jain and Jadhav 2008). Additionally, the goals stated by the NMHP have yet to be reached in all states, even today (Murthy 2003). The District Mental Health Program One of the accomplishments of the NMHP was to establish the District Mental Health Program (DMHP) project. In each district, there would be a psychiatrist in charge of overseeing the DMHP, creating a mental health team responsible for visiting different Taluks, providing mental health diagnosis, care, consultation, treatment, and spreading awareness of mental illness. The program was piloted in 1984 in Bellary district, Karnataka, hoping to integrate mental health care into the existing system. The pilot was not successful due to lack of public support and difficulty in taking over the local health staff’s ectivities. Outcomes and adherence to treatment were poor, and community awareness activities were not effective. The model was revised, to include education, investment in hospitals, training and research. Pharmacotherapy was heavily adopted by this program, as the treatment garnered more public support. The program was able to emphasize the “treatability” of mental illness in a way that was more effective than just offering psychotherapy. It was also supported by a budgetary increase (Jain and Jadhav 2008). The DMHP has been successful in select districts, such as in Trichy district, Tamil Nadu, where the authors were able to interview the managing psychiatrist. The DMHP team at the Annal Gandhi Memorial Hospital has sponsored many awareness programs, and it works to provide care for five Taluks in the area. However, even in this district, each Taluk visit is attended by many times more patients than the doctors are able to see in the limited time that they have available. In this, the DMHP has failed to provide adequate accessible care for the rural areas they serve. The NMHP programs maintained the insistence on using the health systems already in place and incorporate mental health care, rather than creating new systems (Ganju 2000, Jain and Jadhav 2008). Union Health Minister, Dr. A. Ramadoss, has recently declared the re-strategized NMHP a “failure,” and announced that a new, improved program will soon be implemented, to run in all districts within five years. � Previous Section: Addressing the issue Next Section: Community Mental Health � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
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Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam An Indian perspective (Page 1 of 2) Prevalence of mental illnesses in India According to the Mental Health Atlas, published by the WHO in 2005, the estimated prevalence of mental illness in India is about 5.8% of the total population. This includes psychosis, alcohol and drug dependence, schizophrenia, affective disorders, neurotic disorders, mental retardation, and epilepsy (WHO Mental Health Atlas). This figure has been supported by a number of other national studies (Nandi et al. 1997, Ganguli 2000, Reddy and Chandrashekar 1998). The suicide rate alone, 17.38 suicides per 100,000 people, is greater than many other South Asian nations (Pakistan at 10.47, Nepal at 10.32, Bangladesh at 12.2), as well as the global median of 6.55 per 100,000 (Jacob et al. 2007). Substance and alcohol abuse is also a major problem; the National Household Survey found that 12.2% of men smoke more than 10 cigarettes in one day, and 3.2% of men drink alcohol every day (National Family Health Survey 2005). Across all ages and sexes, the prevalence of alcohol dependency comes out to 1% (Gururaj et al. 2005). In a compilation of data from 15 studies, the prevalence of affective disorders was found to be 34 per 1000 population (Ganguli 2000),though in a compilation of major meta-studies the prevalence was found to be16 per 1000 population (Gururaj et al. 2005). The variation is most likely due to differences in data collection or analysis. Not only do these figures reveal that a large portion of the population suffers from mental illness; they also demonstrate the need for more thorough and up-to-date research. Table 1 summarizes the prevalence of different mental diseases in India, as compiled from previous data. Table 1: Prevalance of mental disorders in India Stigma and discrimination “Sadly, for all the medical help available, many depression patients remain untreated thanks to the stigma that still persists in India about mental disorders.” This quote from The Hindu, a popular publication, reflects the ever-present effect of the stigma surrounding mental health. In the same issue, Dr. Vijay Nagaswami, a practising psychiatrist in Chennai, emphasizes the importance of realizing that depression is not simply a naturally occurring sadness, but rather an illness that needs treatment. He points out that “most Indian languages do not have a word for ‘depression’ […] and when we say it in English, it ends up sounding like a Western import or a disease related to ‘decadent’ lifestyles.” This type of stigma, combined with lack of awareness of mental illness, is still common in India today. The mentally ill are often mistreated and abused by society as well as by their families. Families are reluctant to admit a mentally ill member to a hospital. Both the family and the patient risk stigmatization by admitting a mental illness often because of a lack of understanding in the community. A major study of stigma in the National Institute of Mental Health and Neurosciences in Bangalore found that greater levels of stigma were associated with more severe depressive disorders. The study hypothesizes that stigmatization can influence the severity of mental illness, and their result supports this (Raguram et al. 1996). Another study published in the Indian Journal of Psychiatry studies stigma in rural and urban populations. They found that there was greater stigma in the rural populations, contradicting the initial hypothesis that an industrial lifestyle sponsors greater intolerance. Particularly, there was a marked difference in personal interaction with the mentally ill, including sharing food, allowing marriages, and allowing the subject to be enrolled in an educational role. Saravanan et al. (2008) surveyed community members in Vellore, Tamil Nadu, on their perceptions of psychosis and psychiatric services. Participants were more likely to invoke spiritual or lifestyle beliefs about causation and avoided mentioning psychosis as a “disease.” While environmental stresses do contribute to mental illness, it is important to recognize the biological and genetic connections of the disease as well. In these situations, much blame is placed on the patient and their personal situation which drastically effects how these patients are viewed in society. Relatives of patients were often unaware about the course or outcomes associated with mental illness. Those with no mentally ill relatives often saw their “mad” neighbors as a nuisance or concern. While the hospital was seen as the first place to seek care, complaints about the lack of results or understanding were common. Often people wanted to learn more but the resources to do so were simply unavailable. Studies such as these offer a keen insight into the problems stigma, discrimination and lack of awareness present to the mentally ill. Table 2: Selected quotes from Saravanan et al. (2008) � Previous Section: Global burden of mental illness Next Section: An Indian perspective (2 of 2)� Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
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Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam An Indian perspective (Page 2 of 2) Economic burden of mental illness in India With all of these estimated prevalences, it is difficult to calculate a definite total cost of mental illness in India. The rate of DALYs due to neuropsychotic conditions in India is 3,112.41 per 100,000 (Jacob et al. 2007). The median calculated globally was 2,964 DALYs per 100,000. Roughly calculating the monetary value of these DALYs in India, with a population of 1.17 billion, and a per capita income of Rs. 35,198.32 per year, the total value comes to be Rs. 1.28 billion, about 2% of the nation’s GDP. Of course this doesn’t take into account the enormous disparity between the upper class and the lower agricultural classes, or costs due to health care itself, but the figure does put into perspective the amount of manpower lost per year due to neuropsychiatric conditions. Currently India spends about 4.8% of its GDP on health, and only 2% of the health expenditure goes to mentalillnesses(Jacobetal.2007).Foranadded perspective, it was estimated that it takes Rs. 500 per day to support a patient in a mental hospital, but India only spends Rs. 200 per capita on health (Goel et al. 2003). A large portion of the costs associated with health care, particularly for mental illness, is due to lost days of work and travel expenses to be able to reach adequate treatment (Thomas et al. 2001, Chisholm et al. 2005, Saxena et al. 2007). A study done by S.V. Thomas et al. (2001) made an estimate of the total economic burden of epilepsy in India. They found that the annual cost per patient was Rs. 13,755, which is a measurement that incorporates both the direct costs (medical treatment, travel to hospital, and other non-medical expenditures) and indirect costs (due to lost productivity). There are about 5 million people in India with epilepsy, bringing the total economic burden to approximately Rs. 68.75 billion, which constitutes 0.5% of the GNP of India. The study also found that 72.9% of this burden was from indirect costs, particularly because often patients had to travel long distances and take more time away from work in order to get adequate care. Another study, done in Bangalore and Pakistan, demonstrates the cost-outcome methods in evaluation of mental health, screening four rural populations for prevalence of mental illness, diagnosing the illness (using ICD-10), and inviting the individuals to seek treatment. The researchers then followed up with an assessment of the costs and effectiveness of the program. An important result that they found was the economic burden of depression and anxiety in the field sites that they examined. In Bangalore, the combined health costs and patient family costs amounted to Indian Rs. 700 a month, and in Pakistan the value was Pakistani Rs. 3000 a month. To put this in perspective, they compare the first amount to between 7 and 14 days of an agricultural worker’s wages, and the latter amount to about 20 days. Emphasized is the fact that costs of informal care giving, traveling, and lost days of work were as much as three times greater than formal health care costs. After the follow up assessment, the group noted that these total costs had fallen appreciably in most of the sites (Chisholm et al. 2000). This study illustrates the economical advantage gained in the implementation of community-level mental health care in India and other developing countries, and once again points out the large costs incurred by travel and days lost from work, illustrating the need for more easily accessible care. Resources available for mentally Ill in India Unfortunately, there is a severe shortage of manpower and resources to care for the mentally ill in India. In the entire country, there are only 42 mental hospitals, with an estimated 20,000 beds (Murthy et al. 2003). There are about 3,000 psychiatrists in the country, approximately 1 psychiatrist for every 500,000 people. There are also severe shortages in neurosurgeons (0.06 per 100,000 population), psychiatric nurses (0.05 per 100,000), neurologists (0.05 per 100,000), psychologists (0.03 per 100,000), and social workers (0.03 per 100,000) (WHO 2005, Jacob et al. 2007). In 2000-2001, only 66 new psychiatrists were trained in the country (Goel et al. 2003). Not only is there a lack of psychiatrists, but also the systems for education and improvement of care are not often put to practice. Clinical practice guidelines (CPGs) are used to incorporate new knowledge into the daily practice of psychiatry, and a study carried out by the Indian Psychiatric Society (IPS) found that 35% of psychiatrists never used CPGs, did not have access to them, or were not aware of them. Psychiatrists argue that the CPGs do not focus on an Indian perspective, but rather are based off of Western practices (Grover and Avasthi 2009). The inconsistencies within the psychiatric field indicate that even when a psychiatrist is available, the care that is received by patients may not be the most effective. In Tamil Nadu, there is one psychiatrist at every government district hospital, and the fact that the infamous Erwadi incident took place in this state further illustrates the lack of resources available. Tamil Nadu is considered to be progressive in its health reforms, with mortality rates that are lower than the national averages. However, even in this state there are enormous shortages in required health care professionals. At an ideal rate of one psychiatrist per 100,000 population, Tamil Nadu (with 262 registered psychiatrists) has a deficit of 539 psychiatrists (Goel et al. 2003). The state of mental hospitals and asylums reveals the public and government opinion of the mentally ill. The burning down of an asylum in Erwadi, Tamil Nadu, on August 6, 2001is a case in point, in which twenty-five people chained to a pillar at the asylum were burnt alive. The victims of this fire suffered from a variety of mental disorders and were undergoing spiritual treatments. They were brought by their families who paid fees for them to be healed in the nearby dargah, a faith healing center. All of the inmates were put in fetters, also known as “divine chains”, within the asylum. Hence, when the fire spread, the patients could not escape. Erwadi was no different than many other asylums within India that were made up of makeshift huts with no sanitation or electricity. This unfortunate incident directed negative media attention towards the practices of magico-religious treatment of mental disorders, questioning the humanity of these facilities and prompted an investigation of asylums in Tamil Nadu (Kumar 2001b). After the incident, the Tamil Nadu government ordered the immediate closing of all asylums in Erwadi. The 571 patients there had little choice of where to go. Some were returned to families that did not have the resources to take care of them, others were brought to the Institute of Mental Health, Tamil Nadu’s only psychiatric hospital, where the conditions were hardly better than in the asylums. An article in Frontline at the time remarks that for these patients, “Nothing has changed […] they continue to live in misery, stripped of dignity and shunned by their families and society.” (Krishnakumar 2002). A psychiatrist at the IMH remarked that “The IMH follows the 18th century concept of the mental asylum. It is like a concentration camp. Patients are checked once in 15 days. They are paraded outside their wards while a psychiatrist checks each one quickly. There are no doctors. Patients with physical complications are referred to other government hospitals. Some of the 21 wards do not have toilets.” (Krishnakumar 2002). The state of other psychiatric hospitals in India is not much different, and reflects the public view of the mentally ill. In a national survey of mental hospitals, published in 2002, it was found that the facilities in the hospital were severely lacking, particularly in facilities that encouraged anything but basic survival. Most facilities had little in the way of recreation or rehabilitation efforts, and the hospitals operated for mostly long-term patients (Agarwal et al. 2003). Patients brought to mental hospitals were not expected to recover enough to contribute to society, or be returned to their families. � Previous Section: An Indian perspective (1 of 2) Next Section: Disorders in specific populations � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[16]=new Array(0,1,"./paper-8-introduction.html","2009-10-09","17K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Introduction Nicholas De Vito is an undergraduate student at Cornell University in Ithaca, NY, studying Biology & Society with minors in Global Health, Science and Technology Studies, Nutrition and Law & Society. After finishing his undergraduate education Nicholas hopes to pursue a Master’s in Public Health with a focus on health and nutrition policy. His work with ICTPH centered around mental health in developing countries with a special focus on India. Amudha Panneerselvam is doing her Bachelor’s of science degree course in biology from Massachusetts Insitutute of Technology. She has won several awards (National Society for Collegiate scholars, Rensselaer Medal, Bausch and Lomb Award, Women in Engineering award are a few of them). She has also done research in genetics at the Koch Institute for Cancer Research at MIT and at Hybrigene Laboratory (University of Rhode Island). She has also taught a course on Introduction to Biotechnology at Cranston High School West. She is the president of MIT Resonance, a capella group. Kavya Vaghul is a passionate high school senior at the International Community School in Kirkland, Washington, currently pursuing her interests in the field of Medicine and Public Health. While she is thoroughly intrigued by natural sciences, her dedication for learning has nurtured her zeal for the arts and culture as well, showing immense enthusiasm in successfully participating and promoting various activities both locally and internationally. Applying her strong leadership capabilities, she has fostered and shepherded several projects within her school and in her community. With the aspirations of a career in the medical sector, Kavya hopes to diversify her knowledge by volunteering and traveling around the world in different health organizations, as it has given her the inspiration to undertake meaningful work. Juhi Sutaria has completed her M Phil in Development Studies from Cambridge, UK, and an MA in Social Work from Tata Institute of Social Sciences. She has been trained in qualitative social research at both these institutions. She has worked on research projects in the field of reproductive and sexual health in India. Her interests include repoductive and sexual health and education. Ravikumar Chockalingam graduated from Madras Medical College, one of the oldest in India, in 2003. He has five years of post-graduate clinical experience including training in Surgical Laparoscopy and Intervention Gastroenterology in Buffalo, NY. He worked as a Registrar in the Critical Care unit in Apollo Hospitals for a year and a half after which he joined ICTPH as Assistant Vice-President – Human Capacity. Dr. Chockalingam is the founding member of the CHW (Community Health Worker) focus at ICTPH, looking at alternate disease focus areas e.g. mental health, oral health and sexual health. Dr. Chockalingam also played an instrumental role in operationalizing the CHW pilot in Tanjore district of Tamil Nadu – from coordinating field teams for mobilizing the CHWs to designing and implementing the in-house three-phase training programs. Dr. Chockalingam is currently pursuing his Masters in Public Health (MPH), at The Warren Brown School of Social Work, Washington University, USA. Mental health is “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (WHO 2009). While it may seem like a factor that is often taken for granted, good mental health influences the outcome of an individual’s life. Consequently, a mental illness can not only compromise these indicators of well-being, but it can also jeopardize her or his quality of life. Worldwide, 10% of individuals are living with a mental disorder, and 25% or individuals develop one or more mental or behavioral disorders at some point in their lifetime. Two-thirds of these people never seek help from a health professional due to stigma, discrimination or neglect. However, these individuals may not always have access to the proper resources and facilities. Over 40% of countries do not have a mental health policy, over 30% have no mental health program, and 25% have no mental health legislation (WHO Report 2001). There are attainable and inexpensive treatments available for many mental illnesses, but they are not being used effectively. Limitations in monetary allocations devoted to mental health care and shortages in psychiatric professionals exist in many developing countries today (Saxena et al. 2007). While many ideas have been offered to resolve this issue, providing community-based health care seems like a promising option. The entire concept of community-based health care focuses on using members from villages or small communities for health purposes. These methods are effective in serving individuals within the community directly. Community-based health care involves diagnosing different diseases, educating and raising awareness about different disorders, and providing supportive counseling to patients and their families. Especially when considering the prevalence of mental disorders within rural communities and the lack of resources provided to these low-income and middle income areas, community health care may prove to be an effective method for providing preventative and primary mental health care (Chatterjee et al. 2008). This paper will review the current status of mental health care, with a focus on the situation in India and will illustrate the gaps in the system. It will also provide details of the mental health in particular demographic groups in India, and examine successful programs and initiatives that have made an improvement in mental health. Through this, it will attempt to build a case for establishing basic primary facilities for mental health care at the community level, which are currently nonexistent in the Indian health system. Next Section: Etiology of mental disorders � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[17]=new Array(0,1,"./paper-8-ngo-initiatives.html","2009-10-09","15K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam NGO initiatives Private organizations have contributed significantly to making health care more accessible to the public, and improving the quality of mental health care. Here, three organizations that have been successful in providing primary care using limited resources will be discussed. For more details on each organization, see Appendix D-F. The Banyan The Banyan is a private organization, founded in 1993 by two Master’s students, Vandana Gopika and Vaishnava Jayakumar, with the primary goal to rescue and rehabilitate mentally ill homeless women. The organization is unique, in being one of the first to provide care for the wandering mentally ill, and striving to return them to their families, as well as educate the families on proper care of the patients. The organization also runs a health center, the equivalent of a PHC that incorporates mental health care with primary care. They train community health workers to recognize mental illness, educate families about the treatment of mental illness, and lead the rehabilitation programs. Vocational training, as well as community self-help groups, have proven successful in helping even chronically ill patients to become more independent. In addition, the organization cooperates with faith healers and a dargah, providing outpatient care and allowing patients to stay in the dargah. This allows patients to maintain their community support while at the same time getting treated for their illness. The Schizophrenia Research Foundation (India) The Schizophrenia Research Foundation (SCARF) which was founded in 1984 by Dr. M. Sarada Menon provides an excellent example of another NGO that has made an impact in delivering mental health care to the public. The organization is centered in Chennai, Tamil Nadu, and from this center they reach out to urban slums and have set up clinics in various cities in Tamil Nadu. Research and evidence based interventions form the basis of the programs that the NGO sponsors. Among these programs are vocational training, rehabilitation, outpatient and inpatient care, and training community workers to diagnose and provide access to mental health treatment, as well as spread awareness of mental illness in the community. The organization also spreads awareness through skits and entertainment that are targeted for a wide audience. Similar to The Banyan, SCARF has residential centers as well as outpatient clinics and a day-care center for mentally ill patients. Daily activities and vocational training have helped these patients build independence and are important to their recovery. This organization has been successful in providing treatments to the community, as well as performing numerous research studies in mental illness and the society, particularly in uncovering stigma, discrimination, and other factors that prevent adequate treatment of mental illness. Sangath Sangath is an organization initiated in Goa in 1996, devoted to promoting health in all aspects, with a focus on child development, adolescent health, and adult mental health. They have grown since then to be one of the largest NGOs in the state. The organization specializes in reaching out to the public to deliver health care, particularly to disseminate awareness materials and multi-disciplinary interventions. Evidence-based research is considered of utmost importance to the interventions. The organization provides clinical services, treating a total of 300 new clients during 2006-2008. Sangath has developed training programs using lay people to spread awareness and perform various outreach activities to the community, including diagnosing and treating mental illnesses in adults, cooperating with special needs schools to further child development. Their program MANAS focuses on integrating mental care with the primary care services offered at PHCs. The program has been implemented in 12 PHCs in Goa, and is currently being evaluated. Sangath has been successful in evidence-based research and tailoring interventions to provide the greatest impact to the community. � Previous Section: Community Mental Health Next Section: Conclusions about addressing the issue � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[18]=new Array(0,1,"./paper-8-pediatric-disorders.html","2009-10-09","23K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Pediatric disorders “One in every five children has a mental health issue” (Shastri 2009). The prevalence of mental disorders among children has been reported to be 14% to 20% in various studies, and according to a world health report, 20% of children and adolescents suffer from a disabling mental illness worldwide. The World Health Organization reported in 2001 that the most common mental health disorders that affect children between the ages of nine and seventeen are anxiety disorders (13.0%), disruptive behavioral disorders (10.3%), mood disorders (6.2%), and substance use disorders (2.0%). Major Depressive Disorder (MDD) and other mental illnesses often have an onset in adolescence, across diverse countries, and are associated with substantial psycho-social impairment and risk of suicide (Weissman, 1999). Prevalence of mental illness in pediatric populations Out of the worldwide population, 35% to 50% of all children and adolescents live in low and middle-income countries (LAMIC) (Patel et al. 2007c). In these LAMICs, the majority of the population lives in rural areas where access to health care, especially mental health care, is particularly sparse. Thus, a focus is placed studying and monitoring physical mortality and morbidity such as infection, nutrition and injury. However, emotional, behavioral and psychiatric problems in children and adolescents remain a substantial public health problem in developing nations. According to Patel et al. 2007c, the gap between the “needs” of child and adolescent mental health care (CAMH) and the “availability” of these CAMH resources continues to widen as the developing countries experience rapid urbanization. Essentially, pediatric mental disorders receive less that adequate attention due to the stigma mental illnesses hold, the lack of knowledge about these mental disorders, and a lack of services provided at the primary health care level in low and middle income countries. A series of the priority mental disorders for children have been compiled based on the higher frequency of occurrence, degree of associated impairment, therapeutic possibilities particularly at the PHC level, and the long-term care consequences. Some of these priority disorders found in pediatric mental health are: Table 3: The overall rates of child and adolescent mental disorders (CAMDs) in India and other LAMICs range between 6%-15%. Most CAMDs have typical ages for development and presentation. These tend to continue to adulthood and exacerbate several adult mental disorders. Therefore it is extremely important that the incidence and context of CAMDs are studied to identify and to undertake preventive intervention early in the course of illness. In India, these preventative measures should be taken at the primary health center level. Unfortunately, the government and non-governmental organizations have performed very little research in regards to pediatric mental health in India, thus making it difficult to accurately create a method in which the public can be well informed about the multitude of mental illnesses that children face. Nonetheless, a series of studies have been performed in the field of children’s psychology in developing countries. A study performed by Patel et al. 2007c outlines the major risk factors that contribute to a mental disorder in adolescent children, a time when most mental illnesses are unveiled. There are three main categories that can trigger a disorder in children and adolescents. Biologically, a child who is genetically prone to a psychological disorder, has a physiological disease or has a substance and toxin abuse problem may be a potential candidate for a neurological illness. Psychologically, a child or adolescent with learning disabilities or mood and temperament disabilities may be prone to a mental illness. And socially, problems with family, at school or within the community can contribute to a mental illness during childhood or adolescence. The importance of recognizing these risk factors of a potential mental disorder is integral to preventing pediatric mental disorders. In 1980, a study was conducted in four developing countries, Sudan, Philippines, Colombia, and India. The purpose of this study was to follow 925 children who attended “primary health care facilities” in their regions and understand how the children were diagnosed by their own families and by their healthcare providers (Giel et al. 1981). To do this, a ten-question survey was given to the children’s parents. In this questionnaire, most parents displayed that they recognized that their children had a mental disorder. However, when these same children were taken to the primary health centers, the health workers were only able to detect 10%-22% of the mental disorders, suggesting that there is an inadequate amount of training provided to the average health worker. These results support the claim that creating awareness in rural communities about pediatric mental health issues and specifically reconfiguring the training procedures for primary health workers are necessary steps for prevention. There is a consensus among many sources that the ability of the primary health care workers to diagnose a child patient with a mental illness is weak. Because of this, there have been difficulties recording an accurate number on the prevalence of mental illnesses within the youth of India. One attempted to provide a better prediction of the number of children in India who suffer from a mental disorder. In Bangalore, India, a sampling of about 2000 children between the ages of 0 and 16 was selected to participate in this study. These children came from one of three places: the rural areas, the urban slum, or the middle-class urban areas. The children were given a manipulated version of the Child Behavioral Checklist (CBCL) that followed the ICD-10 diagnosis. The 0-16-year-olds were put through a screening phase, and those who were diagnosed with a mental problem were put through the detailed evaluation phase, in which a final diagnosis could be made. Of 2064 children, 13.8% of the children between the ages of 0 and 3 had some form of a mental disorder, but this result may have suffered from a small sample size. Within 4-16 age group, a total of 5.3% of the population was reported to have some type of mental disorder, ranging from isolated phobias to hyperkinetic disorders to epilepsy. According to Srinath et al. (2005), it is important to guarantee early recognition of these developmental disorders at the primary health level for children to ensure that these mental illnesses are not aggravated beyond a treatable and manageable point. This study showed that it is necessary for policy, clinical training, and practice to be improved in the pediatric psychology field within the Indian health system. Another prevalence study was conducted in the Calicut District in the state of Kerala, South India. A total of 1403 children between the ages of eight and twelve were selected and put into random clusters within two villages on the outskirts of Calicut. A Malayalam speaking psychiatrist observed the daily activities of each child and conducted screening interviews, and then followed up with ICD-10 assessment diagnostic tests. The results of the observations showed that 9.4% of the sample population of children had some type of mental disorder. The report found that a greater portion of the males had mental disorders, specifically, socialized conduct disorder. Other associations with mental disorders were less parental education, lower socio-economic class, school difficulties, and the Muslim religion. It was concluded that nutrition and perinatal climate did not affect the potential to develop mental illnesses in children. Both malnutrition and perinatal problems are dilemmas that are found in the rural and developing areas, but this study provided more evidence that the physical living area may not be a leading cause for mental health issues in children. This test also provided an insight into the common mental illnesses that can be found in rural areas, though. Hyperkinetic disorders, conduct disorders, socialized conduct disorders, and emotional disorders were all noted as mental illnesses with the highest frequency in the Calicut district. Only more studies conducted in pediatric mental health can give a full view of its epidemiology (Hackett et al. 1999). Study: Substance abuse in pediatric populations Among the many different types of mental disorders that are prevalent in children, substance abuse and addiction represent a continuously rising number. Specifically, tobacco and alcohol use by children and adolescents can lead to adverse health problems in their adulthood and senescence (Gururaj et al. 2005). In a study, students between the ages of thirteen and fifteen in sixty randomly selected schools in Karnataka, India, were given a survey regarding their use of tobacco. A total of 4.9% of the students were tobacco users, with a dominance of males who used the smokeless variety of tobacco. However, 80.6%-82.0% believed that smoking and chewing were harmful to health. Karnataka’s numbers were well below the national average of 17.6%, but it still calls for the concern of the public health systems in rural areas, the government, and the anti-substance use organizations. According to several health sources, substance use is one of the fastest growing health issues, and it is a health hazard that can greatly contribute to mental illnesses (Gururaj et al. 2005). The most effective strategy in reducing the number of substance users is to directly educate the youth about the associated health and mental health issues that can arise from abuse. Suicide associated with pediatric mental disorders There is a wide range of mental disorders that affects the youth on a global scale. Many of these disorders can lead to manifestations of another, more severe disorder. Specifically, many mental illnesses can be associated with eventual suicide. Suicide is the “leading cause of death in young people in countries such as China and India” (Patel et al. 2007c). In a study conducted in India over a ten-year period, the deaths of 108,000 people were recorded. Of these deaths, children between the ages of ten and nineteen were most likely dead due to suicide. 25% of the boys between this age group died from suicide, while 50%-75% of the girls in this age group committed suicide. According to several sources, the rates of suicides among adolescents have significantly increased due to factors like depression, exposure to alcohol and drugs, and increased individuality (Patel et al. 2007c). A majority of these suicides probably begin with a minor mental disorder that escalates due to stress and various other factors. Thus, by creating a strong primary health care system that can recognize and diagnose different mental health issues in children, the percentage of suicides in India, and around the world, can be decreased. Ultimately, educating the public about the prevalence of mental diseases in the youth, tackling the stigma associated with these diseases, creating policy that directly addresses the mental health care issues, and providing services to those who suffer from these mental disorders are the most effective method for preventing mental health problems in children and adolescents. � Previous Section: Disorders in specific populations Next Section: Womens disorders � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. 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array_files[19]=new Array(0,1,"./paper-8-pharmacology.html","2009-10-09","16K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Pharmacology Pharmacology plays an important part in the treatment of the mentally ill in India. Though not always the best treatment option for certain patients or by itself, the general efficacy of these drugs to alleviate symptoms has been well documented. Fluoxetine, Risperidone, Olanzapine and Imipramine were all commonly used medications described in the literature (Wasan et al. 2009; Chakrabarti & Kulhara 2000a & 2000b). In Wasan et al. 2009, a comparison of American and Indian psychiatrists showed that Indian psychiatrists rely more heavily on medication than other forms of treatment, with drugs often being the only form of treatment. This finding fits with the severe shortage of psychiatrists in India. The average Indian psychiatrist in this study saw more than twice the amount of patients in a day than the average psychiatrist in the U.S (24.3 vs. 11). This lack of resources does not allow much more than the writing of prescriptions to occur in most scenarios. One respondent to the Wasan et al. (2009) study recalls that his senior resident would have seen upwards of 100 patients in only four hours. Government initiatives such as the DMHP don’t fare much better in terms of time or resources. Additionally, when drugs are prescribed it may not be of correct dosage, administered for the correct amount of time or be monitored properly. A series of studies by Chakrabarti & Kulhara (2000a, 2000b) show evidence of depressed patients having medication switched inappropriately, starting at too high a dose, having dosages changed inappropriately and deficiencies in receiving continuation treatment. Further complications with medication arise through a number of channels. Non-compliance is a huge problem represented both in the literature and in the experience of the authors in discussions with mental health professionals in India. Patients might be non-compliant for any number of reasons: general aversion to pharmaceuticals, unwillingness to continue after alleviation of symptoms, monetary and access problems and side effects are but a few of the more common occurrences. Pregnant and lactating women present another problem in pharmacotherapy. These women may be undergoing periods of great stress or depression due to the pregnancy or newborns and this requires treatment. Unfortunately, many of the psychotropic medications are potentially unsafe for the fetus or newborn child. Table 4: As a result of the many potential risks, the doctors of pregnant women should try to rely on psychotherapy or carefully monitor the pregnancy and be up to date on the side-effects of the medications. Another problem is self- medication. Due to the relatively easy access to pharmacies patients can not only often gain access to medicines without a prescription but also be ill-informed by the pharmacists themselves (Wasan et al. 2009). Unfortunately, easy access to medicines can be both a curse and a blessing. The problem with India’s national healthcare policy in relation to the overdependence on prescription drugs and scarce resources is documented in Jain & Jadhav (2009). The original NMHP focused more on access to care and community participation. Over time this focus has shifted to the distribution of psychotropic medications. Many of these medications are provided for free by the government, but a reliance on medication lacks the personal, cultural and therapeutic nature of more focused psychiatric care. Jain and Jadhav identify “the pill” as “a bureaucratic tool for implementation,” “a common minimum...that balances the need of a range of stakeholders,” “constrained by the social, political and economic context of rural life” and “limited by its inability to engage with the existential problems on the ground.” The use of medication is seen as constructing a multitude of identities. All at once, medications serve as a proxy for the government to rural dwellers, create a boundary between patients and professionals as well as within professionals (prescribing psyciatrists vs. non-subscribing psychologists) and acts as the main interface between professionals and the community. Furthermore, many patients do not view anything other than a pill or injection as a treatment leaving the non-prescribing team members even more powerless. This complex identity of “the pill,” in the opinion of the authors, stands to silence community voices and ultimately leads to the ultimate failing of the Indian mental health programme. � Previous Section: Traditional treatments of mental disorders in India Next Section: Psychotherapy � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. 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array_files[20]=new Array(0,1,"./paper-8-psychotherapy.html","2009-10-09","22K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Psychotherapy (Page 1 of 2) Psychotherapy is a potential alternative or complementary treatment to pharmacological interventions. Unfortunately, this form of therapy has its hindrances in the context of developing countries. Compared to psychoanalysis, which is virtually absent amongst the poor, psychotherapy is more active and has a shorter treatment span. Repeated meetings over a few weeks can yield positive results. Concerns over travel or missed work, however, can create problems even for the shortest of repeated interventions. Prevailing thoughts on treatment being pill and injection-based as well as with concerns over privacy, many may be unwilling to try psychotherapy at all. This plays out in practice as psychiatrists in Delhi were significantly less likely to use psychotherapy than their American counterparts (Wasan et al. 2009). There are numerous types and schools of thought on psychotherapy; however the scope of this review will focus on those types of interventions discussed with practising psychiatrists in Thanjuvar and Trichy, Tamil Nadu, as well as those with an Indian context in the literature. These are Cognitive (Behavioral) Therapy, Supportive Psychodynamic Therapy, Vocational Rehabilitation, and Family Therapy. Cognitive behavioral therapy Cognitive Behavioral Therapy (CBT) combines the conditioning approaches of behavior theory and the clinical application of cognitive therapy. In this type of treatment, the therapist and patient work together to identify current problems and address the relationship between thoughts, feelings and behavior. The basic goal of treatment is to empower the patient and aim to provide them with psychological and practical skills that they can use outside of the sessions. These techniques have worked across culture and can be performed by a variety of mental health professionals (Grazebrook et al. 2005). Cognitive theory is based on the idea that the brain categorizes information into schemata and it is the dysfunction of these schemata that causes mental illness. The location and correction of these dysfunctional schemata is the basis of the cognitive therapy. The behavioral part of the therapy is used to identify and continue activities that promote good mental health and cease those that contribute to a poor mental state (Driessen et al. 2007).The literature shows how Cognitive Behavioral Therapy has been used to address a multitude of mental illnesses. Depression, panic disorders, psychosis and personality disorders, among others, have all been shown to respond positively to CBT (Manjula et al. 2009; Leichsenring & Leibing 2005; Jones 2002). In a study protocol devised by Driessen et al. 2007, CBT was to be implemented through a series of 16 sessions over 22 weeks and based on the Boelens and Bloedjes model. Table 5: In a review of the literature conducted by Leichsenring & Leibing (2005), 11 studies used CBT in randomized or naturalistic study designs in the treatment of personality disorders (e.g. borderline personality disorder, schizoid or schizotypal personality disorder etc.). The treatments were of varying lengths and follow-up periods and the authors concluded that CBT is an effective treatment for personality disorders (mainly of DSM-IV cluster A and B type disorders as only 2 of the studies looked at cluster C type disorders). A study by Manjula et al. (2009) showed that CBT was more effective than a behavioral intervention alone in the treatment of panic disorders. Patients were assessed at the beginning and end of every week of therapy for five weeks. This included between 15 and 20 therapy sessions. The treatment structure was psycho education and applied relaxation (AR) for the first week, continuation of AR in the second week, cognitive restructuring in the third week and interoceptive exposure and in vivo exposure in the fouth and fifth weeks respectively. Applied relaxation was a positive behavior taught to patients coping technique to help deal with panic attacks. CBT proved more effective on a number of measures including panic symptoms, panic diaries, and a large change in clincally significant change. (Manjula et al. 2009). Gaudiano (2006) in a metal analysis examined the reduction of symptoms of psychosis patients treated with CBT. Initial results were promising with 48% of the CBT conditions (12 studies) showing reliable change in at least one measure of disorder. The author also points out the need for more research in this area. A brief overview of the CBT treatment conditions of the 12 studies examined by Gaudiano is available in the text. Sava et al. (2008) demonstrated the common finding that CBT (in this case both a cognitive therapy and a rational emotional behavioral therapy) was not only as effective as the commonly prescribed drug, fluoxetine, in treating major depressive disorders but was actually more cost-effective with a patient deriving the same benefit from 70 of CBT as against 100 of medication. The use of CBT at the community level is possible; however it must also be treated as challenging and complex. Jones (2002) recognizes this but also sees the possibility of community mental health teams with a focus on prevention over maintenance of illness. While Jones deals with CBT for psychosis many of her points could easily be generalized to treatment of other mental illnesses as well. Community psychiatry nurses form an important part of the team and help reduce caseload stress on the other members (i.e. the psychiatrist or psychologist). Quality training, clinical supervision, proper personnel and resources as well as solid operational policy and philosophy are all identified as requirements for a successful community mental health program based around the delivery of CBT. Dattilio and Bahadur (2005) describe a case in which Dattilio, a clinical psychologist, was able to adopt CBT to fit Eastern Indian cultural norms about family. While the family were immigrants to the U.S. from Madras (Chennai) and the issue of a rebellious teenager may not be directly applicable to the uses of CBT among poorer Indian populations within India, this case study informs the ability of CBT to adapt to cross-cultural beliefs. Dattilio concedes that CBT is a largely North American construct but can be applied to other cultures if the psychologist has sufficient familiarity with the culture of his patients. Dealing with the whole family in therapeutic manners will be addressed further in another section of the paper. Supportive Therapy Supportive Psychotherapy from the psychodynamic tradition is another type of psychotherapy used in India and has been shown to work for a number of diseases including depression and eating disorders. It is based on the psychological theories “that assume six innate, basic and social needs: sexuality, aggression, the need to engage in relationships, and the need to be protected, loved and esteemed.” Gratifying these needs is key to treatment (Driessen et al. 2007). In reality, many types of therapy can be seen to have a supportive element to it. This includes CBT and psychoanalysis. Therapies often rest on a spectrum between supportive or expressive therapies. Pure supportive psychotherapy abandons the expressive element in favor of the relationship build-up between the patient and the therapist.. The treatment should extend to patients that have had an ego broken down by severe environmental pressures. The therapist aims to provide understanding, security and relationship to the patient (Winston 1986). Table 6: Elements of supportive therapy In supportive psychotherapy the subconscious is not explored. If a patient presents with anxiety in psychoanalysis, it is allowed to continue as part of the therapeutic work. Supportive psychotherapy looks to control anxiety. The therapist’s best tool is being “real” with the patient as both a relatable figure and with the avoidance of the subconscious. According to Winston (1986) style of communication, respect, ventilation, feeding, praise, reassurance, advice, lending ego and self-disclosure are all important parts of the therapeutic process. Interventions with medication can also be treated in a different matter in conjunction with this form of therapy with an emphasis on the rationale and expectations from the medication. In the literature, this type of treatment takes many names and slightly different iterations. Some therapeutic elements, however, remain consistent. They are usually time limited, preformed in a face-to-face setting and all come from the psychodynamic tradition. It differs from CBT on matters such as identifying past experiences, interpersonal experiences, and the therapeutic relationship among others (Leichsenring et al. 2004). The Driessen et al. (2007) study protocol included a methodology for testing Short Psychodynamic Supportive Psychotherapy alongside CBT. This allowed for three treatment phases over 22 weeks in 16 sessions: Table 7: In Leichsenring & Leibing’s (2005) meta-analysis, fourteen of the studies used a psychodynamic therapy to treat personality disorders. The authors concluded that psychodynamic was at least as effective as CBT as a treatment form for panic disorders. A second meta-analysis by Leichsenring, Rabung & Leibing (2004) included seventeen studies of short-term psychodynamic psychotherapy for various psychiatric disorders and saw significant pretreatment-posttreatment effect sizes for target problems, general psychiatric symptoms and social functioning. A mega-analysis of three previous trials by de Maat et al. (2008) concluded that independent observers, patients and therapists all preferred short psychodynamic supportive psychotherapy along with mediation to medication alone. The combination therapy was higher for both symptom reduction and quality of life measures. Also, the authors concluded that independent observers found SPSP to be equally efficacious as treatment methods. � Previous Section: Pharmacology Next Section: Psychotherapy (2 of 2) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[21]=new Array(0,1,"./paper-8-psychotherapy-2.html","2009-10-09","17K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Psychotherapy (Page 2 of 2) Vocational therapy Vocational Rehabilitation is shown to have positive effects and outcomes on patients. This type of practice highlights the importance of the continuation of an intervention even after the treatment phase. A study by Kumar (2008) in Kerala, India, highlighted that in cases of chronic schizophrenia, where patients were given rehabilitation services at the Governmental Metal Health Center, Kozhidoke. Rehabilitation included various jobs for both male and female patients in which they earned between 75 and 100 rupees/day. Compared to a control, those in vocational rehabilitation had less severe of symptoms, improved social functioning, reduced re-hospitalization and enhanced cognitive functioning. Such programs allow the patients an outlet to function as normally part of society, which improves cognitive health. Also, with a steady income, patients are better able to handle the expenses that may come with their treatment, such as medication. The author goes on to praise this model as a cost-effective option for developing countries but further research is needed. The vocational rehabilitation model is particularly attractive because there is an infrastructure available from the government for it and other organizations working to promote it. In the authors’ experience at the Banyan NGO, a patient with a history of mental disorder from head trauma was brought to the National Institute for the Empowerment of People with Multiple Disorders, which is a site for vocational rehabilitation like that described in the study above. It is important to consider the post-treatment lives of patients and vocational rehabilitation seems like a promising answer to this concern. Family therapy In treatment, it is important to consider the family as an important asset to recovery. In many cultures all over the world, the familial unit is important as a source of support. As a result of the various stigmas surrounding mental illness in India, the patient can be robbed of that support structure. This is why education is both important and essential to the fight against mental illness. It cannot be overlooked, however, that for a family to care for a member who is experiencing mental illness can be an incredibly draining and stressful experience in itself. Time, money and human resources most often are dedicated to the patient that the family may not have to spare. The newsletter, India Together, featured the story of one father of a schizophrenic daughter who was not offered family therapy as a option for treatment. Instead drugs and advice for reduced pressure were given. This is viewed not only as a failure of the doctor to recognize that “in cases [of schizophrenia] involving teenagers […] family therapy is of the utmost importance,” but one incident in the overall failure of Indian mental health policy as a whole (Kanjilal 2006). While this method holds promise for a number of potential mental illnesses, much of the literature in the fields of family educational interventions deal with schizophrenia patients. McFarlane et al. (2003) in a review of the family psychoeducation literature surrounding schizophrenia offer a general overview of the field, its techniques and its efficacy. Since, often, medication alone can only partially treat the effects of schizophrenia, family therapy is a viable outlet to continue to make further advances in treatment. The paper identifies behavioral family management, family psychoeducation, psychoeducational multifamily groups, relatives, groups and family consultation as some short-term models as types of familial intervention strategies (See appendix for a detailed description of these therapies). Most importantly, many of these types of interventions not only show promising outcomes in the literature but also show that they are effective in cross-cultural contexts. Two studies, one by Gutierrez et al. (2009) and one by Garcia et al. (2009), both speak on the promise of working with the families of schizophrenic patients. In Guiterrez et al. (2009) the intervention group received eighteen weeks of a multi-family psychoeducation program in Chile. The program was geared towards changing attitudes and perceptions about schizophrenic patients, teaching coping and communication styles and reducing the emotional burden on families. Families shared experiences, attended to education sessions, and learned the importance of communication and self-care. This study showed that family members left the program with improved attitudes about schizophrenia with the best outcomes in those family members who have lived with the patient the longest and cared for female patients. The study did not assess if and how this change in attitude affected care but the authors point to previous studies where such an effect had been described. In Garcia et al. (2009) the importance of teaching families to cope with the burden of a schizophrenic family member is stressed in the Mexican American setting. A subject more efficient at coping was more likely to be positive and cordial to the patient. Poor coping efficiency was associated with a sense of helplessness and eventually psychological distress on the part of the caregiver. By working to improve coping mechanisms, the attitude of the caregiver to the patient is improved which can lead to better outcomes for the patient. Though neither of these studies reports outcomes for the patient they offer an insightful glance into the complex attitudes and strains facing these families. Although both studies have a Latin American focus, the family unit is just as important in an Indian context and the findings are likely applicable to other contexts. Lastly, as the Dattilio & Bahadur (2005) paper shows, many of the general psychotherapy techniques discussed above can be applied to a family setting. Jones (2002) offers “marginalization of family members appears to disadvantage not only the relatives but also the psychotic sufferer in failing to protect against future relapse.” � Previous Section: Psychotherapy (1 of 2) Next Section: Conclusions about treatment options � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. 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Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam References National family health survey, India, 2005-2006: Tamil Nadu. 2008. Dementia in developing countries: A consensus statement from the 10/66 dementia research group. 2000. International Journal of Geriatric Psychiatry 25, : 14-20. Agarwal, S. P., S. Shrivastava, and D. S. Goel. 2003. National survey of mental health resources. Mental Health: An Indian Perspective 1946-2003: 113-8. Al Bawaba. Doctor advises ayurveda on world mental health day. RedOrbit. October 10, 2005. http://www.redorbit.com/news/health/266369/doctor_advises_ayurveda_on_world_mental_health_day/index.html. Andrews, Gavin, Tim Slade, and Lorna Peters. 1999. Classification in psychiatry: ICD-10 versus DSM-IV. British Journal of Psychiatry 174, : 3-5. Astbury, Jill, and Meena Cabral. 2000. Women’s mental health: An evidence based review. Avotri, J. Y., and V. Walters. 1999. “You just look at our work and see if you have any freedom on earth”: Ghanaian women’s accounts of their work and health. Social Science and Medicine 48, : 1123-33. Banyan, rescue wandering persons, psychiatric service, rehabilitation for homeless mentally ill. 2005. http://www.thebanyan.org/ (accessed on July 24, 2009) Badrakalimuthu, Vellingiri, and Vellankoil Rangasamy Sathavathy. 2009. Mental health practice in private primary care in rural india: A survey of practitioners. World Psychiatry 8, (2) (June): 124-5. Blue, I., M. E. Ducci, A. Jaswal, B. Ludermir, and T. Harpham. 1995. The mental health of low income urban women: Case studies from Bombay, India; Olinda, Brazil; and Santiago, Chile. In Urbanization and mental health in developing countries., eds. T. Harpham, I. Blue, 75-101. Aldershot: Avebury. Breslau, N., R. C. Kessler, H. D. Chilcoat, L. R. Schultz, G. C. Davis, and P. Andreski. 1998. Trauma and post-traumatic stress disorder in the community: The 1996 Detroit area survey of trauma. Archives of General Psychiatry 55, : 626-32. Chakrabarti, S., and P. Kulhara. 2000a. Patterns of antidepressant prescriptions: I acute phase treatments. Indian Journal of Psychiatry 42, (1): 21-8. Chakrabarti, S., and P. Kulhara. 2000b. Patterns of antidepressant prescriptions: II continuation phase treatments. Indian Journal of Psychiatry 42, (1): 29-33. Chandran, M., P. Tharyan, J. Muliyil, and S. Abraham. 2002. Post-partum depression in a cohort of women from a rural area of Tamil Nadu, India: Incidence and risk factors. British Journal of Psychiatry 181, : 499-504. Chatterjee, Sudipta, Nerrja Chowdhary, Soluchana Pednekar, Alex Cohen, Gracy Andrew, Richard Araya, Gregory Simon, et al. 2008. Integrating evidence-based treatments for common mental disorders in routine primary care: Feasibility and acceptability of the MANAS intervention in Goa, India. World Psychiatry 7, : 39-46. Chatterjee, Sudipto, Vikram Patel, Achira Chatterjee, and Helen A. Weiss. 2003. Evaluation of a community-based rehabilitation model for chronic schizophrenia in rural india. British Journal of Psychiatry 182, : 57-62. Chisholm, D., A. J. Flisher, C. Lund, Vikram Patel, S. Saxena, G. Thornicroft, and M. Tomlinson. 2007. Scale up services for mental disorders: A call for action. The Lancet 370, (September): 1241-52. Chisholm, D., K. Sekar, K. Kishore Kumar, K. Saeed, S. 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Indian Journal of Psychiatry 49, (3) (July-September): 189-94. Jain, Sumeet, and Sushrut Jadhav. 2008. A cultural critique of community psychiatry in India. International Journal of Health Services 39, (3): 561-84. Jain, Sumeet, and Sushrut Jadhav. 2009. Pills that swallow: Clinical ethnography of a community mental health program in northern India. Transcultural Psychiatry 46, (1): 60-85. Jones, Meena. 2002. Cognitive-behavioral therapy for psychosis: Implications for the way that psychosis is managed within community mental health teams. Journal of Mental Health 11, (6): 595-603. Kanjilal, Debabrata. 2006. Neglect of the mentally ill. Manushi. 52. May. http://www.indiatogether.org/manushi/issue152/mindill.htm Koenig, Harold George. 2005. Faith and mental health: Religious resources for healing. In Illustrated ed., 117-119 Templeton Foundation Press. Krishnakumar, Asha. 2002. Beyond Erwadi. Frontline. 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Canadian Journal of Psychology 44, : 34-9. � Previous Section: Appendix (2 of 2) Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
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Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Traditional treatments of mental disorders in India A psychiatric disorder is a “curse from God”. While this might seem like a slightly archaic thought, in many rural parts of India, faith is an extremely important aspect of life. The reality is that mental illnesses hold such an overwhelming stigma due to the fact that they are associated with retribution for sin. For many in rural India, mental illnesses are perceived to be a sign that one has performed a morally questionable deed, has been possessed, is under the spell of sorcery, or has lost his or her soul (Kulhara et al. 2000). The symptoms of the disorders are regarded as punishment, and thus are considered to be shameful for the person inflicted with the mental health issue. Subsequently, families do not publicize mental illnesses in the attempt to remain respected in society. These cultural and social factors consequently affect the way in which a person with a mental disorder or his or her family approaches treatment. In order to escape public humiliation, many rural Indians flock to magico-religious or traditional methods of curing their mental health problems (Mukalel & Jacobs. 2005). Magico-religious attitudes have been found in several societies throughout time. This practice follows the belief that “various supernatural influences operating in the environment [affect] an individual’s physical and mental health” (Kulhara et al. 2000). It then pursues treatment for these health problems through rituals and spiritual healings performed by a faith healer. In India, these supernatural beliefs were influenced by the Vedas, which discuss the “wholeness” of the human body. The concept of faith healers in India has been regarded as a non-invasive medical practice for centuries, and despite the forms of clinical treatments available, many still respect this alternate medical practice. Not only is it a method of reconnecting with God, but it is also a way to avoid publicizing a health problem. Especially in traditional villages, magico-religious healing may be the only option for patients with mental health disorders. Few studies have researched the concept of magico-religious beliefs and treatments within the Indian community. However, of the studies that have been conducted, certain trends have indicated that some demographic groups are more accepting of magico-religious ideas. One study in North India analyzed the magico-religious beliefs in patients with Schizophrenia. A total of 40 patients were observed and their relatives were questioned about their opinions about supernatural treatments. The patients were diagnosed with many different variations of Schizophrenia. Some possessed delusions, while others experienced psychotic symptoms. After this diagnosis, the relatives of the patients were given the Supernatural Attitude Questionnaire in which they were to respond to what they believed the cause of Schizophrenia was in their loved one. The survey showed that a sizable portion of the relatives did believe in the magico-religious causation of Schizophrenia. And nearly 33% of the relatives believed that better treatment could be found in magico-religious methods (Kulhara et al. 2000). In essence, the results showed that the magico-religious aspects of causing mental illnesses and treating them are still widely believed by a multitude of people; 74% of the sample population believed in the supernatural causes and treatment (Koenig 2005). Similar results were found in Southern India. Participants in a study in Vellore widely held that psychosis was the result of karmic or magico-religious factors. Emphasis is given to black magic or past lives’ impact on health outcomes. The community made frequent use of shamans, temples and traditional healers and informed others to do so as well. Both those who had mentally ill relatives and those who didn’t, viewed folk healing methods as entirely complementary to modern medical treatments (Saravanan et al. 2008). This is important to consider because the two systems don’t need to be competitive. Even the most well-informed and, educated family may still choose to use magico-religious methods as a complement to modern medicine and, as long as the patient isn’t put at further risk, it should be allowed. Unfortunately, the lack of mental health resources in India makes it difficult for modern medicine to show the results it could and the common citizen grows frustrated. Families were willing to use mental health hospitals but were often not given sufficient treatment or explanations. This is a large problem in India due simply to a lack of resources. It is only logical that families would turn to traditional healers to fill the gap created by a low quality of modern medical care. In 2008, Anubha Sood asserted in a paper that based off of her research, there was evidence that a large number of women seek mystical healing traditions to cure their mental illnesses because of the greater stigma that is held against them. In fact, there is only one woman for every three men who uses a public health facility (Sood 2008). In India, women predominantly are the ones who receive magico-religious treatment. Within these treatments, the women are rid of “[spirits, possessions, and sorcery, using] healing practices such as exorcism and ritualized ceremonies” (Bourguignon 1973). Sood questions the reason why women seek these ancient medical practices. She proposes two main reasons. When considering why women seek alternative mental health treatments, Sood believes that the mental health facilities that are provided for women are limited and “detrimental” to “women’s mental health needs” (Sood 2008). If policy were set against magico-religious practices that include physically harmful methods in India, women would be safer or would seek help for their mental disorders from public health centers. Her next argument states that women’s problems with the current public health system are not well understood, and thus they cannot be persuaded to stop using these magico-religious methods. Appearing to be against the idea of using magico-religious practices, Sood concludes that the outreach must be made to inform the public about mental illnesses and the proper treatment procedures. Magico-religious treatments have become extremely controversial over the past few decades. However, considering that a large majority of the Indian population in rural areas believes in the positive attributes of these alternative treatments, the cultural value of these medicines is extremely significant. A majority of the negative attitudes towards the magico-religious treatments arise from the “Erwadi Tragedy” that questioned whether these spiritual methods adhered to human rights. This incident, explained earlier, exposed potential human rights violations within some magico-religious practices. While magico-religious treatments may not provide the most effective results, the entire concept of the spiritual well being of the individual has remained an important part of the culture within India for several centuries and may possess therapeutic qualities themselves. Tiple et al. (2006) demonstrates how the incorporation of spiritual aspects to treatment can foster a positive environment for inpatients. These magico-religious beliefs are an integral part of the Indian tradition, and breaking these conventions to integrate more effective forms of treatment will require the removal of the stigma associated with mental health issues. Using natural forms of treatment for mental illnesses has been subject to much experimentation in developing countries. Ayurveda, Siddha, and other forms of homeopathic medicines have been approached as possible treatment options for patients with mental disorders. Ayurvedic treatment focuses on using the five elements (air, water, earth, fire, and ether) in different combinations (Vata, Pita, and Kapha) to create a harmonious balance within the human body. In the context of mental illnesses, Ayurveda recognizes four forms of mental disorders, which include “neurosis, psychosis, convulsive disorders, and obsessive disorders” (Al Bawaba 2005). To treat these disorders, the practice uses daivivyyapasraya and satvapajaya – psychotherapy – and yukti vyapasraya chikitsa – a drugs, diet, and lifestyle plan (Al Bawaba 2005). While there are few reports on the efficacy of these treatments, Indians in urban areas as well as rural areas follow this medical practice faithfully. A study from 1993 experimented with a newer psychological approach to treating mental health. It used Indian mythological material that correlated to psychotherapeutic themes to treat patients with mental disorders (Shamasundar 1993). In the study, 538 excerpts from Indian mythological stories were taken that focused on common themes that are used in the treatment of mentally ill patients. These excerpts were distributed to psychiatrists, laymen, and patients, who were asked to assess whether the themes selected would be applicable to any form of therapy. 50% of the surveys said that these themes present in the mythological works were useful in the therapeutic process. The purpose of these excerpts from mythological works was to stimulate a response by the reader (the patient) to a certain emotion or incidence found in a particular work. Shamasundar lists three main contributions that mythological therapy can make towards a mental patient’s treatment. Firstly, it can stimulate “insight in a patient”. Secondly, it can explain potential coping methods to the patient through metaphors. And lastly, it can help the therapist devise a new approach to treating a patient with a mental disorder. This form of treatment has been especially effective in treating mental health issues in rural parts of India. The traditional methods as well as newer alternative methods of treating mental disorders have been widely accepted in the Indian community. While modern medicine does not regard these forms of treatment for mental disorders as effective, the cultural value of these practices is immense and must be considered in the process of creating a more efficient primary health care system that encompasses mental health care facilities. � Previous Section: Treatment options Next Section: Pharmacology � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. 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array_files[24]=new Array(0,1,"./paper-8-treatment-options.html","2009-10-09","11K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Treatment options People can treat mental illness in a number of ways. A multitude of both ancient and modern techniques exist that try and cure mental disorders. In the Indian context, folk and magico-religious methods can range from localized community healers to whole alternate schools of medicine, as in ayurvedic traditions. Modern psychiatric care in developing countries is based around two options: psychotherapy and pharmacology. Often a combination of both modern and ancient techniques can be used for effective treatment. This section will examine traditional, pharmacological and psychotherapeutic interventions and look at their application as is relevant to the developing world, especially India. � Previous Section: Conclusions about addressing the issue Next Section: Traditional treatments of mental disorders in India � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[25]=new Array(0,1,"./paper-8-womens-disorders.html","2009-10-09","19K","Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Paper Contents... Introduction Etiology of mental disorders Classification and diagnosis of mental illness Global burden of mental illness An Indian perspective Disorders in specific populations Pediatric disorders Women’s disorders Geriatric disorders Conclusions about disorders in specific populations Addressing the issue Government initiatives Community Mental Health NGO initiatives Conclusions about addressing the issue Treatment options Traditional treatments of mental disorders in India Pharmacology Psychotherapy Conclusions about treatment options Conclusion and recommendations Appendix References Nicholas De Vito, Amudha Panneerselvam, Kavya Vaghul, Juhi Sutaria, Ravikumar Chockalingam Womens disorders Many studies have demonstrated that women are disproportionately affected by mental health problems (Patel et al. 1999). In the Global Burden of disease, Murray and Lopez estimate that by 2020, unipolar depression will be the second largest cause of disability burden in the world. Women in developed and developing countries alike are almost twice as likely as men to experience depression (Astbury and Cabral, 2000). Another two of the 15 leading causes of disease burden estimated for 2020, violence and self-inflicted injuries, have particular relevance to women’s mental health. The three most common health problems affecting women in developing countries are anemia, reproductive tract infections and depressive disorders (Patel et al. 2007b). Patel et al. (2007b) stressed that if researchers working on gender and health issues were more aware of the powerful linkages with mental health, a more complete picture of health could be achieved by integrating mental health concerns into their study designs. The area of maternal and reproductive health, one of the Millennium Development Goals, provides a good example of the potential offered by adopting such an approach. Social position, poverty and mental health Women’s mental health is strongly influenced by social, cultural and economic factors. A strong inverse relationship exists between social position and physical and mental health outcomes. According to Stein, women’s health outcomes are inextricably linked with their low social status. “Perceptions of equity and equality directly affect health […] there is a direct effect on health where one stands in the scale of things in society […] it is no longer physical causes but social and cognitively mediated processes.” Adverse health outcomes are two to two-and-a-half times higher amongst people in the most disadvantaged social position compared with those in the highest (Astbury and Cabral 2000). Two major factors contribute towards the low social position of women. One of them is poverty. As UNDP (1997) states, “In today’s world, a poor person is more likely to be African, to be a child, a woman or an elderly person in an urban area, to be landless, to live in an environmentally fragile area and to be a refugee or a displaced person.” The link between mental health and low income among urban women has been documented in Bombay, Olinga and Santiago (Blue et al. 1995). Patel et al. (1999) undertook an analysis of mental health as indicated by common mental disorders such as depression, anxiety, and somatic symptoms in four restructuring societies. Data was obtained from primary care providers in Goa, India, Harare, Zimbabwe, and Santiago, Chile and community samples from Pelotas and Olinda, both in Brazil. Strong associations were found across these data sets between female gender, low education, poverty, and common mental disorders. The study reveals strong linkages between gender inequality, economic inequality, and rising income disparities, all of which increase the risk for mental disorders in women. The inter-linkages between gender, mental health, social position and barely sustainable income levels despite heavy work have also been illustrated in a study in the Volta region of Ghana, West Africa. Avotri & Walters (1999) found that the combination of financial insecurity and financial and emotional responsibility for children, together with heavy workloads, a sense of work being compulsory and a gender division of labor, exacted a heavy toll on women’s emotional health. Patriarchy puts women at a disadvantageous position in family and work places. Recent reviews on the risks associated with women’s health, and more specifically mental health, highlight the important role of gender disadvantage. The most likely explanation for the association is that gender disadvantage increases the likelihood of experiencing adverse life events, a well established risk factor for CMDs. There is also established evidence linking domestic violence with an adverse effect on women’s mental health in both rich and poor countries. Common mental disorders in women From the perspective of women and mental health, the key epidemiological finding is the much-replicated association of female gender and Common Mental Disorders (CMD) such as depression and anxiety (Thara and Patel 2006). Both community-based studies and studies of treatment seekers indicate that women are, on average, two to three times at greater risk to be affected by CMD (ibid). There are a number of potential factors, which may make women more vulnerable to depression. Davar (1999) has reviewed this issue in detail in a recent book on the mental health of women in India. Some of the implications of the greater vulnerability of women to suffer CMD are considered below: There is considerable evidence demonstrating that stressful life events are closely associated with depression and such events are more common in the lives of women. Thus, women are far more likely to be victims of violence in their homes. The multiple roles played by women such as child-bearing and child-rearing, running the family home, caring for sick relatives and, in an increasing proportion of families, earning income, may lead to considerable stress (Patel et al. 2006). The reproductive roles of women, such as their expected role of bearing children, the consequences of infertility and the failure to produce a male child and postnatal depression (this has special significance in India), are examples of mechanisms which make women vulnerable to CMDs (ibid). About 10-15 % of women in industrial societies and between 20-40% of women in developing countries experience depression during pregnancy or/and after childbirth (WHO, 2009). Post-partum depression is another common health problem faced by women. In a study done on 270 mothers from Goa, India, Patel et al. (2002) found that depressive disorder was detected in 23% of the women at 6-8 weeks after childbirth; 78% of these patients had had clinically substantial psychological morbidity in their antenatal period. Economic deprivation, poor marital relationships and the gender of the infant (a daughter is born when a son is desired) were important risk factors for the occurrence and chronicity of depression. Linkages between physical health and mental health Psychological factors play a role in a lot of physical health problems in women. A population-based cohort study in Goa by Patel et al. (2006) sought to investigate the contribution of psychosocial and infectious factors in common genital complaints in women. The researchers concluded that the complaint of abnormal vaginal discharge had a multifactorial etiology with both infectious factors, principally bacterial vaginosis, and psychosocial factors, notably social disadvantage and poor mental health contributing to the risk. The researchers suggest that the presence of gynecological problems lead to CMDs and also those gynecological complaints are somatic idioms for CMDs. All the above literature strongly indicates the need to incorporate mental health into existing health programs for women. � Previous Section: Pediatric disorders Next Section: Geriatric disorders � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[26]=new Array(0,1,"./paper-7-appendix.html","2009-10-09","23K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Appendix (Page 1 of 2) Primary Sources Manufacturers/Distributors/Importers Bhat Biotec Lab Care Diagnostics Inverness Apex Diagnostics Pinki Diagnostics Entrepreneurs ubio Bigtec AnaeMedia Medroid/Drishti Care Potential Partners PATH Commercialization Associate Field Site Associate India Program Research Advisor State Manager/Tuberculosis Diagnostic Development FIND WHO Acumen Center for Integration of Medicine and Innovative Technology RTI IKP/ India Innovation Fund Network Enterprise Fund Government Deputy Director of Public Health and Preventive Medicine Thiruvallur Chief Malaria Officer Epidemiologist WHO Guidelines for CRO Contract Research Organization (CRO) guidelines 24 are clearly described by the World Health Organization. “The CRO used by the sponsor to undertake the bioequivalence studies complies with WHO GCP and considers relevant elements from WHO good laboratory practice (GLP) and good practices for quality control laboratories to ensure integrity and traceability of data. Those involved in the conduct and analysis of bioequivalence studies on products to be submitted for prequalification therefore need to ensure that they comply with the above-mentioned WHO norms and standards to be prepared for any inspections by WHO.” The guidelines provide specific requirements in all of the following areas: Organization and management Computer systems Hardware Software Data management Archive facilities Premises Clinical phase Clinical laboratory Personnel Quality assurance Ethics Independent ethics committee Informed consent Monitoring Investigators Receiving, storage and handling of investigational drug products Case-report forms Volunteers – recruitment methods Dietary considerations Safety, adverse events and reporting of adverse events Sample collection, storage and handling of biological material Bioanalytical data (laboratory phase) Documentation Pharmacokinectic and statistical calculations Study report In addition to above guidelines, CROs are required to follow Good Clinical Practice requirements dictated by the International Conference on Harmonisation 25 and Good Laboratory Practice requirements dictated by the Organization for Economic Cooperation and Development 26. Regulations specific to India: MDRA and DTAB GCP In 2006, a bill was proposed to create the Medical Device Regulatory Authority 27 (MDRA) of India in order to establish and maintain a “national system of controls relating to quality, safety, efficacy, and availability of medical devices that are used in India whether produced in India or elsewhere.” This act encompasses medical diagnostics: ‘Medical device’ means any instrument, apparatus, implement, machine, appliance, implant, in vitro reagent or calibrator, software, material or other similar or related article intended by the manufacturer to be used, alone or in combination, for human beings for one or more of the specific purpose(s) of: (1) diagnosis, prevention, monitoring, treatment or alleviation of disease, (2) diagnosis, monitoring, treatment, alleviation of or compensation for an injury. Although the status of the bill is unknown, it is fair to recommend that the testing of any device/diagnostic meet the criteria set forth in the MDRA. In addition, there are Good Clinical Practice guidelines specific to India as dictated by the Drug Technical Advisory Board (DTAB). There is considerable overlap between the India-specific and the ICH GCP. The following is one of the relevant sections from the DTAB GCP 28: Clinical trials with surgical procedures/Medical devices Of late, biomedical technology has made considerable progress in the conceptualisation and designing of bio-equipments. Several medical devices and critical care equipments have been developed and many more are in various stages of development. However, only through good manufacturing practices (GMP) can the end products reach the stage of utilization by society. Most of these products are only evaluated by Central Excise testing for taxation purposes, which discourages entrepreneurs to venture in this area with quality products especially when they do not come under the strict purview of the existing regulatory bodies like ISI, BSI and Drug Controller General. This is evidenced by the very low number of patents or propriety medical equipments manufactured and produced in the country. As the capacity of the country in this area is improving day by day the need for a regulatory mechanism/ authority is increasingly obvious. The concept of regulations governing investigations involving biomedical devices is therefore relatively new in India. At present, except for needles and syringes these are not covered by the Drugs and Cosmetics Act, 1940. The Chief Executive of the Society of Biomedical Technology (SBMT) set up under the Defence Research Development Organisation (DRDO) has drafted a proposal for the setting up of a regulatory, tentatively named as the Indian Medical Devices Regulatory Authority (IMDRA). Until the guidelines are formulated and implemented by this regulatory authority, clinical trials with biomedical devices should be approved on case to case basis by committees constituted for the specific purpose. Definitions Medical devices: A medical device is defined as an inert diagnostic of therapeutic article that does not achieve any of its principal intended purposes through chemical action, within or on the body unlike the medicated devices which contain pharmacologically active substances which are treated as drugs. Such devices include diagnostic test kits, crutches, electrodes, pacemakers, arterial grafts, intra-ocular lenses, orthopaedic pins and other orthopaedic accessories. Depending upon risks involved the devices could be classified as follows: a. Non critical devices: An investigational device that does not present significant risk to the patients’ e.g. Thermometer, B.P. apparatus. b. Critical devices: An investigational device that presents a potential risk to the health, safety, welfare of the subject – for example, pacemakers, implants, internal catheters. All the general principles of clinical trials described for clinical trials should also be considered for trials of medical devices. As for the drugs, safety evaluation and pre-market efficacy of devices for 1-3 years with data on adverse reactions should be obtained before pre-market certification. The duration of the trial and extent of use may be decided on case to case basis by the appropriate authorities. However, the following important factors that are unique to medical devices should be taken into consideration while evaluating the related research projects. Guidelines Safety data of the medical device in animals should be obtained and likely risks posed by the device should be considered. A clinical trial of medical devices is different from drug trials, as former cannot be done in healthy volunteers. Hence phase I of drug trial is not necessary for trial on devices. Medical devices used within the body may have greater risk potential than those used on or outside the body, for example, orthopaedic pins Vs crutches. Medical device not used regularly have less risk potential than those used regularly, for example, contact lens Vs intraocular lenses. Safety procedures to introduce a medical device in the patient should also be followed as the procedure itself may cause harm to the patient. Informed consent procedures should be followed as in drug trials. The patient information sheet should contain information on following procedures to be adopted if the patient decides to withdraw from the trial. 24 World Health Organization. Annex 9. Additional guidance for organizations performing in vivo bioequivalence studies. WHO Technical Report Series, No. 937, 2006. http://apps.who.int/prequal/info_general/documents/TRS937/WHO_TRS_937__annex9_eng.pdf (Continue reading) 25 http://www.emea.europa.eu/pdfs/human/ich/013595en.pdf (Continue reading) 26 http://www.olis.oecd.org/olis/1998doc.nsf/LinkTo/NT00000C5A/FILE/01E88455.PDF (Continue reading) 27 http://dst.gov.in/whats_new/whats_new07/MDRA-Act.pdf (Continue reading) 28 http://cdsco.nic.in/html/GCP.htm (Continue reading) � Previous Section: Conclusion Next Section: Appendix (2 of 2) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. 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Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Appendix (Page 2 of 2) Regulations specific to India when entering international collaboration Biomedical research between India and other countries/international agencies must be approved by the Division of International Health (IHD) which is part of the Indian Council of Medical Research (ICMR). Anecdotally, this can be a lengthy process lasting longer than one year. From the ICMR website 29: The following general information is to be given while submitting proposals for foreign collaboration/assistance after identification of foreign collaborator and its role: (i)Role/Status/Expertise of the Indian Principal Investigator. (ii)Availability of infrastructure and manpower in the institution. (iii)Justification for foreign collaboration/funding. (iv)Relevance to India’s national health priorities. (v)Role, Consent and biodata of foreign collaborator. (vi)Budget with justification and year-wise break-up in single currency i.e. Indian currency including training as well as foreign exchange component, if any. Apart from the technical details such as rationale for the studies, objectives, review of literature, materials and methods, techniques to be used etc, the following additional information is required for any Indo-Foreign collaborative project: (i)Nature of work to be done in Indian lab/institution and foreign collaborator’s laboratory/institution. (ii)Number of international collaborative projects (approved by HMSC) being undertaken by the Indian PI and the outcome of such approved projects (publications, patents, etc.) (iii)Whether there would be transfer of technology as an outcome of the project. (iv)Whether there would be transfer of human biological material from India to the foreign lab, or vice-versa and if so the requisite details for the same, such as nature and quantity of material to be sent abroad; purpose/need of transfer; nature of investigation to be done utilizing the material; institution(s)/scientist(s) to whom material to be sent, along with their addresses; copy of Material Transfer Agreement (MTA). With the progress in the cell and molecular biology the following points also become very important for careful consideration by scientists in preparing their proposals, as these have a bearing on the approval process : (a) Safety during transfer – risk of transportation; (b) National security – the research should not lead to development of biological weapons; (c) Risk (relative) from the defence and internal security point of view of the country; (d) Intellectual Property Rights; (e) Potential for commercial exploitation, such as by development of vaccines, diagnostics, therapeutics, drugs, etc. (v) Information pertaining to likely visits (year-wise) by Indian and Foreign scientist(s) including duration and purpose of each visit. (vi) Institutional ethical clearance to be submitted at the time of submission of the proposal to ICMR (vii) Appropriate clearances for research involving human subjects, radio-tagged material (for clinical and/or experimental purposes), recombinant DNA/genetic engineering work. (viii) The proposals involving ICMR institutes / centres should be submitted with the recommendations of the Scientific Advisory Committee (SAC) of the concerned institute/centre. (ix) Mutual agreement on IPR claims. Additional guidelines Regulation and guidelines are not limited to the above regulatory boards. Depending on the client, project, and consumer market, the CRO could have to adhere to various additional parameters. Of particular importance are the U.S. Food and Drug Administration 30 and European Medicines Agency/European Clinical Trials Database/EudraLex guidelines 31. Additional qualities desired in ideal CRO 32 SOPs, training logs, internal vs external training opportunities Project reporting tools: internet portal, spread sheets, prompt meeting minutes Low attrition, stable staff, project team member longevity Expertise in target indication: in-house vs external consultants Large database/network of vetted investigative sites Testimonials: customer (sponsor), investigator site comments Audit reports; inspection outcomes Study start-up times Recruitment speed: actual vs projected; on target vs overtime Patient/site ratio Data integrity/query resolution Number of indications, patients, trials, sites, countries (where, and since when) Sponsors: big pharma vs biotech Direct presence vs partner CROs, eg, Russia, India Drugs/Device/Diagnostics brought to market; success in phase 1-3 Demonstrated leadership in industry organisations Sponsor awards (best recruiting CRO) Composition of Scientific Advisory Committee/Board Members Professional certifications (lab professionals) Membership in professional organisations: Association of Clinical Research Organizations (ACRO) Association of Clinical Research Professionals (ACRP) Society of Clinical Research Associates (SoCRA) 29 http://icmr.nic.in/guide.htm (Continue reading) 30 http://www.fda.gov/ScienceResearch/SpecialTopics/RunningClinicalTrials/default.htm (Continue reading) 31 http://ec.europa.eu/enterprise/pharmaceuticals/eudralex/vol10_en.htm#chap5. (Continue reading) 32 http://www.bio-m.org/_resources/dynamic/hauptbereich/download_praesentationen_der_foren/2_neville_cro_selection.pdf (Continue reading) � Previous Section: Appendix (1 of 2) Next Section: Case study: These excerpts are illustrative of disease-specific field testing � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. 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array_files[28]=new Array(0,1,"./paper-7-case-study.html","2009-10-09","24K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Case study: These excerpts are illustrative of disease-specific field testing Field evaluation of Malaria Rapid Diagnosis Test World Health Organization: Malaria Rapid Diagnosis Making it Work Minimum Trial Standards For Malaria Rapid Diagnostic Test Field Trials 33 Aims and scope: To define minimum standards for field trials of malaria RDTs. These will allow identification of the likely reasons for variation in RDT accuracy, allowing trial results to be used in determining suitability of RDTs for operational use. Some issues common to the conduct of all clinical trials are not included, and can be found in reviews elsewhere. Potential problems/Pitfalls and general suggestions for Rdt trials Transport/Storage of RDTs Most RDT products state that storage should be at 4-30°C, which is difficult in a field trial in the tropics and impossible for many end-user health workers who will be using the products operationally. RDTs are sensitive to moisture (humidity) and high temperatures. It is thereforeessential that storage and transport be carefully controlled and documented. Particular attention is needed during transport; RDTs baked in non-airconditioned vehicles or under tin roofs may rapidly lose sensitivity. Protection from mechanical damage and minimization of time from package opening to use will reduce exposure to humidity. At the end of the study, it may be useful to test RDTs taken to the study area against samples stored under controlled temperature. This will allow documentation of any deterioration in sensitivity under field conditions. Local Epidemiology Sensitivity and specificity are dependent on the parasite density of cases, and predictive values are dependent on the parasite prevalence in the group recruited to the study. The study population therefore needs careful definition (recruitment criteria). Recruitment will depend on the aims of the study, and could range from patients fitting defined clinical criteria to recruitment of known parasitaemic patients and non-parasitaemic controls. It is preferable for parasite density to be recorded, if this can be done accurately, and sensitivity and specificity expressed in terms of density. At a minimum, a summary of local epidemiology of the area (previous surveys, local treatment practices etc) must be given. Test preparation and reading Various studies have documented significant variation between technicians in both RDT preparation and interpretation. RDT sensitivity is also directly proportional to the blood volume used when parasite density is low (up to the manufacturers’ specified volume). Accuracy may also vary with the volume of reagent added to the test strip or well. Therefore, use of separate technicians for different products in comparative RDT studies may bias results. Multiple blinded readings and/or rotation of technicians will reduce this. Timing of readings needs to be documented (e.g. “Strictly according to manufacturer recommendations” or otherwise stated). Comment on later changes in results may be useful, though late readings should not be used in analysis. Any technical problems encountered in preparation of the tests should be noted. Trials aimed at assessing local suitability of products need to address the suitability of the instructions and the technical demands of the products themselves and the proposed end-users (health workers) and the patients. Given the dependence of test sensitivity on user technique, this information may be the most relevant in assessing RDT suitability. The quality of product instructions and training can be documented both quantitatively (sensitivity, specificity, proportion of observed mistakes) and qualitatively (preferences of end-users). Deterioration with time RDTs have a limited shelf-life at room temperature. This may cause variation in the sensitivity of the RDT over the duration of the study, particularly at low parasite densities. Designs for prospective studies need to control for this. Standards for comparison Most studies employ microscopy as a ‘gold standard’. PCR is often more sensitive for detection and species identification, but subject to its own limitations and not generally accepted as a primary means of malaria diagnosis. Comparison with both can allow estimation of relative benefits of RDT compared to present microscopy-based diagnosis. Microscopy of a single blood sample has reduced ability to detect fluctuating parasitaemia (as does an RDT based on a rapidly cleared antigen), while microscopy, PCR and rapidly-cleared antigens respond more quickly to treatment-related parasite death (in the absence of gametocytes). Microscopy is highly technician-dependent, requiring blinded confirmatory readings. Recent treatment Recent treatment may reduce true specificity (persistent antigen after parasite death), or apparent specificity with regard to standard microscopy (reduction of parasite density below microscopy threshold but antigen still detectable). Parasites seen on microscopy post-treatment may not be viable. Documentation of recent treatment must be made, or these cases excluded from the study. Note on the availability of anti-malarial drugs near the study site assists interpretation of results. Suggested minimum standards for efficacy trials of malaria rapid diagnostic tests The following should be identifiable to all individual cases: 1. Details of RDT kits used: 1.1. manufacturer (company name, actual site of manufacture) 1.2. batch number (includes strip, reagents, wells) 1.3. date of manufacture 1.4. date of expiry 1.5. Whether product is under trial or commercially available 2. Record general description of test kits: 2.1. packaging type (sealed individually, multiple strips in same canister etc.) 2.2. state and type of packaging, and whether canisters of test strips have been opened previous to the first patient seen. (RDTs in damaged packaging should not be used) 2.3. inclusion of desiccant with strips 2.4. inclusion of lancets/ capillary tubes etc needed to perform the test (or otherwise note the items used). 3. Description of previous storage /transport conditions since manufacture: 3.1. duration of storage 3.2. general temperature and humidity at storage (monitoring of temperature and humidity if available). RDTs should be stored away from direct sunlight. 3.3. time to complete use from opening of canister (when this packaging is used). 4. Description of trial site: 4.1. climatic conditions (mean local temperature and humidity). 4.2. workplace conditions (type of facility, lighting used for reading RDTs.) 4.3. local malaria situation 5. Description of trial subjects: 5.1. criteria for patient selection (symptoms and signs, relation to normal selection for treatment, exclusion criteria). 5.2. demographics (age, sex) 5.3. recent anti-malarial therapy 6. Description of technique used: 6.1. time of strip package opening to time of use 6.2. blood extraction (venous or capillary) 6.3. blood transfer to strip (device provided by manufacturer or pipette etc) 6.4. time taken to obtain reading (per manufacturer guidelines, or reason if longer). 7. Record each line on strip separately, including control. Record of intensity is not necessary. 8. Record organization of RDT readers /technicians 8.1. one or multiple readers 8.2. blinding to microscopy, other RDT readers, and preferably to clinical presentation (latter may not be possible in some circumstances). 8.3. same technician/reader per RDT type, or alternating 8.4. if possible, identify technicians/readers for later comparison. 8.5. training/experience of technicians in this RDT use (including recency of training, validation of quality of training). 8.6. any significant/recurrent problems encountered in kit preparation (including opening of packaging, obtaining blood etc.). 8.7. record any variation from the exact RDT preparation technique detailed in the manufacturer’s insert. 9. Consider formal independent qualitative appraisal of ‘ease of use’ of product by each technician. 10. Microscopy: 10.1. Reagents used. 10.2. Time from preparation to staining. 10.3. pre-qualification and training of microscopists 10.4. blinding 10.5. Criteria for counting parasites and assessment of slide negativity, parasite density. 11. Consider collecting dried blood on filter paper or EDTA samples etc. to allow for later clarification through microscopy/PCR. The criteria for settling discordant results (e.g. PCR, ELISA, independent microscopist) should be formulated beforehand and clearly stated. 12.Sampling size, data analysis. Results should include sensitivity, specificity, positive predictive value, negative predictive value. The kappa statistics can give a useful guide to agreement between readers. 13. Ethical considerations and approval, including treatment guidelines and informed consent. 33 http://www.wpro.who.int/NR/rdonlyres/7CED3B2D-71B8-4D95-BBA8-C7C5315CB90B/0/MalariaRDTsmakingitworkmeetingreport2003.pdf (Continue reading) � Previous Section: Appendix (2 of 2) Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. 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array_files[29]=new Array(0,1,"./paper-7-conclusion.html","2009-10-09","12K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Conclusion The overall goal of the IKP Centre for Technologies in Public Health is to promote and encourage the use of appropriate technologies which facilitate less trained medical professionals to provide a high quality of care. Hence the technologies which are of interest have a strong applicability to a primary care setting, and should meet the three critical tests of low cost, high accuracy under different environmental conditions and ease of use. Given these parameters, point of care diagnostics are an important sub-category of these technologies, though the organization would endeavour to support other technology areas which meet the above criteria as well. The organization aims to achieve this support by three major areas of contribution. Consulting healthcare technology firms on market entry for the rural/underserved space. This includes regulatory assistance. Providing additional services such as field testing capabilities through a contract research model. This will allow technologies to build capabilities and prove credibility in harsh environments with poor infrastructure and training. Providing funding to promising projects or entrepreneurs who have developed a strong product and aim to scale up. This will be through a syndicate- based model where ICTPH would advise provisions for mitigating some of the risks involved in financing business plans which face uncertainties due to their applicability to a public health setting. This three-pronged approach will enable ICTPH to achieve a maximal impact in the context of its current strategies and infrastructure. � Previous Section: ICTPH Healthcare Venture Fund proposal (2 of 2) Next Section: Appendix � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[30]=new Array(0,1,"./paper-7-cro-proposal.html","2009-10-09","13K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Contract research organization proposal The current mode of validation for technologies is variable. All companies go through a series of in-house validation processes, that include the purchasing of testing samples, clinical testing at laboratories and hospitals, as well as robustness studies. Those who have attempted to garner rural validation have partnered with government agencies, non-governmental organizations, or hired outside consulting agencies (eg. McEvoy and Farmer). While once required, it is now unclear whether licensing/validation from national agencies such as the National Institute of Biologicals is necessary. There have been mixed responses to the need of rural validation of diagnostics. All respondents acknowledged the growth of the rural healthcare market and indicated a desire to participate in this market. All cited various limiting factors for why certain products had not penetrated said market, which is discussed in the “Consulting Proposal”. Large Established Manufacturers and Developers – These companies can be characterized by a wide portfolio of diagnostic products comprised of products developed in-house and those licensed. The general sentiment is that rural validation could potentially be useful for pipeline products. However, for products already on market, additional validation is not necessary, especially once it has been endorsed by the WHO. Importers and Distributors – Both indicated that feedback ranging from ease of use to temperature and humidity sensitivity on existing products would be useful information to relay back to the manufacturer. Global Health Technology Developers – These organizations considered this service vital and under-supplied. They cited the need for an efficient, end-to-end service provider in order to mitigate the lengthy process they undergo for field testing. Entrepreneurs – Those who have considered the rural market as end users/consumers consider the service critical. Those who have Tier 1 and Tier 2 markets in mind are less convinced. Internal sources – Rural validation should be considered given that it does not appear to be a standard process of validation for products that currently exists. Manufacturers, listed sensitivities and specificities may not be applicable in rural settings; often decisions are made based on reputation of the manufacturer. In addition some technical difficulties during the first round of epidemiologic surveys support the need for rural testing. Initially, ICTPH plans to proceed by manufacturers, listed information but if indicated, ICTPH will consider independently verifying products. � Previous Section: Point of care diagnostics landscape Next Section: Scope for CRO � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[31]=new Array(0,1,"./paper-7-ictph-consulting-proposal.html","2009-10-09","22K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR ICTPH Consulting proposal (Page 1 of 2) The knowledge base ICTPH has and will continue to build should not be limited to ICTPH functions but extended to supporting the organizations end goal: sustainable health systems in rural India. Understanding that multiple public and private players are developing products and services applicable to ICTPH’s target population, the organization should develop a formal and professional consulting product. This consulting service is another aspect of the “endtoend”solutionneededfor technology implementation. Context Introduction of new technologies in public health setting is a challenge globally. A recent FIND article 8 highlighted the challenges and illustrated the type of partnerships required to overcome the barriers. “The new technologies must be matched to the specific diagnostic needs of a particular disease.” In tuberculosis for example, there is a need to diagnose pulmonary and extra pulmonary disease. In malaria, some regions require P. vivax detection as well as P. falciparum. “The tests must respond to the operational needs of the health system.” For example in the target settings, point-of-care diagnostics are more suitable than laboratory equipment. “Health systems have to be positioned to embrace rapid integration of new tests as they become available.” This point encompasses stakeholders, regulatory frameworks, supply chain, infrastructure, human resources, and financial constraints. “Financing the introduction of new tests into control programmes is the single most important limiting factor.” Finding sources of funding is a formidable constraint, which to be overcome requires tapping a large network including governments, NGOs, foundations, etc. Innovative private sector investments should be considered as well. Figure 4: Focus areas for consulting opportunities in technology adoption (FIND) Fig. 4 above is illustrative of the complex interactions required to introduce technologies. ICTPH consulting can operate across all three sectors to provide its “end-to-end” solution. When posed the question “Why is technology not getting to rural populations?” the responses from various key stakeholder interviews were remarkably consistent with the conclusions derived in the FIND paper listed above. The responses have been categorized within government, regulatory, distribution/supply chain, market, financing, and technology development resources. For each category, an ICTPH consulting solution and/or value proposition is suggested. These solutions are aligned with current or projected capabilities within the organization. Government As of now, all public health efforts must go through the government. Engaging the government is a complicated process and is often the greatest hurdle in technology implementation. Government has a vertical-wise approach; each national programme has its own division looking into the requirements. In an effort to decentralize the process and facilitate enhanced implementation, the whole process of procurement has been structured allowing decisions to be made at the central, state as well as the district level. Through the central budget, funds are allocated for health. Health is a state subject; hence it is the state government’s role to utilize these funds to provide healthcare services. The planning and implementation are done keeping in mind the national health goals so that neither is there duplicity of services provided by the various national disease prevention programmes. In every state, the first level of interaction with the public healthcare system is a Primary Healthcare Centre. At this primary level, the decision of the procurement, if amounting to a sum less than a limit stated in the guidelines, is made at the district level with the guidance of the chief medical officer regarding both equipment and drugs. At the different districts the district health services headed by the deputy director of health services regulates the operations at the district level. All this is done under the supervision of the Directorate of public health and preventive medicine. Procurement is done by the state government for the healthcare facilities. But, for specific national disease prevention programmes, there are designated personnel and divisions who are referred to or are responsible for the procurement. But generally as mentioned above, there is a district level purchase committee which includes the chief medical officer (if a national programme specific procurement, designated officer is involved). The procurement is on the way to become streamlined, with the government taking initiative in the form of the formation of the Empowered procurement wing in the ministry of health and family welfare. The aim of this wing is to install a well functioning procurement process for health services at both central and state levels. In an effort to have a transparent system, this wing is guiding states to develop proper procurement capabilities. Procurement manuals, detailing each step and function of the different organizations in it, are being prepared. An excerpt from the tuberculosis diagnostics procurement manual is in the Appendix. Another noteworthy accomplishment of this wing has been preparing a data base of organizations with WHO GMP certification. The practice of having dedicated procurement agencies is also being promoted alike in Tamil Nadu – the TNMSC which works to furnish the needs of the healthcare facilities in both diagnostics and drugs. The following example is based on the district health services office in Tamil Nadu district of Tiruvallur. At the PHC level the decisions and procurement for replenishing the stock of diagnostic supplies and drugs is made primarily by the chief medical officer or even the doctor in charge. A request signed by the CMO goes for approval to the district health services office and then to the procurement agency TNMSC. In regards to procurement of existing technologies, large manufacturers and distributors who have a portfolio of products seemingly applicable to rural settings argue that they have tried (some fairly aggressively) to introduce their products for public health efforts. The general roadblock, agreed upon by every source in this category, is that the government’s tender prices are too low to achieve any margin. They believe they cannot compete on price alone, as foreign manufacturers such as those in China can produce diagnostic kits cheaper. Majority of manufacturers felt that the government often compromised on quality for cost. Ironically, many of the manufacturers have substantial business selling products via the WHO process to African countries for their public health needs. In regards to adoption of new technology, entrepreneurs and NGO developers of technology cited the multiple layers within the government as complex and a key challenge. Introducing new technology has to go through multiple steps and multiple people, and at any given point could be rejected. Sources recommend and find advocates within the government early in the process, incorporate their input, and leverage their contacts within the approval process. In addition, endorsement from global organizations such as the WHO greatly improve ability to gain government attention. Additional perspectives from government officials are needed to fully understand the procurement and adoption process. ICTPH solution and value proposition Since the government is the most influential aspect of introducing technology in public health, ICTPH must have capabilities to understand the process, the people, and to have access to officials when needed. Sources that have successfully navigated this process often have former government officials on staff. Given ICTPH’s goals and prominent network (i.e. ICICI Foundation), former officials conceivably could be interested in being part of the organization. This official could serve all efforts and verticals of ICTPH. Regulatory Although diagnostics are not held to as extensive of regulatory process as pharmaceuticals, there are still a number of regulations that must be adhered to. The challenge in diagnostics is the lack of standard guidelines in India, despite proposals for such standardization. Regulatory criteria include World Health Organization standards, Good Clinical Practice, Good Laboratory Practice, Medical Device Regulatory Authority, Indian Council of Medical Research guidelines. Excerpts from these guidelines can be found in the Appendix. This regulatory process can be particularly challenging for international companies. One source said that their company’s development efforts were stalled for more than one year pending regulatory clearance in India. ICTPH solution and value proposition There is direct overlap here with the proposed CRO activities. For ICTPH to move forward with any technology-related objectives, a mastery of the regulatory landscape is critical. ICTPH should allocate resources (commission an employee or hire a consultant) to put together a comprehensive regulatory resource guide. Next, the organization should establish relationships with relevant officials in order to advocate for and expedite technology development. 8 http://www.finddiagnostics.org/export/sites/default/resource-centre/scientific-articles/docs/nantulya_getting_dx_into_countries.pdf (Continue reading) � Previous Section: Projected CRO-related expenses and investment beyond baseline clinic Next Section: ICTPH Consulting proposal (2 of 2) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. 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array_files[32]=new Array(0,1,"./paper-7-ictph-consulting-proposal-2.html","2009-10-09","19K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR ICTPH Consulting proposal (Page 2 of 2) Distribution/Supply chain Supply chain is a unique challenge in this setting. The rural populations/BOPs are large in aggregate, but in fact are small pockets scattered over large geographies. In addition, there are particular challenges for medical products such as the requirements for a cold supply chain. All respondents identified supply chain as a limiting factor. Despite the facts that distributors are located in even smaller cities within reasonable distances from villages, it is hard to cost effectively achieve that last leg of distribution. ICTPH solution and value proposition For the sake of the clinics, ICTPH is going to have to develop effective distribution networks to serve villages. Accordingly, ICTPH could offer its knowledge of distribution process and even extend its offering for “piggy back” opportunities where others could actually use ICTPH distribution resources. Financing Entrepreneurs and the NGOs consider capital constraints the largest hurdle in global health technology development. Once exhausting the “free” money through government and foundation grants, traditional sources of funding through equity and/or debt arrangements is very hard to come by. This argument is furthered in the “ICTPH Health Care Venture Fund” proposal. ICTPH solution and value proposition ICTPH can serve as a bridge between social minded finance instruments and global health technology projects. This includes leveraging and continuing to build “soft funding” partners including government, foundations, academic grants, and NGOs. In addition, ICTPH has connections to traditional funds within the ecosystem and innovative financing models such as that of Commons Capital 9, 10 and potentially the ICTPH Health Care Venture Fund. Finally, conceivably using ICTPH consulting services would result in more efficient uses of capital and potentially increase credit worthiness of company seeking outside funding. Market All sources indicated that the BOP/rural market is attractive conceptually, but currently extremely complicated to navigate. First, the market is not homogeneous and in fact is highly varied in different geographies from language to culture. Therefore, segmentation of consumers is very difficult. Secondly assessing willingness to pay is challenging. It is universally accepted that products need to be “low cost,” but that is still a relative term. In addition, when providing low cost products, profits are made in volumes. Yet making accurate estimates of market size is a challenge given the geographies and segmentation issues. Finally, gaining trust is significant obstacle. Multiple sources indicated that there is a high degree of suspicion of medical products in rural settings, as traditional healing methods are highly used and the lingering impact of the government’s forced sterilization program in the 1970s. Sources have used companies such as McEvoy and Farmer to provide rural market research. ICTPH solution and value proposition Arguably, ICTPH’s greatest asset moving forward will be its thorough understanding of rural communities. As a research organization, ICTPH’s core competency is gathering vast range of data, and in the process developing an intimate familiarity with the community. That type of knowledge is considered invaluable when creating marketing strategies. Accordingly, ICTPH could offer its general market understanding of BOP/rural segments. If further information is required, ICTPH could offer the market research it already performed in its clinic areas and the application of refined market research process in areas where ICTPH does not yet have a presence. Technology development value chain Diagnostic innovation is a relatively nascent field in India. Major manufacturers typically license and manufacture, with limited research and development. The value chain challenge they cite is the right sourcing for raw materials. Often reagents have to be imported, thereby adding additional cost. In regards to research and development, since the field is nascent, so is the available incubation space. Incubators in the biotech sector are growing in number, but as of now diagnostic development appears to be happening at academic settings where incubation space is available. Entrepreneurs could benefit from access to incubation centers, although there does not seem to be a shortage of supply as yet. Final point to consider is that traditionally innovation happens first in the academic setting and is then commercialized. Since India lacks a robust technology transfer system, it is difficult to assess how much diagnostic innovation is happening or being encouraged. ICTPH solution and value proposition Research and development might be slightly outside the scope of ICTPH at this juncture, as the organizational core competency appears to be in field research and technology implementation. That being said, feedback from the field does feed into technology modifications and can serve as inspiration for technology development. At minimum, ICTPH could again offer access to its network of scientists, academic institutions, NGO developers, incubation centers, and manufacturers. This facilitation of partnerships is an integral aspect of FIND, the private-public-partnership model for introduction of new technology (illustrated earlier in paper). Technician ability Manufacturers and distributors that currently have a portfolio of diagnostics unanimously cited technician’s inability to follow directions as a major reason for ineffective diagnostic kits. These directions include details of blood sample quantity and amount of reagent to be used; if either parameter is incorrect, the test is compromised. While following the directions seems like an obvious process, it can be confusing as different diagnostic products have different parameters, often with only slight variations. Secondly, manufacturers indicated that interpretation of bands on lateral flow tests (the most common test on market currently) poses another challenge. With lateral flow tests, the presence of a band is indicative of presence of disease; the intensity of the band is meaningless. Yet many technicians have interpreted intensity of band to be indicative of intensity of disease and adjusted recommendations incorrectly. ICTPH solution and value proposition ICTPH will have to be assessing its own staff’s ability to follow instructions regarding diagnostics. Accordingly, it will be able to identify best practices and help guide a more standard approach to diagnostics. Some examples of companies that provide similar services are CIMIT, RTI, McEvoy and Farmer. 9 http://www.bvgh.org/documents/LakeAN_3-12_1130AM_Bailey.pdf (Continue reading) 10 http://www.commonscapital.com/global_health.htm (Continue reading) � Previous Section: ICTPH Consulting proposal (1 of 2) Next Section: Revenue model for CRO and consulting services � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. 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array_files[33]=new Array(0,1,"./paper-7-ictph-venture-fund-proposal.html","2009-10-09","21K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR ICTPH Healthcare Venture Fund proposal (Page 1 of 2) A new model Public health has traditionally been funded by grants from governments, global organizations and foundations. However, traditionally the most efficient solutions are able to tap the market economy in order to build rapid scale and penetration. We propose a syndicate venture capital model focused on private initiatives in public health. The model is similar to the “patient capital” approach employed by social investors, in that it assesses the large market potential of any path-breaking innovation in this sector as significant enough to be approached by private investors. However, since the public health market offers higher risk of monetary returns despite the significant social pay-off, a fund is proposed which mitigates the risk of co-investors through a syndication model, while enabling additional funds to be employed in building businesses targeted at public health. Engaging traditional venture funds Private organizations have occasionally contributed to public health projects as part of philanthropic efforts or desire to meet Corporate Social Responsibility metrics. This proposal recommends ICTPH partnering with funds to support social impact companies that meet Corporate Social Responsibility goals to pursue healthcare delivery projects that are applicable to underserved populations. Via this syndication model, ICTPH will provide a vehicle to traditional funds to be active in the BOP market which serves CSR ambitions and has true potential for returns. Figure 5: Model for a proposed global health fund History ICTPH initially considered developing a “PCD Fund”, a venture capital like fund, that would be invested in early-middle stage startup companies developing point of care diagnostics that theoretically could be used by its clinics. The first pass investigation into this fund was done by Hideyuki Hirama in July 2008. The report was comprehensive detailing the venture capital landscape in India and recommendations on how to approach the fund with a traditional venture capital lens. Below are critiques of certain assumptions from the original “Point of Care Diagnostic Fund Concept Paper”. It should be noted that while this new proposal suggests a revamp of the structure of the fund, the initial concept paper contains applicable information critical to a successful fund. This new proposal addresses some of the oversights, but does not repeat the fundamentals of a fund that are listed in Hirama’s paper. High level issues with initial proposal Does not accurately capture risk of non-traditional market. Global health projects typically cannot achieve same IRR goals, require longer lifecycles, and do not have same access to traditional public and private markets that provide liquidity. Does not account for social impact/double bottom line Lack of diversification by limiting scope of fund to Point of Care Diagnostics Needs to look at larger ecosystem Organization and ecosystem considerations Although it seems obvious, the fact that start-ups need capital cannot be overlooked. Despite all the other services provided by ICTPH that will encourage technology development, the single largest constraint in the process is lack of funding at various stages. There are established and emerging investors of various kinds looking to address the gap. However, as investors screen venture businesses with traditional investor lenses, evidence suggests that public health projects carry more risk than investors would prefer. This risk can largely be attributed to the nascence and the uncertainties of the BOP market. Accordingly, ICTPH should consider creating the proposed fund that can leverage its organization competencies and carry such commercially viable social impact projects forward. Given that ICTPH fits into larger ecosystem, it is possible that more synergistic relationships could be formed for a successful organizational level investment and impact strategy. Secondly, this will allow the fund to expand beyond point of care diagnostics to incorporate a broader scope of technologies that positively impact primary healthcare delivery. NASSCOM ICICI Innovation Fund (NIIF): NASSCOM and ICICI Knowledge Park have promoted this fund to stimulate technology innovation in India through providing seed capital funding for opportunities in emerging technologies. NIIF will focus on Intellectual Property asset creation in emerging or frontier technologies. A key criterion for identifying investment areas is the presence or expected emergence of sophisticated demand within India for either the core technology or applications based on the core technology. Potential syndication with NIIF lies areas of medical devices and other technologies which are suitable from a public health perspective, e.g. Lab-on-a-chip platforms IFMR Trust’s Network Enterprises Fund� (NEF): Created to invest in specifically chosen companies focused on rural supply chains for products and services called Network Enterprises (NEs), which address gaps in rural supply chains such as high costs of intermediation, severe constraints of access to working and investment capital and information asymmetry. Potential syndication with NIIF lies in businesses working in the area of service/product delivery such as system facilitators and care delivery mechanisms. Value proposition to ICTPH stakeholders (compared to original PCD fund concept) - Sourcing, Syndication, Diversification -Sourcing: Will have access to steadier stream of projects Will benefit from vetting done by partner institution -Diversification: “Increasing the number of products in the portfolio results in an exponential decrease in the probability of no products succeeding” 14 The lower the correlation between the various products through diversification lowers unsystematic/un-market risk Broadening scope by -Moving from only diagnostics to wider range of healthcare products -Being active in early and later stage start-ups -Designing solutions and accordingly building companies (NEF) More impact by developing more healthcare products -Syndication 15: Can leverage management and due diligence skills of respective partners Reduces downside risk Value proposition to respective partners - Same model, Less risk, Double bottom line potential - Same model: Partner using same investment vehicle Attracts same stage companies -Less risk: Syndicate mitigates downside risk ICTPH expertise in BOP healthcare market mitigates risk associated with challenges of BOP market -Double bottom line potential -Profit: Upside rewards greater than traditional syndication, since ICTPH fund can consider selling equity stake to partner once technology is commercialized (at adjusted valuation) in order to avoid downstream conflict of interest potential if ICTPH clinics become consumers of technology. Can be structured through first right to rejection model. Being active in untapped market that has potential to grow to size of traditional markets, thus establishing first mover advantage and learning curve advantages when market matures -Social impact: Partnership can serve as Corporate Social Responsibility vehicle Appeal to certain investors in fund (i.e. Department of Science and Technology in IIF) might be prioritizing impact over profit 14 Global Health Care Fund presentation (Continue reading) 15 Structure and Management of Syndicated Venture Capital Investments – Wright and Lockett, 2002 (Continue reading) � Previous Section: Revenue model for CRO and consulting services Next Section: ICTPH Healthcare Venture Fund proposal (2 of 2) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. 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array_files[34]=new Array(0,1,"./paper-7-ictph-venture-fund-proposal-2.html","2009-10-09","22K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR ICTPH Healthcare Venture Fund proposal (Page 2 of 2) Value proposition continued: ICTPH can increase uptake and penetration Figure 6: Projected Impact Of ICTPH On Uptake And Coverage Of Critical Health Interventions In Low-And Middle-Income Countries, Compared To A Typical U.S. Drug Launch, By Years From Availability 16 Fig. 6 above is an illustrative example of the potential impact ICTPH can have on the uptake and penetration of an intervention. In context of the Indian BOP healthcare market, each ten per cent of coverage represents 70 million people and is worth 1.8 billion 17. The two illustrated interventions, Skilled Birth Attendance and Hepatitis B Vaccine, have analogous privately invested counterparts such as LikeSpring Hospitals 18 and PATH malaria vaccine initiative 19. LifeSpring achieved 43% market share in its first year and plans to expand to nearly 200 hospitals in next five years. In both analogous examples, Acumen and PATH are providing their expertise of a non-traditional market to drive investments; as ICTPH grows, it will have capabilities similar to both Acumen and PATH. Achieving scale is the key metric for both commercial viability and social impact. Although scale is relative to each business, a recent Monitor Group report outlined overarching “Lessons about Scale,” for which ICTPH will be building capabilities to address (see Consulting and Contract Research proposals). One of these lessons suggested that “An organization that builds on its own from scratch will probably take decades.” With the projected in-house capabilities and growing network of public health partners, ICTPH could considerably shorten the adoption period and increase the penetration, thereby increasing pace of achieving scale and commercial viability. Encouraging indicators India BOP healthcare can be successful: Aravind is one of the most cited examples of achieving scale in the BOP. Aravind is a model of efficiency in cataract surgeries performing nearly 250,000 procedures annually. The adoption of multiple interventions from paraskilling 20 to no-frills service has kept the business sustainable and profitable, with less than 8% of its revenue coming from grants and donations. 21 Social syndication is being done: Voxiva is an internet and phone based communication system that allows for real-time outbreak tracking and epidemiological surveillance 22. It has attracted traditional venture investors and socially minded investors interested in its global health potential. For example, the primary investor is Richmond Management, yet Acumen has also made a 600,000 equity investment in Voxiva. These types of dual platform technologies with first world and developing world applications can successfully attract co-investment from traditional and social funds. Private public partnerships (public represents non-profits, NGO, foundations and government): Commons Capital, a venture fund that seems closest in structure and objectives as the proposed ICTPH fund, has committed a portion of its portfolio to global health businesses including a diagnostics company and a telemedicine company. It has partnered with an NGO, RTI International, to provide the global health technical assistance. This is similar to the concept of the ICTPH fund receiving advisory services from ICTPH Consulting. Evident hurdles Limited success stories: There are not too many examples of healthcare ventures that have successfully captured the BOP market outside hospital chains such as Aravind and Lifespring. Acumen has a large portfolio of global health interventions, but it is difficult to assess whether they would meet the level of commercial viability required for traditional venture funds. The lack of success stories does not imply an excess of failures; it could simply suggest that these types of businesses and investments are in its infancy. Hard attracting capital, especially in this environment: Raising the fund for this type of investment strategy is challenging, especially given the tenuous environment for all venture capital funds. Commercial viability is difficult to project and social impact is difficult to assess, making the pitch to investors difficult. ICTPH should pursue sources of “soft-funding” such as NGOs, foundations, governments and/or guarantee structures involving those sources 23. Investment dynamics Types of technologies: Technologies relevant to healthcare delivery for target populations should be considered. Dual use technologies – platforms from which an up-market and down-market version can be made – are particularly attractive. All technologies listed below are being developed by multiple players and have both commercial viability and social impact potential. Life science technology can be considered, although the lifecycle and size of investment required are deterrents, despite the greater “blockbuster” potential. Diagnostic devices – Strips, Cards, Reagents Diagnostic devices – Platforms, Lab-on-a-chip Interventional devices – Incubators, Ventilators, Drug delivery Communication Devices – Telemedicine, Mobile- based technologies Information technology – EHR, DSS, IMS System facilitators – Drug/Devices supply chain/sales, Insurance facilitation/sales Care Delivery – Clinics/Primary Care centers Limited partners: The fund should attract socially minded investors and/or those who have vested interest in primary care and public health. For example: IKP Trust (current) Skoll Foundation Omidyar Network Insurance companies Government organizations: eg. Department of Science and Technology Philanthropic investors Syndicate partners: Co-investors should be venture capital funds that have at least portion of portfolio dedicated to social impact and can accept higher risk in regards to monetary returns. Acumen Omidyar Network Aavishkar Nasscom India Innovation Fund Network Enterprise Fund Traditional VCs who have shown some interest in healthcare technologies and delivery mechanisms (Accel India, IDG ventures, Inventus capital, Lumis Partners, GTI, Venrock, Ventureast, Iven medicare, GE healthcare, Sequoia Capital) Investment size: Investments can be relatively small (less than 1.5 million), allowing ICTPH to have a more diversified portfolio. Examples of investments made in relevant technologies: -Acumen investments Sehat First: E-health consulting – 200K Vision Spring: Affordable reading glasses – 500K Voxiva: Cell phone technology – 600K -Inventus Capital InstaHealth: Online medical services – 1m -IDG Ventures and Accel India/Erasmic Perfint: Medical devices – 3.5m combined -Ignia Primedic: Healthcare delivery – 6 m combined 17 Monitor group (Continue reading) 18 Acumen (Continue reading) 19 http://www.malariavaccine.org/ (Continue reading) 20 Emerging markets, Emerging Models – Monitor Group, 2009. (Continue reading) 21 Harvard case study – Aravind Eye Care (Continue reading) 22 Acumen (Continue reading) 23 Global Health Care Fund presentation (Continue reading) � Previous Section: ICTPH Healthcare Venture Fund proposal (1 of 2) Next Section: Conclusion � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. 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array_files[35]=new Array(0,1,"./paper-7-introduction.html","2009-10-09","14K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Proposal & Introduction Neil Parikh is currently pursuing the joint MD/MBA program at the Keck School at the University of Southern California and the Wharton School at the University of Pennsylvania. He is majoring in healthcare management. He has an undergraduate degree from the University of Southern California, where he majored in biology and journalism. His range of experience in the area of health access includes research in India investigating barriers preventing patients’ access to HIV medication and work for a non-profit organization that is developing methods to overcome cultural barriers. His areas of interest are healthcare access and healthcare systems in emerging markets. Arijit Sarkar is Vice-President, Health Care Solutions at ICTPH. His primary interest is to invest in and provide support to socially relevant and sustainable business models, with a particular focus on nascent and early stage entrepreneurships. He has two years of financial modeling experience. His previous role was that of a quantitative research associate at Lehman Brothers, where he built models of liquidity in public equity markets. He has a bachelor’s degree in Electrical Engineering from IIT Bombay. Proposal The IKP Centre for Technologies in Public Health (ICTPH) provides end-to-end service for public and private companies seeking to develop and/or introduce healthcare technology, particularly diagnostics, for rural settings. This encompasses market entry consulting, regulatory navigation as well as field testing through contract research organization model. ICTPH’s role in financing, which is also an important aspect of the technology development process, is discussed separately. Introduction Development and promotion of healthcare interventions via technology are a clearly stated objective of ICTPH. Of several different kinds of interventions, diagnosis technologies are of particular interest to the organization. Diagnostic testing till now has been mainly restricted to a laboratory setup, and requires trained staff, who are mostly not available at remote places. Point of care diagnosis (PCD) techniques can be utilised to alleviate this situation. Diagnostics which are not only easy to use, but require little or no training and give accurate results instantaneously, will be instrumental towards providing improved healthcare. At the primary level, PCD technologies aid the healthcare professional to assess a patient’s condition more quickly and accurately. This in turn will ensure timely guidance and interventions beneficial for the patients. From the point of view of infrastructure, it will help reduce the burden on secondary and tertiary care centres by helping restrict the flow of patients to only those who actually require higher care. Fig.1 shows the different stages of diagnostics development, and areas where ICTPH hopes to contribute in the same. Figure 1: Stages of diagnostic development Next Section: Methodology � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[36]=new Array(0,1,"./paper-7-market-size.html","2009-10-09","14K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Market Size The increasing awareness of the “base of the pyramid (BOP)” market is an opportunity for those interested in providing services to better access this population. A recent Monitor Group report cites the BOP Indian healthcare market at approximately 18 billion 1, indicative of the opportunity and interest of both the public and private sector. Based on ICTPH’s indicated interest in point of care diagnostics (PCDs), narrowing the scope to only PCDs still leaves lucrative market potential. The Indian PCD market in 2007 ranged from 100 million to 250 million and is projected to double by 2012 2. Acknowledging that these PCD figures encompass all economic tiers, part of this projected growth is accounted for by increased accessibility of healthcare by lower classes including the BOP. Approaching the market from another angle, in the unlikely event that the private sector were to completely reject ICTPH’s service offerings, at a minimum ICTPH could provide services to non-profit global health organizations that are developing such products, which still represent a large market. Organizations such as PATH, FIND, CIMIT, and WHO all have extensive portfolios of global health products that require “end-to-end” solutions. Currently this encompasses nearly 50 pipeline technologies and hundreds of existing products in different disease areas. Finally, in addition to the private and NGO markets, the government, national programs, and academic institutions contribute to the market potential. In fact they are the traditional organizations that have been serving the BOP population. Accordingly, ICTPH could provide its research facilities and expertise to support or supplant governmental or national program epidemiologic and disease surveillance. For example, the Government of India (with the Ministry of Health and Family Welfare as the implementing agent) is involved in a multiyear, 88.64 million Integrated Disease Surveillance Project 3. In fact, other countries’ governments are active contributors to this market. In this past year the United States Department of Health and Human Services committed nearly 30 million to US-India collaborations including a “Low-Cost, Diagnostic, and Therapeutic Medical Technologies Research Collaboration (NIH-NIBIB): To promote collaboration with India’s Department of Biotechnology on the development and use of low-cost medical technologies and devices for healthcare in resource-limited settings. 4 1 Emerging markets, Emerging Models – Monitor Group, 2009. (Continue reading) 2 Natexis Bleichroeder, Association, Kalorama 2009, Piramal Healthcare Investor Presentation 2008 (Continue reading) 3 http://web.worldbank.org/external/projects (Continue reading) 4 http://globalhealth.gov/news/factsheets/fs020409.html (Continue reading) � Previous Section: Methodology Next Section: Value Proposition � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[37]=new Array(0,1,"./paper-7-methodology.html","2009-10-09","11K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Methodology The following report represents information gathered from primary and secondary research. External primary sources include national and international manufacturers, distributors, importers, entrepreneurs, global health organizations, technology developers, non-governmental organizations, and government officials. Internal primary sources ranged the ecosystem including employees from ICTPH, IKP, and the NEF. A comprehensive list of sources can be found in the appendix. Per request for anonymity, primary sources are not always identified but referred to as part of broader categories. Throughout the report, point of care diagnostics (PCDs) are used as the example of “technology”, as that is where significant research has taken place thus far. It should be noted that much of this proposal can extend beyond PCDs and is applicable to a wide range of interventions. � Previous Section: Proposal & Introduction Next Section: Market size � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[38]=new Array(0,1,"./paper-7-operational-considerations.html","2009-10-09","14K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Operational considerations Allocation of appropriate laboratory space and laboratory supporting infrastructure (electricity, internet, water) is critical during clinic design. The organization will have to achieve some level of scale in order to achieve the necessary sample size for certain research activities. This scale will be project-dependent. Product testing is more effective in areas with relevant disease endemicity. Accordingly, sites will have to undergo necessary studies to understand disease burdens in populations it serves. A number of regulatory criteria must be adhered to including World Health Organization, Good Clinical Practice, Good Laboratory Practice, Medical Device Regulatory Authority, Indian Council of Medical Research guidelines. Excerpts from these documents are listed in the Appendix. In addition to regulatory conformity, ICTPH may consider establishing government relationships with Ministry of Health and engage relevant parties along the development process. Sources often cited good relationships with government early on made process more efficient. Further, these relationships could be leveraged for disease surveillance contracts down the line. Based on regulatory guidelines and needs of research projects, capital expenditures in addition to those already necessary for the proposed clinics will be necessary. A thorough vetting of the guidelines and further conversations with potential clients and/or other CROs will give framework for necessary investments. Given the fixed costs accounted for in the implementation of the clinics, these additional investments should be minimum. All testing will require a gold-standard confirmation. This can be achieved by partnership and/or contracting out to an outside laboratory service. When certain scale is achieved, ICTPH can consider opening its own central laboratory which can be used for CRO as well as clinical activities. Revenue models balancing the ideals of being both providing public service and being sustainable must be considered. A discussion of options is as below. Quality personnel involved in research design to implementation to field work are essential. The hired personnel should have experience and ideally a set of relationships that can be leveraged by the organization. A 2008 survey of pharmaceutical companies revealed key factors in CRO selection 7. The top 5 were: Your team’s general sense that you can work with this CRO The project management team to be devoted to the study The CRO’s recent experience in the same indication A CRO’s overall experience in the study’s therapeutic area The backgrounds of the project team members Additional qualities desired in ideal CRO including professional certifications and membership organizations are listed in Appendix. 7 http://appliedclinicaltrialsonline.findpharma.com/appliedclinicaltrials/article/ articleDetail.jsp?id=506847&sk=&date=&%0A%09%09%09&pageID=2 (Continue reading) � Previous Section: Timeline and Process Next Section: Projected CRO-related expenses and investment beyond baseline clinic � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[39]=new Array(0,1,"./paper-7-point-of-care.html","2009-10-09","13K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Point of care diagnostics landscape Current state A majority of products currently on market are based on lateral flow platforms. In general, these products are more cost effective than status quo diagnostic approaches in rural settings. While they have been extensively evaluated, the lack of standardization has impact confidence in choosing the right product. Again, these products have had limited penetration in the Indian rural setting. Pipeline PCDs are moving in the direction of “lab-on-a-chip” platforms, which basically amounts to the miniaturization of gold standard lab technologies such as PCR and ELISA. The simplicity and accuracy of these products make them ideal candidates for rural settings. Cost and sustainability in regards to rural settings are the main areas of needed improvement. Pipeline technology is hardly limited to lab-on-a-chip platforms, and ICTPH should actively be surveying the vast number of innovations in the PCD industry. Figure 2: Snapshot of PCD landscape and areas of intervention in select disease areas as of July 2009 5 Note: A more thorough investigation of PCD landscape was done separately by Namrata Sharma 6 and Wharton team. These papers/presentations provide a contextual framework by which to evaluate new technologies in select disease areas. PCDs is a rapidly evolving technology space, thus these frameworks will require constant updating. 5 Wharton Presentation on the Point-of-Care Diagnostics Fund (Continue reading) 6 Point-of-Care Diagnostics Situation in India – Namrata Sharma, ICTPH (Continue reading) � Previous Section: Value proposition Next Section: Contract research organization proposal � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[40]=new Array(0,1,"./paper-7-projected-cro-expense.html","2009-10-09","12K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Projected CRO-related expenses and investment beyond baseline clinic Costs already assumed by clinic Facility with separate laboratory space Appropriate storage (protective from temperature/humidity) of diagnostic kits Electricity source with back-up generator Internet connectivity Computers Personnel Additional capital expenditures Refrigerator/freezer for samples* Standard medical fridge (2oC and 8oC) is necessary for clinic Subzero will be required for handling of viral/bacterial/fungal samples Additional variable expenses Hiring of CRO expert Training for administering of research Software: Laboratory Information Management System (LIMS) Regulatory processing Diagnostic and sample collection specific accessories i.e. syringes, gloves, sharp boxes, tubes* Other considerations Cold supply chain/distribution/transportation capabilities* Contract with outside laboratory for gold standard services* Eventual development of own laboratory – requires much more significant analysis *Given that it is likely that the clinics will need to independently verify the quality of PCDs which it considers using for the purposes of the clinics, these clinics will already be equipped with these capabilities. Therefore, the incremental costs for CRO outfitting will be minimal. � Previous Section: Operational considerations Next Section: ICTPH Consulting proposal � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[41]=new Array(0,1,"./paper-7-revenue-model.html","2009-10-09","17K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Revenue model for CRO and consulting services Pricing CRO This is highly variable and dependent on the technology being evaluated, the specific question that must be answered, the number of study participants (and study sites) required to generate statistically sound data, etc. Study types might include: Quick and dirty field evaluations that are not statistical Statistically powered field evaluations Studies focused on collecting and characterizing specimens for a sample bank Pricing range: 200,000 to 5,000,000 11 Consulting This is highly variable depending on client. Conceivably different rates could apply to private companies versus non-profits. Need to look at comparable organizations such as RTI International. Fee for service CRO CRO Financial arrangements often include 12 Low up-front payment, eg, Letter of Intent (LOI) Incentivization and milestone based payment schedule Should be anticipatory, complete and comprehensive at start of project Should insure low likelihood of Change(s) of Scope due to insufficient planning Define liability in event of project delay, failure (risk sharing) Feasibility analysis “free” in the event of award Consulting Traditionally enter contracts with billable hours. Payment in kind CRO and consulting services could be provided in exchange for discounted contracts for products within the companies’ portfolio, conditional on the products being of appropriate quality for patient care. From the series of interviews, a majority of respondents across all categories indicated the potential for collaboration, implying a payment in kind type model. It should be noted that this type of structure requires complicated accounting, especially if CRO, consulting, and clinics are considered their own strategic business units (SBUs). Service for equity model 13 Professional service firms have sometimes “accepted equity in lieu of fees for services rendered.” This model rapidly grew in size and scope during the dot-com era and since has been relatively stagnant. In general, there is no definite stance on whether these arrangements increase firm performance/value, especially since there are a number of other variables at play. However the Henderson et al study of 12 major service providers with a combined experience of 179 equity-for-service deals effectively illustrates major consequences of such arrangements. Pros Increased client pool Increased upside potential Fosters sense of partnership and greater alignment with client Cons Backlog effect: companies in which equity is offered have priority over companies providing traditional fee-for-service. Negative self selection: “Clients with least optimistic prospects tend to be the most interested in equity-for-service arrangements, whereas those with the best prospects may be most reluctant to part with shares” Perceived that service for equity clients receive preferential treatment Project creep: clients will potentially ask more of service firm than is stipulated in original contract Increased risk profile for service firm Liquidation signal: liquidation may negatively affect client-firm relationship for future engagements Unbalanced portfolio effect: undiversified and overexposed to downside risk if only a collection of similar companies Organizational behavior consequences: compensation based on service for equity deals can create internal issues Revenue model recommendation While a number of above service for equity arguments are directly applicable, the one of particular importance is conflict of interest. If ICTPH were to attain equity in exchange for consulting or field testing a product i.e. PCD, the perceived notion will be that it is in ICTPH’s interest to provide positive data as it will increase the value of its equity position. Further, ICTPH would also be incentivized to use products of companies in which it holds equity, exposing it to questions on whether purchasing decisions are truly motivated by strict quality standards. Accordingly a mixture of traditional fee for service and payment in kind models should be pursued, depending on the client. 11 PATH. Jay Gerlach and Chris Crudder (Continue reading) 12 http://www.bio-m.org/_resources/dynamic/hauptbereich/download_praesentationen_der_foren/2_neville_cro_selection.pdf (Continue reading) 13 Henderson et al. Service for equity arrangements: Untangling motives and conflicts. Journal of Business Venturing 21 (2006) 886-909. (Continue reading) � Previous Section: ICTPH Consulting proposal (2 of 2) Next Section: ICTPH Healthcare Venture Fund proposal � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[42]=new Array(0,1,"./paper-7-scope-for-cro.html","2009-10-09","11K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Scope for CRO Initially, CRO capabilities should be limited to sample collections and rural validation studies with purpose of providing data on two primary components of any technology intervention in rural settings: ease of use and accuracy. It should NOT replace the in-house sensitivity and specificity research clients should engage in prior to rural validation. At later time, ICTPH can consider expanding its field testing offerings i.e. pharmaceutical clinical trials. Implementation of CRO will require the hiring of a consultant and/or expert in this area. Fig. 3 below includes general considerations regarding Timeline, Operations, Expenses, and Revenues. � Previous Section: Contract research organization proposal Next Section: Timeline and Process � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[43]=new Array(0,1,"./paper-7-timeline-and-process.html","2009-10-09","10K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Timeline and Process Figure 3: Framework for planning CRO capabilities Potential Sources for CRO Expertise (contact information can be found in Appendix) Walter Reed WHO ICAP � Previous Section: Scope for CRO Next Section: Operational considerations � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[44]=new Array(0,1,"./paper-7-value-proposition.html","2009-10-09","13K","Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009    ","",""," Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper | ICTPH - Global Internship Programme 2009 Font Size Facilitating Market Entry for Technologies in Rural Health – An ICTPH Strategy Paper Paper Contents... Proposal & Introduction Methodology Market size Value proposition Point of care diagnostics landscape Contract research organization proposal Scope for CRO Timeline and Process Operational considerations Projected CRO-related expenses and investment beyond baseline clinic ICTPH Consulting proposal Revenue model for CRO and consulting services ICTPH Healthcare Venture Fund proposal Conclusion Appendix Case study: These excerpts are illustrative of disease-specific field testing Neil Parikh, ARIJIT SARKAR Value proposition A number of PCDs are available that meet the basic requirements of low cost, easy to use, and satisfactory quality to be used in rural settings. The products are being procured in large quantities for other global health settings, but have yet to successfully penetrate the Indian rural market. After a thorough analysis of the barriers to adoption which is highlighted in this report, ICTPH is well suited to address these gaps through a broad array of services including market entry consulting, regulatory navigation, field testing through contract research organization model. In a general sense, ICTPH can be a market entry vehicle by leveraging its public health knowledge and clinic infrastructure, thereby providing services that would be aligned with its established core competencies. In addition, ICTPH has the ability to gain implicit trust in its public health motives by being a non-profit organization. Given the growing market size for rural healthcare, ICTPH has a unique opportunity to pursue a sustainable strategy in which revenue can be generated and its public health ambitions can be furthered. CRO value proposition Given the research-oriented nature of the organization, the projected infrastructure including clinics and e-capabilities, the overall institutional goals of developing technology for public health, as well as the general support for rural validation studies, ICTPH should outfit its sites with Contract Research Organization capabilities. The outfitting would come at a minimal incremental investment, as the majority of the capital expenditures would already be in place as part of the clinical infrastructure. Further, the organization will have access to innovative technologies which serve the dual role of positive public relations in the community and the ability to evaluate for possible adoption of such technologies into the clinic. Finally it could serve as an inroad with Ministries of Health, other government agencies, and national disease programs if our services could be used for their on-going research and epidemiological activities. Consulting services value proposition As ICTPH builds its own capabilities in technology development, a majority of these capabilities can help to address the gaps in technology development that other organizations face. Given the end goal of improving health delivery, ICTPH could offer its competencies via a consulting model for outside organizations. By doing so, ICTPH will grow its network, generate revenue with modest incremental cost, be introduced to new concepts potentially relevant to ICTPH clinics, and strengthen its credibility in the public health landscape. � Previous Section: Market Size Next Section: Point of care diagnostics landscape � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[45]=new Array(0,1,"./paper-6-appendices.html","2009-10-09","20K","Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Paper Contents... Introduction Background Literature Review Methods Geography Findings: Alakudi Limitations and Challenges Conclusion Appendices References Chiai Uraguchi, Maki Ueyama, Sunayana Sen Appendices (Page 1 of 2) 1. Question Banks 2. Consent Form for Key Informant Interview-Tamil version 3. Consent Form for Focus Group Discussion-Tamil version 4. Operational definition of key terms Appendix 1 Question Banks (Demand Side) Question Bank: Demand Gaps in delivery of public health services What do you feel about the public healthcare services (PHCs) in the area? How competent do you think the doctors/other health staff in the PHCs are? Do they discuss the problem that you are seeking care for, with you? How long is the waiting period in a PHC? What distance do you have to travel to reach the PHC? How long does it take? Share your experience of a visit to the PHC. How frequently does the VHN visit your village? What kind of services do they provide? Are these visits helpful? What other services do you think they could provide that you could benefit from? Which one of the following aspects do you consider most problematic as far as public healthcare facilities in your area are concerned - Quality - Affordability - Accessibility - Availability What according to you are the problems in the public health system in the village that need to be addressed immediately? Role of private healthcare providers All of the above with respect to the private providers in the village. Have you heard of ‘quacks’? Do you visit them? Why? Health Expenditure How much do you spend on healthcare in a year? For those who pay, do you think this is affordable? Would you be ready to pay more for better services that take care of all the expectations you have from the healthcare system? Suggestions for alternatives to improve the health system What are some of the areas that the private/public health systems could improve on? What according to you needs to be done to address the problems in the existing health system in the village? Appendix 2 Consent Form for Key Informant Interview-English version IKP Centre for Technologies in Public Health Guna Complex, 6th Floor, 443, Anna Salai, Teynampet, Chennai 600 018, India. Informed Consent Form – Key Informant Interviews The Informed Consent Form has 2 parts: 1. Information sheet to share the information with the interviewee 2. Certificate of consent (for signature when you agree to be interviewed) Part 1: Information sheet Purpose ICTPH is a not-for-profit research centre that aims to learn, discover and apply relevant innovative solutions for healthcare leading to improved health for the rural populations in India and other developing countries and to integrate technological advances with delivery of affordable, accountable and accessible healthcare. ICTPH is currently involved in conducting a study that seeks to explore whether there are any gaps in the existing healthcare delivery system in Thanjavur district of Tamil Nadu, India, and find out whether there is a need for intervention to fill those gaps. The information you provide will only be used to understand how people view the existing healthcare services and their expectations from the healthcare delivery system which would then help us look into the need to come up with alternatives to supplement or complement the health ecosystem for making it an ideal one. Therefore, we request you to cooperate and seek your permission to conduct an interview. We believe you can contribute greatly to the study by sharing your experiences, both good and bad, about healthcare access, facilities and the initiatives that are being taken to promote good health in your area and build a strong, well functioning health system. We will conduct these interviews in other villages in Thanjavur as well and will deal with the same issues. Please answer the questions in as detailed a manner as possible so that we can get the maximum information possible to help enrich our research. Procedure We are going to discuss issues related to awareness on public health programs and knowledge on causes and effects of common health problems prevalent in your areas. The questions will be based on your perception of local health problems, your views on treatment facilities available, both public and private and the role that you play (if any) in creating health related awareness and promoting good health. We expect that you will co-operate with us by discussing your views and experiences. Please feel free to give suggestions and express your opinions during the interviews. Audio tapes will be used for voice recordings. The audiotapes will be destroyed after completion of the project. Please do not hesitate to share information with us. All the personal and private information you share will remain strictly confidential. Duration of activity The interview will last for about for 30 to 45 minutes. Your participation is voluntary and there will be no cash or other reimbursements. Risks and Benefits The procedure may seem time-consuming and lead to disruption of routine. However in the long run it will benefit the community as a whole even though there may not be any direct benefits associated with it. Information on the outcome of the research Community meetings to be held in your area after the completion of the research process during which information regarding the research findings will be shared with you. Privacy and confidentiality Your name and identification will only be known to the researcher and will not be linked with your responses. Your responses will remain confidential and this information will only be used by research staff. The tape recorded discussions will be stored in a locked cupboard/filing cabinet until the completion of the study. We will write a number code and not your personal details on the response sheet to ensure confidentiality. Right to refuse or withdraw Your participation is voluntary and you can withdraw from the interview at any point even after having given consent. You are free to refuse to answer any question that is asked in the interview. If you have questions to ask during the interview, I will answer them. Whom to contact If you have any questions about this survey you may ask me or contact: Sunayana Sen, IKP Centre for Technologies in Public Health, Guna Complex, 6th Floor, 443, Anna Salai, Teynampet, Chennai 600 018, India Signing this consent indicates that you understand what will be expected of you and are willing to participate in this survey. At this time, do you want to ask me anything? May we begin the interview now? Part 2: Certificate of Consent � Previous Section: Conclusion Next Section: Appendices (2 of 2) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[46]=new Array(0,1,"./paper-6-appendices-2.html","2009-10-09","18K","Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Paper Contents... Introduction Background Literature Review Methods Geography Findings: Alakudi Limitations and Challenges Conclusion Appendices References Chiai Uraguchi, Maki Ueyama, Sunayana Sen Appendices (Page 2 of 2) Appendix 3 Consent Form for Focus Group Discussion-English version IKP Centre for Technologies in Public Health Guna Complex, 6th Floor, 443, Anna Salai, Teynampet, Chennai 600 018, India. Informed Consent Form – Focus Group Discussion with Villagers The Informed Consent Form has 2 parts: 1. Information sheet to share the information with the participant 2. Certificate of consent (for signature when you choose to participate) Part 1: Information sheet Purpose ICTPH is a not-for-profit research centre that aims to learn, discover and apply relevant innovative solutions for healthcare leading to improved health for the poor populations in India and other developing countries and to integrate technological advances with delivery of affordable, accountable and accessible healthcare. ICTPH is currently involved in conducting a study that is designed to explore whether there are any gaps in the existing healthcare delivery system in the Thanjavur district of Tamil Nadu, India, and find out whether there is a need for intervention to fill those gaps. The information you provide will only be used to understand how people in Thanjavur view the existing healthcare services, their expectations from the healthcare delivery system which would then help us look into the need for alternatives to supplement or complement the health ecosystem for making it an ideal one. Therefore, we would like to invite you to participate in this study as we think you can contribute to our knowledge by sharing your experiences with us about healthcare access and facilities. We will conduct this discussion in other villages in Thanjavur as well and will deal with the same issues. Please answer the questions in as detailed a manner as possible so that we can get the maximum information possible to help our research. Procedure We are going to discuss issues related to awareness on public health programs and knowledge on causes and effects of common health problems prevalent in your areas. The discussion will be based on what you know about local health problems, the treatment you seek for common illnesses, preventive measures that you take (if any) to keep diseases away, your views on treatment facilities available, both public and private. We expect that you will co-operate with us by discussing your views and experiences. Please feel free to give suggestions and express your opinions during the meeting. Audio tapes will be used for voice recordings. The audiotapes will be destroyed after completion of the project. Please do not hesitate to share information with us. All the personal and private information you share will remain strictly confidential. Duration of activity The meeting will last for about for 45 to 60 minutes. It is based on voluntary participation and there will be no cash or other reimbursements. Risks and benefits The procedure may seem time-consuming and cause disruption of routine but in the long-run it will benefit the community as a whole even though there may not be direct benefits associated with it. Information on the outcome of the research Community meetings to be held in your area after the completion of the research process during which information regarding the research findings will be shared with you. Privacy and confidentiality Your name and identification will only be known to the meeting organizers and will not be linked with your responses. Your responses will remain confidential and this information will only be used by research staff. The tape recorded discussions will be stored in a locked cupboard/filing cabinet until the completion of the study. Right to refuse or withdraw Your participation is voluntary and you can withdraw from the discussion after having agreed to participate. You are free to refuse to answer any question that is asked during the course of the discussion. If you have questions to ask during the meeting, I will answer them. Whom to contact If you have any questions about this survey you may ask me or contact: Sunayana Sen, IKP Centre for Technologies in Public Health, Guna Complex, 6th Floor, 443, Anna Salai, Teynampet, Chennai 600 018, India. Signing this consent indicates that you understand what will be expected of you and are willing to participate in this survey. At this time, do you want to ask me anything? May we begin the discussion now? Part 2: Certificate of Consent Appendix 4 Operational definitions of key terms Gaps are defined as the inability to seek heath care services due to lack of accessibility, availability, affordability and/or quality of the particular service in question. Accessibility: The ease with which a patient (healthcare seeker) can cover the physical distance required to get to a heath care facility. Availability: The presence of healthcare services including emergency care as well as the presence of qualified medical professionals, adequate supply of drugs and other facilities such as diagnostic facilities. Quality of service: The time for which a patient has to wait at a healthcare center in order to receive the healthcare service he/she is seeking, the treatment both medical and behavioral that he/she receives, the physical environment (cleanliness and hygiene) that he/she is exposed to and the ability of medicines to solve the health problem under question without harming the individual, define the quality of the service being sought. Affordability: The ease with which a patient is able to cover the financial costs of the healthcare service being sought. � Previous Section: Appendices (1 of 2) Next Section: References � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[47]=new Array(0,1,"./paper-6-background.html","2009-10-09","22K","Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Paper Contents... Introduction Background Literature Review Methods Geography Findings: Alakudi Limitations and Challenges Conclusion Appendices References Chiai Uraguchi, Maki Ueyama, Sunayana Sen Background Healthcare System in India The first National Health Policy that aimed to achieve ‘Health for All’ by 2000 was introduced in 1983. Improvements, through focus on better infrastructure for primary healthcare and healthcare delivery systems, resulted in reductions in infant mortality and death rates, longer life expectancy, and higher rates of childhood vaccinations. However, not every segment of the population was benefiting equally, and, according to a human development health report by UNDP, India ranked 128 out of 177 countries (Human Development Index 2007/2008). Other South Asian countries, such as Vietnam, Indonesia, and the Philippines, ranked higher than India. Since the Community Development Program 1 was launched in 1951 in India, the country has gradually enhanced the healthcare infrastructure. The National Healthcare system in India is delivered by public and private players. As of 2005, 142,655 sub-centers, 23,109 primary health centers (PHCs) and 3222 community health centers (CHCs) provide services to 742.49 million rural people (72.2% of India’s population live in rural areas). Over 5479 sub-divisional and district hospitals play a role in the public sector (Bulletin on Rural Health Statistics in India, 2005). The population coverage norms are 3000/5000 per sub-centre, 20,000/30,000 per PHC and 80,000/120,000 per CHC respectively, depending on the location of the center (i.e. in a hilly, tribal, or other difficult area to be accessed) (Central Bureau of Health Intelligence, 2005). On the other hand, the private sector plays a significant role in the delivery of healthcare, catering to 46% of hospital inpatients and 81% of outpatients (WHO Financing and Delivery of Healthcare Services in India, 2005). While both players are indispensable to the nation’s healthcare delivery, the latter predominates in the health sector. Healthcare delivery in the public sector is targeted towards sections of the population that cannot afford appropriate healthcare. A Facility Survey in 1999 by the Government of India indicated that 75% of the government-run Community Health Centers lacked in adequate equipment – and only 33% of the Primary Health Centers provided quality delivery care – if they provided any care at all (Bulletin of Rural Health Statistics in India, 2006). These inadequate public health facilities have led to the non-utilization of such facilities. A lack of managerial and technical ability in the Public Healthcare system is a major part of primary challenges here. Unequal distribution of facilities is also found between rural and urban health service areas in India: Although 75% of the population still lives in villages, 59% of all practitioners and 84% of hospital beds are in urban areas (Duggal, 2000). There are about 4621 hospitals and 18.5 beds per 100,000 population in rural areas. The number of hospitals and beds per 100,000 population in urban areas are 10,406 hospitals and 232.36 beds. This presents a stark contrast existing in the health infrastructure development between urban and rural India (Varman and Kappirath (2008). In terms of managerial ability, many public health sectors apply the “first-come, first-served” policy. In 2003, of the 8.8% of the GDP that was spent on health, the public expenditure on health was 25% and private expenditure was 75% (WHO Country Health System Profile, India, 2007). In spite of efforts to provide free public services, health-expenditure surveys consistently show high levels of private out-of-pocket spending on healthcare (Berman, 1997). Today, the capacities for human resources in healthcare are significantly scarce in India – even within low income countries, approximately 1,125,000 practitioners of various levels of qualification – and from different schools of medicine – are registered in the country. Of them, only 125,000 (which constitutes only 11% of the total number) serve the government-public sector, while the rest are all working in the private sector. This excludes an innumerable number of unqualified and unregistered medical practitioners that also operate throughout the country (R. Duggal, 2000). There is a disparity of human resources between rural and urban areas. Only 0.6 doctors per 10,000 population in rural India currently are working; on the other hand, 3.4 doctors per 10,000 population are in urban areas (Ashok Kumar, 2007). Rural/urban disparities are equally pronounced in the outcome of health services. Consequently, despite the fact that large portions of the population seek medical services from the private sector (NHP 2002), due to high medical fees, private healthcare is not equally accessible to everyone in India. This has made it increasingly difficult for the poor to avail of private care and caused them to refrain from seeking any healthcare at all (Levesque et al, 2006). Therefore, poorer households access less preventive and curative healthcare from the private sector than richer households. Due to the lack of ability to pay the fees, the poor are much less likely to be hospitalized. Indians who are hospitalized tend to spend 58% of their total annual expenditures on healthcare (David H. Peters, Abdo S Yazbeck, Rashmi R.Sharma, Lant H. Pritchett, Adam Wagstaff, 2002). More than 40% of hospitalized people in India manage to cover expenses by borrowing money or selling assets to cover expenses. Consequently, many hospitalized people are likely to fall into poverty. There is a great financial risk that hinders the poor from accessing private healthcare. Healthcare indicator and system in Tamil Nadu Within India, healthcare services in the country vary substantially between states, regions and societies. These differences in healthcare provision translate to differences in various health indicators, including: Life Expectancy at Birth (LEB) and Infant Mortality Rate (IMR). The state of Tamil Nadu, located in the South of India, is one of the foremost states in terms of overall development. The state has the highest number (10.56%) of business enterprises in India (Provisional Results of Economic Census 2005). Tamil Nadu has also done very well in terms of human development among the better performing states in terms of health indicators (R.J Chellian, K.R. Shanmugam, 2002). Tamil Nadu had among the lowest percentage of the hospitalized falling into poverty from medical costs in 1995–96 – less than the national average. Following is the comparison of various health indicators in Tamil Nadu compared with the national averages. Table 1: Life Expectancy Rate at Birth In Tamil Nadu, a male at birth is expected to live for almost 69 years while a female is expected to live for almost 72 years; whereas the national averages for life expectancy at birth in India for males and females are approximately 64 years and 67 years respectively. Table 2: Childhood Mortality Rate 2005 to 2006 With respect to national mortality rate, East India: Jharkhand and Central India: Uttra Pradesh has the highest rate (48.6 and 47.6) and Kerala has the lowest rate of 11.5. Tamil Nadu has a relatively low mortality rate, as compared to other states. This is indicative of the decrease in the death rate and the improvement of the quality and availability of health services in the state. Table 3: Percent distribution of women who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent live birth 2005-06 The percentage of women seeking antenatal care in Tamil Nadu is an encouraging 99% whereas the All-India average is only 77%. In Tamil Nadu, women who access doctors to receive antenatal care are relatively higher in number than the average percentage in India. Only 1.1% women in Tamil Nadu do not access antenatal care; on the other hand, India as a whole averaged more than one fifth of women answering ‘no one’ to receive any information about antenatal care. Table 4: Percentage of Institutional Deliveries The disparity between the state percentage and the All-India percentage of institutional deliveries is even starker – Tamil Nadu has a phenomenal record of 90% institutional deliveries whereas the All-India figures are a dismal 41%. While these may reflect the greater level of health awareness among the people in Tamil Nadu, both increased awareness and greater healthcare use can be attributed to the relatively advanced health infrastructure in the state in comparison to other states. Within the state of Tamil Nadu, there are inter-district disparities as far as healthcare is concerned: Among the 30 identified districts in Tamil Nadu, the district of Thanjavur ranked 9th in health infrastructure development. Thanjavur district also performs well nationally with the ranking of 41 among the 593 districts studied in the country (IIPS, 2006). Although the study failed to cover information from all the districts, due to unavailability of data, it covered most of the districts and hence was successful in providing an idea of where Thanjavur stands with respect to health services and infrastructure. Notably, Tamil Nadu has successfully established a high quality of healthcare management by decentralizing healthcare services. For instance, each PHC covers from 5 to 10 sub-centers and each is staffed by community health workers called ‘Village Health Nurse’ (VHN). Each VHN has a service area comprised of approximately 5000 population in (up to) 7 or 8 villages and receives two years of healthcare training to become eligible for service. According to multi-state studies, Tamil Nadu’s VHNs have better knowledge levels and more effective contact with service communities than their counterparts in other states. Most of the VHNs live in their service villages, and emergency cases are brought to them night or day. Because of their close contact with the community, and the extensive records they keep, VHNs are familiar with the needs and problems in their communities. Their services and the PHCs are widely seen as intended mainly for women and children. VHNs are responsible for house-to-house contacts and for schools. They provide preventive healthcare by providing vaccinations and pre-delivery care for expectant mothers. Their services have generally included immunizations, nutrition and other health education, antenatal care, childbirth services and referrals, and family planning (Lakshmi Ramachandar, Pertti J Pelto, 2002). Despite limited amounts of information and unavailability of data, it successfully illustrates where Thanjavur stands with respect to health standards, services and infrastructure. 1 Community Development Program: In 1951, Government of India viewed rural development as pivotal to achieving economic growth and social development. The objective of the program was to achieve “Samagra Gramin Vikas“, addressing all the issues of basic needs of the people and implementing a number of programs in rural areas. (Continue reading) � Previous Section: Introduction Next Section: Literature Review � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[48]=new Array(0,1,"./paper-6-conclusion.html","2009-10-09","12K","Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Paper Contents... Introduction Background Literature Review Methods Geography Findings: Alakudi Limitations and Challenges Conclusion Appendices References Chiai Uraguchi, Maki Ueyama, Sunayana Sen Conclusion By looking at the overall structures in Alakudi, of both public and private healthcare services – including unqualified doctors – it can be concluded that, despite certain gaps between public and private sectors, private is likely to fill the gap in the needs among villagers. There are linkages between public and private healthcare – such as PHC to private hospitals and private to government medical hospitals – so that patients access healthcare services according to their health requirement despite frequent poor management in the government sectors. The public healthcare system certainly needs improvement. The most serious issue in human resource management is the huge gap in manpower in the public sector that provides healthcare to the poorer segments of the population. Most interviewees and focus group participants addressed the urgent need of longer hours of a doctor’s duty time and for additional numbers of doctors. Lack of management – especially emergency care and the short length of duty for doctors in the PHC – leads to low quality treatment/hasty and careless diagnoses. Due to a lack of careful explanation about diseases, physical problems, and medicines from doctors, patients are likely to lack knowledge about medicines and rely on heavy dosage medicines to seek quick recovery. It is necessary for medical providers to better explain usage of medicines and procedure of treatment in order to build more educated awareness toward medicines and treatment. Both public and private hospitals are located within accessible distances. However, since there are no available hospitals offering any X-ray, ECG, scan, ultrasounds, etc., most villagers have to visit Thanjavur or Buthalur (most likely Thanjavur Medical Hospital). The need of beds, scanning, ambulances, etc. is addressed by women and are strongly related to pregnancy. Accessibility would be more satisfactory for villagers if there would be a nearby clinic or hospital that offers the facilities. The cliché of unaffordable charges in the private sector has been changing due to some private doctors now charging lower fees and providing injections and tablets at an affordable price – although there are some people who still tend to borrow money in order to access the private sector, no matter the cost. Despite it being an illegal medical practice, unqualified doctors (‘quacks’) seem to also meet villagers’ needs with 24-hour access and affordable medicines. Overall, in Alakudi, there are certainly gaps in healthcare both in public and private. However, most villagers manage to access necessary healthcare. There is still more room for the public sectors to improve for the betterment of healthcare service. � Previous Section: Limitations and Challenges Next Section: Appendices � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[49]=new Array(0,1,"./paper-6-findings-alakudi.html","2009-10-09","20K","Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Paper Contents... Introduction Background Literature Review Methods Geography Findings: Alakudi Limitations and Challenges Conclusion Appendices References Chiai Uraguchi, Maki Ueyama, Sunayana Sen Findings: Alakudi (Page 1 of 2) Availability: Doctors, Nurses and Emergency According to the result of this study, both males and females admitted that doctors are available only from 9 am to noon in the PHC in Alakudi. Because of short duty hours for doctors, a ‘compounder’ often prescribes tablets and gives patients first aid when doctors are off duty. While nurses are on duty, and available for patients the whole day, they often ask patients to come back the next day due to the unavailability of doctors. For daily wage workers, regular visits spoil their daytime work and such consumption of time directly affects their daily income. The majority of people emphasized the need for longer hours of doctors’ availability; some mentioned 24-hour availability is essential. According to some female participants, the public sectors improved in terms of the availability for maternity delivery. One of the participants in the focus group discussions said that there is a nurse available at night for delivery cases. However, most female participants emphasized a need for longer hours of a doctor’s on-call duty. In the case of private hospitals, villagers are able to visit them even after work since doctors in the private sector are usually available till late in the evening; one private doctor in Boothalur is willing to give treatment even after 9 pm. Doctors being available during late hours could be big help especially for working males; thus, many male participants repeatedly pointed out about the particular doctor in Boothalur who is available almost all the time. In the case of emergency, most people complained about the lack of accessible doctors in public sector. However, during the duty hours of doctors, emergency cases are usually given priority in the PHC. Some people access private hospitals in Boothalur, while some go to Thanjavur. Oftentimes patients get medicines from medical shops because doctors are not available or patients try to avoid long lines. Overall, many people experience dreadfully long waiting hours in public hospitals – even in emergency cases. “Even if it is an emergency case, such as a car accident, they (government hospitals) are instructed to give information to the police first, and then only do they proceed with treatment. Sometimes, patients die before they start treatment.” At the same time, female participants also mentioned: “PHC gives us a token and we have to wait. They treat one by one regardless of emergency.” However, it seems the PHC gives priority to the treating of students. According to interviews with school teachers and headmasters, students were treated in a timely and proper manner when they fell sick during school hours: “If the school boys fell sick, we take them to the PHC. Some students fell sick and I sometimes had to take them to the PHC. In the PHC they give first aid for diarrhea and vomiting. Since we are school teachers, and to avoid any disturbance to their education, they treat us first, even if there is a vast crowd waiting.” The private sectors give high priority for emergency cases. Therefore, in an emergency case, many people access private hospitals because some doctors are always available for patients. Quality of service: waiting time Lack of manpower leads to the creation of issues in quality of services, increasing time for which one has to wait in order to get services. One of the quality factors is waiting time. Depending upon the crowd on any given day, the average waiting time is usually 30 min to 1 hour – sometimes up to 2 hours – in the PHC because merely one or two doctors are available for only about 3 hours per day. Particularly, males expressed more concerns about waiting time since it affects their daily wages. Because most villagers work on farms and are paid daily wages, the length of waiting times causes a loss to the patients’ incomes. There is also no proper waiting room in government hospitals in both PHC and government hospital, Thanjavur Medical Hospital, so that many patients must wait outside – even in emergency cases. Due to the needs of diagnosing enormous number of patients – 200-300 patients a day – often hasty treatments are the result. The following comments which were addressed in male focus groups, exemplify long hours of waiting time: ‘It takes2 to 3 hours to see doctors and it is a waste of time. So, I came back home. 200 to 300 people are there in the PHC per day.’ ‘Everyday 15 to 20 are pending from previous day. The patients have the prescriptions which were issued 2 to 3 days ago. They only came back to PHC in order to get tablets. Even then, the PHC sent them back home.’ Long waiting hours in private hospitals is also not unusual for outpatients; sometimes they have to wait on for 1 to 2 hours. However, due to efficient management, private sectors use an appointment system for the patients for the subsequent visit so that they do not waste their time in the waiting room. Quality of service: treatment and quality of service – attitude toward patients Due to the large number of patients that doctors see everyday within their short duty hours, the quality of treatment is affected. Many participants addressed dissatisfaction toward not only medical treatment, but also health workers’ attitudes toward patients. A majority of male participants criticized nurses’ nonchalant attitude toward patients – for instance, talking on the phone unmindful of an emergency case – and rough treatment by staff in the public sector. ‘The government hospitals treat us with frustration’ exemplifies how the staff treat patients. Due to the limited amount of time spared by doctors despite long lines of patients, most villagers who have ever visited government hospitals are dissatisfied with their treatment: “Doctors prescribe medicines without using thermometer or stethoscope. Some doctors give adequate guidance on taking tablets, but some just give medicines and patients do not know when to take them.” Due to ineffective treatment from the public sector, many people are likely to access private hospitals after visiting a PHC. In the PHC, due to a lack of explanation about medicines and diagnoses, there is a lack of knowledge about the root causes of diseases, the process of treatment, and types of medicines among villagers. Consequently, many participants mentioned that they are keen to get injections and heavy dosages of medicines without any awareness of a medicine’s potential – or side effects in the long term. On the other hand, the private sectors are more likely to provide injections and heavy dosage medicines which leads to fast recovery, creating a sense of satisfaction of high dosage medicines without being aware of long-term effect the medicine may cause. Quality of service: medicines and their availability As already mentioned, most participants claimed that they are not satisfied with low-dosage medicines the PHC usually offers since they seek a quick recovery; therefore, they are likely to conclude that medicines in the PHC do not work effectively. When the medicines in the PHC do not work for certain patients, the doctor often refers them to their own clinics. There are usually medical shops in the villages. However, commonly available medicines – such as pain killers – are not always available, both in the PHC and in pharmacies in Alakudi village. Some participants described the inconvenience in accessing medicines. Although there is a tremendous need for diabetes treatment, there is no insulin injection available in the public sector in the village – only oral medicines. For diabetic patients, especially severe cases, they have to go to Thanjavur to get insulin. There is unmet need arising from non-availability of certain medicines. According to the group discussions – many praise a particular private doctor (villagers call him ‘lucky doctor’ 5) in Boothalur since he gives injections and heavy doses to any outpatients. Despite some awareness of the dangers regarding a heavy dosage among educated people, many villagers tend to conclude heavy dosage is effective and they demand to be given in order to ensure speedy recovery. 5 Lucky doctor is a general physician who, people believe, can cure any disease. This belief is attributed to the doctor’s success in having cured patients in the past. (Continue reading) � Previous Section: Geography Next Section: Findings: Alakudi (2 of 2) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[50]=new Array(0,1,"./paper-6-findings-alakudi-2.html","2009-10-09","18K","Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Paper Contents... Introduction Background Literature Review Methods Geography Findings: Alakudi Limitations and Challenges Conclusion Appendices References Chiai Uraguchi, Maki Ueyama, Sunayana Sen Findings: Alakudi (Page 2 of 2) Traditional medicines There is one ‘siddah’ doctor in the Alakudi area and this doctor gives treatment for jaundice, dog bites, minor illness, and panic attack using traditional medicines. Many participants have accessed traditional medicines before. Half of them mentioned it was effective; however, they are aware that it has reduced effectiveness if they take allopathic medicines. Others expressed negative opinions, especially for joint pain, where a few participants had applied traditional treatment; yet, due to the need for long-time to cure, most of them tended to then apply allopathic medicines. Siddha treatment is commonly known and is accessible at the village level at affordable prices. Most of people are aware of effectiveness for certain diseases such as jaundice. Quality of service and availability: facility For X-rays, people go to Thanjavur, since there are facilities offering X-tray, scan, ecocardioglam (ECG), etc. Despite the fact that there is (or are) medical shop(s) in Alakudi, better medical shops were demanded. Due to the fact that diabetes is a common disease, blood tests for regular check-ups for glucose level in the blood are essential. However, the public sector fails to offer adequate blood tests in a timely manner. They often request patients to come back after weeks to collect test results. Therefore, villagers who have time constraints prefer the private sector for check-ups since they would perform most of the tests and have results within the same day. Even though the PHC offers blood tests, some people are unaware of the service. Bed availability is one of the other factors in which many people feel there is a need to improve. The needs of beds, scan, and ambulances are insisted upon by women. Additionally, some women mentioned the need for pediatricians since there is no child specialist in the nearby village. A majority of participants in these qualitative discussions felt that transport facilities for emergency cases, X-rays, ECG, and Ultrasound scans, etc. are essential for the PHC to provide. However, these facilities are available only in Thanjavur (Public) Medical Hospital and a private hospital in Thanjavur, or the closest town, Boothalur. Even in private hospitals, facilities such as X-ray, Ultrasound, and ECG are not always available; therefore, patients often travel from one hospital to another to complete their tests after being prescribed by their doctors. Accessibility: locations A PHC was launched in Vannarapettai in order to increase accessibility to poorer districts. At that time – after a few years of healthcare service in Vannarapettai – access was difficult for those people from Kalrayanpatti (a village nearby Alakudi). Hence, a new PHC was established in the Alakudi area so that more than 8 to 9 villages can access the PHC. Average travel time from Alakudi (and 8 to 9 villages near Alakudi) depends upon the areas where they live in Alakudi: some mentioned it takes 2 to 5 minutes, while some take 15 to 20 minutes. Despite being quite a distance for elderly or disabled people, most of the male villagers who participated in the focus groups and interviews were satisfied with the distance to the PHC. The PHC is currently located in an accessible area from two schools. According to a school teacher and headmaster whom we interviewed, first aid is implemented in a swift manner for students. Thanjavur Medical Hospital is within a reachable distance and takes a 30-minute journey by public transport. There is not a single private hospital in Alakudi village; however, general doctors and specialists are accessible in both Boothalur and Thanjavur. It usually takes 30 to 45 minutes to get to both places by train. During night time, there are buses available; however, most of the villagers use bikes or cars. Quacks During the night, ‘quacks’ are available 24 hours – and most villagers trust the treatment, medicines, and injections from quacks. For emergencies, many of them have ready access to quacks. Some charge money and adjust the dosage of medicines according to how much money patients can afford. One compounder in PHC has so much money experience that, sometimes, the compounder prescribes treatment to patients outside the PHC – and even inside the PHC. Although some comments showed a reluctance to access unqualified doctors, they are likely to fill the gaps by providing urgent care. Expenditure and affordability The average expenditure for healthcare is dependent upon how many family members there are and how severe the disease. According to the self-help group member whose family members do not have any severe chronic disease, this expenditure is approximately Rs. 2000 to Rs. 5000 per year. On the other hand, some who are diabetic, have joint pain, etc., mentioned medical costs come to Rs. 15,000 to Rs. 20,000 per year. Farmers, who receive daily wages and are considered to have less income than other workers – such as teachers – still often manage to pay fees to private hospitals. Depending upon their financial situation, patients are likely to choose access to either public or private sectors. Due to the free charge in the public sector, people think only poor people go to the public sector. Yet, if people get high enough salaries, they are willing to access the private sector. Consulting private doctors – including buying the prescribed medicines and check-up – is typically Rs. 100 to Rs.200. Since some doctors have their own medical shops or labs, doctors typically refer patients to their particular labs in order to generate more money. A majority of participants addressed the need of reduction in fees. For critical conditions or chronic disease, they have to spend Rs. 5,000 to Rs. 10,000, which causes a financial crisis. Some private doctors offer affordable fees to patients such as Rs. 15 for one injection and Rs. 8 for tablets. Some participants mentioned that they are comfortable paying Rs. 30 to Rs. 50 for minor sickness. Those who cannot afford to pay are likely to sell their cattle, jewelry, or borrow money from banks or neighbors; however, these seem to be relatively few. Corruption The Indian government regulations ensure free diagnosis and medicines in public health sectors in PHCs to all people. However, due to corruption, some practitioners, assistant doctors, and other general workers demand bribes when villagers get injections, medicines, and visit their relatives in both government hospital and PHC. “The only good thing about public sectors is they prescribe medicines for free. Yet, they (workers) sometimes deceive patients and demand money. They openly ask us to pay extra money for injections and tablets. They always use the excuse that their salary is so little, that they have to ask for extra money”. Village Health Nurse (VHN) Even though the literature reviews showed satisfactory results of the VHN program, the performance of Village Health Nurses is very satisfactory only among school workers and villagers. VHNs visit schools regularly to provide vaccines and tablets. VHNs issue a healthcare card called “Vaalvu Oli Thittam” for individual students so that they can be tracked on their health history. VHNs often refer students to the Thanjavur Medical Hospital or private hospitals in a swift manner. VHNs also pro-actively visit villages to provide filarial and iron tablets – mainly to women. However, most villagers simply do not take the tablets because of lack of awareness of the benefits of the tablets. Further explanation and healthcare-related education seems to be necessary. � Previous Section: Findings: Alakudi (1 of 2) Next Section: Limitations and Challenges � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[51]=new Array(0,1,"./paper-6-geography.html","2009-10-09","13K","Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Paper Contents... Introduction Background Literature Review Methods Geography Findings: Alakudi Limitations and Challenges Conclusion Appendices References Chiai Uraguchi, Maki Ueyama, Sunayana Sen Geography The qualitative research was conducted in one village, Alakudi. Alakudi is located east of Thanjavur district and is the closest village from Thanjavur city. It usually takes 30 minutes by a car or bus. Public transports run frequently so that villagers can easily access a train or bus service. Only at certain times do trains run from Alakudi to Thanjavur: from 8 am to 10 am and from 4 pm to 6 pm. Public bus service is available 24 hours. The total estimated population in Alakudi is 2,900 2 (excluding the number of non residents). 28.12% of total surveyed residents that are above 3 years old, out of 2,738 3, have completed secondary school despite high illiteracy rate of 18.48% in Alakudi. Total 83.48% of work forces are committed to agriculture: 50.35% of them are daily wage earners on other people’s land and 33.14% cultivate their own land. 4 Geographical map: Alakudi In Alakudi, most people have access to public and private hospitals regardless of their financial level. Although many villagers are more likely to visit the PHC for the first treatment, they visit private hospitals when it is necessary. According to the interviews and focus group discussions, owing to absence of private hospitals in Alakudi, many villagers access private healthcare in either Boothalur or Thanjavur. Boothalur is two stops away by train from Alakudi – within approximately 30 minutes – the travel costs only Rs. 2.00. There is frequent bus service to Thanjavur and the journey takes around 45 minutes from Alakudi village. The PHC doctor and nurses often refer patients to private hospitals, clinics, or Thanjavur Medical College Hospitals for further treatment. There are unqualified doctors – ‘quacks’ – in Alakudi and they are accessible 24 hours. Especially, during night time or in an emergency, villagers are likely to access these ‘quacks’. Map 1: Alakudi and Boothalur 2 The number is from Census Survey conducted by ICTPH epidemiology team. The surveys contained demographic, health related information, and financial information. Survey residents were 2,812 and non-residents were 224 (total:3,036). (Continue reading) 3 For 74 residents information on education is missing because they are 2 years or below. (Continue reading) 4 Epidemiology Census Survey (Continue reading) � Previous Section: Methods Next Section: Findings: Alakudi � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[52]=new Array(0,1,"./paper-6-introduction.html","2009-10-09","18K","Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Paper Contents... Introduction Background Literature Review Methods Geography Findings: Alakudi Limitations and Challenges Conclusion Appendices References Chiai Uraguchi, Sunayana Sen, Maki Ueyama Introduction Chiai Uraguchi is a candidate for a Master of Public Administration at the Cornell Institute for Public Affairs. She acquired a Master’s degree in Environment, Development and Policy from the University of Sussex and a Bachelor of Arts degree in Environment and Information from the Musashi Institute of Technology in Japan. She has worked in the Philippines on several projects, including one that explored the ‘Role of scavenging in urban livelihoods in the Philippines’ and a ‘Case study of livelihoods in the INAYAWAN dump site in Cebu and a strategy for the poor.’ She was also the project manager for a project aimed at ‘Income Generation for Disadvantaged Women’. Sunayana Sen has a Bachelor’s degree in Psychology from Sophia College, Mumbai. She completed her Master’s in Human Rights, from the University of Calcutta in 2008 and volunteered for several non-profit organizations. She worked on several projects related to child health and the human rights of rural populations before she joined ICTPH as a Research Analyst, Epidemiology. Maki Ueyama obtained her Ph.D. in Policy Analysis and Management from Cornell University (Ithaca, USA). Her main research interests are in the fields of health and healthcare in developing countries. She has a Master’s degree in Policy Analysis and Management and in Public Administration, both from Cornell University. She has a Bachelor’s degree in Economics from Keio University (Tokyo, Japan). Executive summary In 1978, the International Conference on Primary Healthcare, meeting in Alma-Ata, made a historical declaration that expressed the urgent need for action by all governments, all health and development workers, to protect and promote the health of all the people of the world. After more than two decades, India has achieved tremendous improvements in human development factors: e.g., Life Expectancy at Birth (LEB) is 65 and Infant Mortality Rate (IMR) has become 32.31 deaths/1,000 live births. Compared to year 2003, the rate improved drastically from 60 deaths in 2003 to 32.31 deaths per 1,000 population. Public sectors are actively involved in the healthcare system and contribute to society. However, the healthcare sector as a whole is still facing many challenges. According to UNDP, India ranked 128 out of 177 countries (Human Development Index 2007/2008). There are obviously more gaps to fill or unmet needs in the current healthcare system. There is an understanding that South India performs relatively well in terms of healthcare: e.g., a male at birth is expected to live for almost 69 years while a female is expected to live for almost 72 years, whereas the national averages for life expectancy at birth in India for males and females are approximately 64 years and 67 years respectively. With respect to national mortality rate, Jharkhand in East India and Uttar Pradesh in Northern India have the highest rates (48.6 and 47.6) and Kerala has the lowest rate of 11.5. Tamil Nadu has a relatively low mortality rate, as compared to other states. However, some studies show that local people – especially in rural areas – face difficulty in accessing healthcare services due to long distances, the lack of facilities the government (public) sector provides, and unaffordable medical fees that the private hospitals charge. This study – Healthcare Needs Assessment – was designed and conducted by the epidemiology team at the IKP Center for Technologies in Public Health. The study aims to explore whether there are gaps in the existing healthcare system in Thanjavur in rural Tamil Nadu, in the Southern part of India – and what kind of interventions are required to fill the gaps, if any. It has been conducted by utilizing qualitative study methods – key informant interviews and focus group discussions. Through the qualitative studies, the following factors were mainly focused on for analysis: quality of service, accessibility, availability, and affordability – both in the private and public healthcare sectors. The overall picture that the study gives is that, while most villagers manage to access necessary healthcare, there is still more room for the public sector to improve in order to offer better healthcare service. The result of this study showed that the most serious issue is the huge shortage in manpower in the public sector that provides healthcare to the poorer segments of the population. Lack of management, especially emergency care and short length of duty for doctors in the government – led Primary Health Centres, leads to low quality treatment and hasty and careless diagnosis. Due to a lack of explanation about diseases, physical problems, and medicines from doctors, patients are likely to lack knowledge about medicines and rely on heavy dosage medicines to seek quick recovery. It could be necessary for medical providers to explain usage of medicines and procedure of treatment in order to build awareness among patients. Both public and private hospitals are located within accessible distances. However, there are no hospitals in the village offering any X-ray, ECG scan, ultrasounds, and so on. So most villagers have to visit nearby towns to avail of these facilities. The need for hospital beds, scans and ambulances, addressed by women, are strongly related to pregnancy and child birth. Accessibility would be even less of a concern for villagers if there were clinics or hospitals in the village that offered the aforementioned facilities. The cliché of unaffordable charges in the private sector does not seem to be entirely true in this geography since some people mentioned that some private doctors now charge lower fees and provide injections and tablets at an affordable price although there are some people who still have to borrow money in order to access the private sector. Despite it being an illegal medical practice, unqualified doctors (‘quacks’) seem to exist and often meet villagers’ needs with 24-hour access and affordable medicines. Introduction India contributes the largest number of births per year (27 million) in the world (Ronsmans C, Graham WJ, 2006). With its high maternal mortality of about 300 to 500 per 100,000 births, a total of 75,000 to 150,000 maternal deaths occur every year in India (Maternal mortality in India: 1997 to 2003 and National Family Health Survey (NFHS-2), 1998- 1999). This makes up about 20% of the global share, hence India’s progress in reducing maternal deaths is crucial to the global achievement of Millennium Development Goal 5, which aims at improving maternal health (UN, 2009). Despite its achievement of rapid economic growth, India ranked 128 out of 177 countries in the Human Development Health Report by UNDP (Human Development Index 2007-2008). A Healthcare Needs Assessment Study was undertaken to explore gaps in the current healthcare system and existing health facilities in the Thanjavur district of Tamil Nadu, India, and subsequently design interventions needed to fill in the gaps. The study was designed to cover the following aspects which were then going to be used for the analysis: quality of healthcare, availability, accessibility, and affordability of healthcare services. The data was collected by conducting key informant interviews with several people holding positions of authority in the village, and two male and two female focus group discussions with villagers in each village. The study is a small part of the Healthcare Needs Assessment study in that it covers only one village, Alakudi, located in the Thanjavur district of Tamil Nadu, India. Next Section: Background � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[53]=new Array(0,1,"./paper-6-limitations-and-challenges.html","2009-10-09","11K","Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Paper Contents... Introduction Background Literature Review Methods Geography Findings: Alakudi Limitations and Challenges Conclusion Appendices References Chiai Uraguchi, Maki Ueyama, Sunayana Sen Limitations and Challenges The length of my contribution toward the healthcare needs assessment was only 2 months and 7 days. Although qualitative resources – via four key informant interviews and four focus groups – were completely collected and transcribed within the time limitation, findings of only one village, Alakudi, could be incorporated into this paper. Human resources were the major challenge in the study. Only two research assistants played the roles of a facilitator and a recorder and transcribed and translated data. Quality of collected data depended upon the number of participants and their interest in being part of the discussion. Even though 6 members were selected in the beginning for a focus group discussion, some of them left, were often distracted by outsiders, or lost their interest to participate. These incidences would affect the quality of data we gathered. Compared with cultural norms, some opinions were judged to be biased or bombastically expressed – despite our giving sincere appreciation toward the contributors. Many participants criticized as ‘less effective’ the medicines that the public sectors provided. On the other hand, they were likely to have a misconception that high-dosage medicine (or injections) cure every disease – consequently, there was certainly some ignorance among the common people who do not know that high-dosage medicines may do more harm in the long-term. The qualitative study was analyzed only on the consumer side; therefore, some quotations might contain biased opinions. The language barrier was also one of the major challenges we faced. Since Tamil Nadu state is a Tamil language speaking region, many people in rural areas – or even urban areas such as Chennai, the capital of Tamil Nadu – do not command enough of a second language to translate qualitative data. The lack of human resources – including professional translators – caused tremendous difficulty in moving the research forward. � Previous Section: Findings: Alakudi (2 of 2) Next Section: Conclusion � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[54]=new Array(0,1,"./paper-6-literature-review.html","2009-10-09","16K","Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Paper Contents... Introduction Background Literature Review Methods Geography Findings: Alakudi Limitations and Challenges Conclusion Appendices References Chiai Uraguchi, Maki Ueyama, Sunayana Sen Literature Review The importance of health needs assessment has been emphasized by several studies done in the Indian subcontinent; the results of which prove to be extremely useful in identifying needs that are not addressed by existing healthcare facilities – and the important factors (social, cultural, economic) that are ignored by existing healthcare systems, thus pointing out areas which need improvement (e.g.: Varatharajan, 1999, Kannan, et al. 1991, Navaneetham and Dharmalingam 2002, Kavitha and Audinarayana (1997), Ravichandran and Mishra (2001). Most existing studies in South India focus on reproductive and child heath, thus not much is known about general healthcare services (e.g.: Navaneetham and Dharmalingam (2002), Kavitha and Audinarayana (1997), Rajaretnam and Deshpande (1994), Ram (1994), Ravichandran and Mishra (2001). A study about the prevalence of reproductive tract infections was conducted since little is known about rates among the youngest married women in South India. A community-based cross-sectional study of prevalence of reproductive tract infections was conducted among an age group – 16 to 22 – of young married women. Qualitative and quantitative data on treatment-seeking behavior were collected. Multivariate analysis found that 2/3 of symptomatic women had no access to any treatment because of lack of privacy, distance from home, and cost (Jasmin Helen Prasad, Sulochana Abraham, Kathleen M. Kurz, Valentina George, M.K. Lalitha, Renu John, M.N.R. Jayapaul, Nandini Shetty, Abraham Joseph). The study clearly shows that some factors – such as quality of healthcare, accessibility in terms of distance, and affordability – hinder patients’ access to healthcare facilities. A study was conducted to explore unmet needs for reproductive health via a cross-section of 70 women from rural Tamil Nadu. TK Sundari Ravichandran and US Mishra concluded the need for an integrated women’s health program within a strengthened health system. Poor facilities, inadequate supplies, insufficient working hours, lack of proper monitoring and evaluation mechanisms – and a mismatch between training and work allocated to health workers – were the key gaps identified (TK Sundari Ravichandran and US Mishra, 2001). Ram K. (1994) used an ethnographic approach to explore maternity practices among lower-caste Mukkuvar women in Kanyakumari, Tamil Nadu, and identified: prolonged stays during delivery disrupted daily activities; caste disparites between the provider and the user created a power hierarchy; harsh treatment by the hospital staff during delivery; and unnecessary medical interventions. These were cited as reasons for the women in the village not seeking medical care during pregnancy and having reservations against institutional deliveries. Despite improvements in the healthcare status and increasing accessibility to healthcare services in the prior decades, Tamil Nadu still has challenges to adequately treat intricate health cases. Tamil Nadu has not done so well in respect of the late neonatal mortality rate; and done poorly with respect of the early neonatal mortality rate (Venkatesh Athreya, Sheela Rani Chunkath, 1998). More than 70% of those with chest symptoms make one or more efforts to seek care – and private practitioners are consulted more often than government healthcare providers. A research with chest symptomatics in a community-based study in Tamil Nadu showed that private healthcare facilities provided ‘good care’ and easy accessibility – and were the main reasons why patients preferred private healthcare (G. Sudha, C. Nirupa, M. Rajasakthivel, S. Sivasubramanian, V. Sundaram, S.Bhatt, K. Subramaniam, Thiruvalluvan, R.Mathew, G.Renu and T.Santha, 2003). The studies above showcased that there could be certain unmet areas in each of the private and public sides. A qualitative study was conducted to identify basic healthcare available to the poorer segmentation of the population in Tamil Nadu. The study focused on quality issues from the perspective of users in 17 villages and 1 town across rural, semi-urban and urban districts in Tamil Nadu. The focus group discussions in the study described public facilities as being less clean, utilizing poorer equipment, and stocking less effective, slower acting drugs. In cases where drugs were necessary to treat a particular ailment and were expensive (such as snakebites or dog bites), PHCs simply did not have any stock of medicines which were in high demand. Moreover, it was emphasized that issues around the non-availability of physicians, poor staff attitudes, and demands for unofficial payments were common in Tamil Nadu. (Pia Malaney, 2000) Lymphatic filariasis is recognized as the second leading cause of permanent disability in Tamil Nadu. A study was designed that aimed to identify the economic impact affected by the costs of constant treatment and the possibility for patients to lose working time. The ranges of treatment costs in private hospitals are from Rs.500 to Rs. 2,000. Such high costs – coupled with loss of working income during recuperation – causes financial crises for poor households in rural areas (K.D.Ramaiah, Helen Guyatt, K. Ramu, P. Vanamail, S.P.Pani and P.K Das, 1999). According to the study, expenditure for healthcare is likely to burden people – especially daily wage workers – and leads to poverty. More often than not, improvement in healthcare requires building better healthcare services and a system of both users and providers. Awareness is one of the factors users can play significant roles in, to contribute to improving individual health. In focusing on maternal knowledge of malnutrition and child health, the study highlighted that the lack of awareness about health issues in general is the major issue – rather than healthcare availability and healthcare-seeking attitudes. Therefore, the study emphasized that building robust health education regarding maternal health among villagers is of primary importance (K. Saito, J. R. Korzenik, J. F. Jekel, and S. Bhattacharji Yale J, 1997). Although a limited number of studies have been conducted in the past, quality of service, treatment and medicines, availability of doctors and nurses, sufficient facilities, accessibility and affordability have been all highlighted as gaps in the healthcare system time and again. � Previous Section: Background Next Section: Methods � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[55]=new Array(0,1,"./paper-6-methods.html","2009-10-09","13K","Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Paper Contents... Introduction Background Literature Review Methods Geography Findings: Alakudi Limitations and Challenges Conclusion Appendices References Chiai Uraguchi, Maki Ueyama, Sunayana Sen Methods Qualitative research instrument This research aims to integrate data from individual interviews and group discussions. One on one interviews consisted of an in-depth conversation on an individual level. In-depth interviews contributed to providing feedback on empirical and personal aspects of input, activities, outputs, outcomes and impacts of the healthcare system. The interviews were initially targeted with several authorized people: Village President/Vice President/Panchayat Leaders/ other village leaders, headmaster/teacher of a school, and a Self-help leader in order to obtain their empirical cases and the indirect information they have often examined in their village. In order to provide general understandings of community norms, interviewing the key community leaders can contribute to a fast overview of a community and its needs and concerns. While in-depth interviews were conducted with individuals, group concerns were also explored. Topics that may not arise in individual interviews thus could be addressed in focus groups. Through discussing a topic in the same Tamil language and with familiar neighbors, group discussions contributed data and insights or personal and deep information that would be less accessible without interaction in a group setting. Only a school teacher, a school headmaster, a self-help group leader, and a self-help group member participated in this key informant interview due to unavailability of other target participants. Through interviewing authorized people, bridge of social network was developed so that it helped to easily recruit focus group participants. Additionally, any information that was gathered had refined question banks to be used for focus group discussions. The focus group discussion is facilitated by a facilitator and observed by a recorder. The role of a facilitator is to ensure that all participants had an opportunity to participate, and were asked for clarification or elaboration – if needed – but did not direct the content of participants’ comments. A recorder plays the role of recording the discussions and taking notes not only for the participants’ expressions but also to note the environment and atmosphere where the discussions were conducted and thus audits comments and reactions. The focus groups were conducted in neutral settings with 6 to 8 participants. Each 45 minute to 1 hour session was audio-taped and then transcribed for analysis purposes. In regard to participants and their recruitment for focus group discussions, two age-stratified groups (21–40, 41–60) of 6 to 8 participants of both females and males were selected. Age groups of 20 to 40 and 41 to 60 of both males and females were eligible to participate in this study discussion. Dividing into two different age groups allowed us to discern educational levels, different health issues, social status such as marriage, etc. Potential participants were recruited randomly, so that people from different backgrounds in similar age groups could contribute diverse and empirical opinions. In the process of recruitment, social networks built through key informant interviews, helped to recruit participants easily. Group members used a common language (Tamil language) to describe similar experiences. Compared to key informant interviews, group discussions produce data and insights that would be less accessible without the interaction found in a group setting; for instance, listening to others’ verbalized experiences stimulates memories, ideas, and experiences in participants. � Previous Section: Literature Review Next Section: Geography � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[56]=new Array(0,1,"./paper-6-references.html","2009-10-09","20K","Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009    ","",""," Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu | ICTPH - Global Internship Programme 2009 Font Size Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Paper Contents... Introduction Background Literature Review Methods Geography Findings: Alakudi Limitations and Challenges Conclusion Appendices References Chiai Uraguchi, Maki Ueyama, Sunayana Sen References Country Health System Profile, India (2007), World Health Organization. Human Development Index 2007/2008: http://hdrstats.undp.org/indicators/1.html Bulletin on Rural Health Statistics in India (2005), Infrastructure Division, Department of Family Welfare: http://mohfw.nic.in/dofw%20website/Bulletin%20on%20RHS%20-%2006%20-%20PDF%20Files/bulletin_on_rural_health_statistics.htm Fact sheet, Rural Development: http://pib.nic.in/archieve/factsheet/fs2000/rural.html Central Bureau of Health Intelligence India, 2005: http://www.cbhidghs.nic.in/ WHO National Commission on Macroeconomics and Health (2005), ‘Financing and Delivery of Health Care Services in India NCMH Background Papers-Delivery of Health Services in the Private Sector’, P. 89: http://www.who.int/macrohealth/action/Background%20Papers%20report.pdf Ashok Kumar, 2007 ‘Managing Human Resource for Health in India, A case study of Madhya Pradesh & Gujarat’ Central Bureau of Health Intelligence, Directorate General of Health services, Ministry of Health & Family Welfare Dhas AC, Helen MJ. (2008). Trends in Health Status and Infrastructural Support in Tamil Nadu. Munich Personal RePEc Archive Paper No 9518. Duggal R. (1996). The Private Health Sector in India : Nature, Trends and a Critique. Centre for Enquiry into Health and Allied Themes. Levesque JF, Haddad S, Narayana D, Fournier P. (2006). Outpatient care utilization in urban Kerala, India. Health Policy and Planning 21 (4): 289-301. National Family Health Survey-3 (2005-06), Ministry of Health and Family Welfare, Government of India. Ministry of Health and Family Welfare, Government of India, April 2006 http://www.measuredhs.com/pubs/pdf/FRIND3/07Chapter07.pdf National Sample Survey- 52nd Round (1986-96), Ministry of Statistics and Programme Implementation, Government of India. Ramani KV, Mavalankar D. (2006). Health System in India: Opportunities and Challenges for Improvements. Journal of Health Organization and Management; 20: 560-572. Ranking and Mapping of Districts – Based on Socio-Economic and Demographic Indicators. (2006), International Institute of Population Sciences. Tamil Nadu Statistics at a Glance (2006), Department of Economic and Statistics, Government of Tamil Nadu. Varman R., Kappiarath G. (2008). The Political Economy of Markets and Development: A Case Study of Health Care Consumption in the State of Kerala, India. Critical Sociology; 34 (1): 81-98. Berman, P. (1997) National health accounts: appropriate methods and recent applications. Health Economics 6,11-30. INDIA National Health System Profile http://www.searo.who.int/LinkFiles/India_CHP_india.pdf David H. Peters, Abdo S Yazbeck, Rashmi R.Sharma, Lant H. Pritchett, Adam Wagstaff, (2002) Better Health System for India’s Poor Finding, Analysis, and Options, the World Bank D.Varatharajan (1999). Improving the Efficiency of Public Health Care Units in Tamil Nadu, India. Takemi Research Paper No. 165, Harvard School of Public Health, Boston, MA. Kannan K.P., Thankappan K.R., Kutty V.R. et al. (1991). Health and development in rural Kerala. Indian Journal of Public Health. K. Navaneetham, A. Dharmalingam (2002). Utilization of Maternal Health Care Services in Southern India. Social Science and Medicine; 55 (10): 1849-1869. Kavitha N. and Audinarayana N. (1997). Utilisation and determinants of selected MCH care services in rural areas of Tamil Nadu. Health and Population – Perspectives and Issues. Malaney P. (2000). Health Sector Reform in Tamil Nadu: Understanding the Role of the Public Sector, Center for International Development, Harvard University; 8-16. PS Rao, V Benjamin, J Richard (1972). Methods of Evaluating Health Centres. British Medical Journal; 26: 46-52. Rajaretnam T. and Deshpande R.V. (1994). Factors inhibiting the use of reversible contraceptive methods in rural South India. Studies in Family Planning. Ram K. (1994). Medical management and giving birth: Responses of coastal women in Tamil Nadu. Reproductive Health Matters. Jasmin Helen Prasad, Sulochana Abraham, Kathleen M. Kurz, Valentina George, M.K. Lalitha, Renu John, M.N.R. Jayapaul, Nandini Shetty, Abraham Joseph 2005 ‘Reproductive Tract Infections among Young Married Women in Tamil Nadu’ International Family Planning Perspectives, Vol. 31 K. Saito, J. R. Korzenik, J. F. Jekel, and S. Bhattacharji Yale J, 1997 ‘A case-control study of maternal knowledge of malnutrition and health-care-seeking attitudes in rural South India’ Biol Med. 1997 Mar–Apr; 70(2): 149–160 Pia Malaney, 2000, ‘Health Sector Reform in Tamil Nadu: Understanding the Role of the Public Sector’ Center for International Development http://www.cid.harvard.edu/archive/india/pdfs/healthsector_malaney0100.pdf K.D.Ramaiah, Helen Guyatt, K. Ramu, P. Vanamail, S.P.Pani and P.K Das, 1999 ‘Treatment costs and loss of work time to individuals with chronic lymphatic filariasis in rural communities in south India’ Tropical Medicine & International Health. 4(1):19-25, January Provisional Results of Economic Census 2005, Government of India, Ministry of Statistics and Programme Implementation, Central Statistical Organization, New Delhi R.J. Chelliah and K.R. Shanmugam, 2002, Some Aspects of Inter District Disparities in Tamil Nadu. Tamil Nadu Economy Annual Indian Econometric Conference, Chennai David H. Peters, Abdo S Yazbeck, Rashmi R.Sharma, Lant H. Pritchett, Adam Wagstaff, (2002) Better Health System for India’s Poor Finding, Analysis, and Options, the World Bank R.J. Chelliah and K.R. Shanmugam, 2002, Some Aspects of Inter District Disparities in Tamil Nadu, Tamil Nadu Economy. Annual Indian Econometric Conference, Chennai Tamil Nadu Health System Project, Department of Health and Family Welfare, Government of Tamil Nadu: http://www.tnhsp.org/ Government of Tamil Nadu, Tamil Nadu Health System Project: http://www.tn.gov.in/gorders/hfw/hfw_e_33_2008.pdf TK Sundari Ravichandran, US Mishra (2001). Unmet Need for Reproductive Health in India. Reproductive Health Matters Journal; 9: 105-113. Ram K. (1994). Medical management and giving birth: Responses of coastal women in Tamil Nadu. Reproductive Health Matters. Venkatesh Athreya, Sheela Rani Chunkath, 1998, ‘Gender and Infant Survival in Rural Tamil Nadu-Situation and Strategy’ Economic and Political Weekly Vol 33, No. 40 October 3-9 G. Sudha, C. Nirupa, M. Rajasakthivel, S. Sivasubramanian, V. Sundaram, S.Bhatt, K. Subramaniam, E.Thiruvalluvan, R.Mathew, G.Renu and T.Santha, 2003, ‘Factors influencing the care-seeking behavior of chest symptomatic: a community-based study involving rural and urban population in Tamil Nadu, South India’ Tropical Medicine and International Health, Vol 8 No.4 pp 336-341 Ronsmans C, Graham WJ. Maternal mortality: who, when, where, and why. Lancet. 2006;368:1189–200 Maternal mortality in India: 1997-2003. Trends, causes and risk factors. New Delhi: Registrar General; 2006. National Family Health Survey (NFHS-2) Key Findings. International Institute for Population Sciences; 1998-99. p.12. UN, 2009, The Millennium Development Goals Report. P.28 Ramachandar A, Pertti J Pelto, 2002. ‘The Role of Village Health Nurses in Mediating Abortions in Rural Tamil Nadu, India Lakshmi’ by Elsevier Science Vol. 10 � Previous Section: Appendices (2 of 2) Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[57]=new Array(0,1,"./paper-5-acknowledgement.html","2009-10-09","10K","Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009    ","",""," Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009 Font Size Validation Study of Community Health Workers Assessment of Oral Hygiene Paper Contents... Introduction Rationale for Study IKP Centre for Technologies in Public Health Objective of Study CHW Training programme Annexures Acknowledgement GEETHA LOGANATHAN, RAVIKUMAR CHOCKALINGAM Acknowledgement I wish to express my sincere gratitude to Dr.Zeena Johar (President-ICTPH) and Dr.Ravikumar C. (Assistant Vice President - Human Capacity) for giving me an opportunity to do my internship in this prestigious organization and for all the support and guidance. I would like to thank all the other members of ICPTH and especially Shruti Mukherjee, Dilip Tripathy, Rufin Jenila and Erin Jeremiah for their kind support and help during my internship. Without the co-operation and help of the Community Health Workers and the Sughavazhvu team, the completion of the programme would not have been possible and I am highly grateful to them for the same. I would like to thank all the Sugavazhvu Nurses [Lavanya, Initha, Madubala, Vanitha, Sooriya, Nandini], field co-ordinators [Alex and Ratinam] and the admin assistant [Jayachandran] for their help during the training programme. I wish to express my sincere gratitude to Dr.Nirmala Moorthy and Dean (School of Public Health – SRM University) for their support, guidance and encouragement. Last but not the least, I am very thankful to all my friends and colleagues for their invaluable suggestions and inputs for making this training programme successful. - Geetha Loganathan � Previous Section: Annexures (3 of 3) Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[58]=new Array(0,1,"./paper-5-annexures.html","2009-10-09","14K","Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009    ","",""," Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009 Font Size Validation Study of Community Health Workers Assessment of Oral Hygiene Paper Contents... Introduction Rationale for Study IKP Centre for Technologies in Public Health Objective of Study CHW Training programme Annexures Acknowledgement GEETHA LOGANATHAN, RAVIKUMAR CHOCKALINGAM Annexures (Page 1 of 3) Annexure 1 Schedule for Training Annexure 2 Syllabus for community health workers on common oral diseases and prevention 1. Oral Cavity & Anatomy of teeth 2. Root Causes of Oral diseases a. Dental Plaque b. Dental Calculus 3. Common oral diseases a. Dental Caries b. Gingivitis c. Periodontitis 4.Prevention of Common Oral Disease a. Oral Hygiene b. Healthy Balanced Diet c. Adapting Healthy Habits d. Visiting Dentist Annexure 3 Protocol for study Preparation for examination Aid ‘Consent Form’ completion by the subject, obtain valid signature/ thumb impression CHWs should wear disposable gloves and masks before handling the subject Subject to be stationed in an upright position by the CHW CHW to follow the below-listed steps to identify Dental plaque, Gingivitis and Caries Protocol for identifying the total number of true teeth in the upper and lower jaw Ask the subject if he/she has any removable dentures If present, ask the subject to remove them Count the number of true teeth in the upper jaw and enter in the dental study form Count the number of teeth in the lower jaw and enter in the dental study form Protocol for identifying dental caries by CHWs Inspect visually all tooth surfaces with the help of a torch light or natural light with the help of a tongue depressor First examine the Upper jaw Start from the right side, then front and then left side of the upper jaw Summation of the number of teeth having dental caries in the upper jaw Record the number of carious teeth in the upper jaw in the sheet provided If no caries record it as ‘0’ Now examine the Lower jaw Start from the right side, then front and then left side of the jaw Summation of the number of teeth having dental caries in the lower jaw Record the number of carious teeth in the sheet provided If no caries, record it as ‘0’ Protocol for identifying gingivitis by CHWs Inspect visually all tooth surfaces with the help of a torch light or natural light with the help of a tongue depressor First examine the Upper jaw Start from the right side, then front and then the left side of the jaw Look for red, swollen, bleeding gums in the upper jaw Record in the sheet provided whether the subject is having gingivitis in the upper jaw by ticking in the relevant section Now examine the Lower jaw Start from the right side, then the front and then the left side of the jaw Look for red, swollen, bleeding gums in the lower jaw Record it in the sheet provided whether the subject is having gingivitis in the lower jaw by ticking in the relevant section Protocol for identifying dental plaque by CHW Apply the disclosing solution on all the surfaces of the teeth, both in the upper and lower jaw, with the help of the cotton buds Wait for 10 minutes Look at the colour change [red colour] Based on the colour change, record it in the sheet provided whether the subject is having dental plaque in the upper and lower jaw by ticking at the relevant section � Previous Section: CHW Training Programme (2 of 2) Next Section: Annexures (2 of 3) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[59]=new Array(0,1,"./paper-5-annexures-2.html","2009-10-09","23K","Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009    ","",""," Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009 Font Size Validation Study of Community Health Workers Assessment of Oral Hygiene Paper Contents... Introduction Rationale for Study IKP Centre for Technologies in Public Health Objective of Study CHW Training programme Annexures Acknowledgement GEETHA LOGANATHAN, RAVIKUMAR CHOCKALINGAM Annexures (Page 2 of 3) Annexure 4 Theoretical assessment tool Multiple choice questions – Written evaluation 1) Dental Plaque is caused by: a. Excess Sleeping b. Excess Eating c. Bad oral hygiene d. Consumption of Alcohol 2) Dental Plaque can lead to: a. Gastric problems b. Headache c. Gum problems and Dental Caries d. Insomnia 3) Dental Caries leads to: a. Toothache b. Excess sensitivity of tooth c. Cavity d. All of the above 4) Symptoms of Dental caries are: a. Sensitive feeling from the tooth b. Toothache c. All of the above d. None of the above 5) Gingivitis is a form of: a. STD b. Neurological disease c. Communicable disease d. Gum disease 6) To prevent Oral Disease, one should: a. Eat a balanced healthy diet b. Adapt healthy habits c. None of the above d. All of the above 7) Oral hygiene means: a.Keeping nails clean b.No dandruff c.Keeping hands clean d.Keeping teeth clean and regular brushing 8) Tooth brushing should take minimum of: a.10 seconds b.1 minute c.2.5 minutes d.None of the above 9) While brushing, we should hold the brush at an angle of: a.90 degrees b.180 degrees c.60 degrees d.45 degrees 10) Dental plaque will lead to a.Bad breath b.Indigestion c.Vomiting d.Diarrhoea 11) While brushing, we should begin with cleaning: a.The lower jaw b.The upper jaw c.Anywhere 12) We should have a Balanced Diet in order to: a.Improve oral hygiene b.Have Healthy gums and teeth c.All of the above d.None of the above 13) While eating, we should generally avoid: a.Sour food b.Green vegetables c.Sweet and sticky food d.Cold drinks 14) Food that is good for your oral hygiene is: a.Low in sugar level b.High in sugar level c.None of the above d.All of the above 15) A dentist is a doctor for: a.Teeth b.Bones c.Heart d.All of the above 16) Smoking can lead to: a.Enhancing good breath b.Reduction of Gum diseases c.Staining of teeth d.Headache 17) We should brush our teeth: a.Once a week b.Twice a day c.Once a day d.Twice a week 18) How do you examine the subject? a.Lying down b.Sitting upright c.Standing position d.None of the above 19) What precaution do you take for yourself before examining the subject? a.Drink water b.Wear gloves and masks c.Talk to the patient d.All of the above 20) While examining the subject you should start from which jaw? a.Upper jaw b.Lower jaw c.Both the jaws together d.Molar teeth 21) If the subject does not have carious teeth how do you record it in the dental form? a.Mark ‘0’ (zero) in the form b.Mark ‘1’ (one) in the form c.Mark ‘10’ (ten) in the form d.Mark ‘2’ (two) in the form 22) If the subject has red, swollen and bleeding gums how do you record it in the dental form? a.Dental Caries b.Gum disease c.Gingivitis d.Toothache 23) With help of what do you apply the disclosing solution on the teeth? a.Pins b.Cotton buds c.Mouth mirrors d.None of the above 24) How many minutes do you wait after applying the disclosing solution on the teeth? a.10 minutes b.One hour c.15 minutes d.One minute 25) If the subject has dental plaque and the disclosing solution is applied it changes into what colour? a.Red colour b.Colourless c.Blue colour d.Grey colour Answers to the Theoretical Evaluation Test � Previous Section: Annexures (1 of 3) Next Section: Annexures (3 of 3) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[60]=new Array(0,1,"./paper-5-annexures-3.html","2009-10-09","14K","Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009    ","",""," Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009 Font Size Validation Study of Community Health Workers Assessment of Oral Hygiene Paper Contents... Introduction Rationale for Study IKP Centre for Technologies in Public Health Objective of Study CHW Training programme Annexures Acknowledgement GEETHA LOGANATHAN, RAVIKUMAR CHOCKALINGAM Annexures (Page 3 of 3) Annexure 5A Practical assessment tool Practical evaluation 1) To evaluate whether CHWs follow the protocol for the examination of the subjects. [10] Completion of dental consent form [4] Wearing of the glove and mask [4] Making the subject sit in a chair in an upright position [2] 2) To evaluate whether the CHWs count and record the total number of teeth in the upper and lower jaw. [20] If they record correctly the total number of teeth in upper jaw [10] If they miss 4 teeth in upper jaw [7] If they miss >= 5 teeth in upper jaw [0] If they record correctly the total number of teeth in lower jaw [10] If they miss 4 teeth in lower jaw [7] If they miss >= 5 teeth in lower jaw [0] 3) To evaluate whether the CHW’s identify the number of carious teeth in the upper and lower jaw. [20] If they record correctly the number of carious teeth in upper jaw [10] If they miss 2 carious teeth in upper jaw [7] If they miss >=3 carious teeth in upper jaw [0] If they record correctly the number of carious teeth in lower jaw [10] If they miss 2 carious teeth in lower jaw [7] If they miss >=3 carious teeth in lower jaw [0] 4) To evaluate whether the CHW’s identify the presence / absence of gingivitis in the upper and lower jaw. [20] If they identify gingivitis as per dentist assessment in upper jaw [10] If they don’t identify gingivitis in upper jaw [0] If they identify gingivitis as per dentist assessment in lower jaw [10] If they don’t identify gingivitis in lower jaw [0] 5) To evaluate whether the CHWs follow the protocol to apply the disclosing solution on all the surface of the teeth, both in the upper and lower jaw. [10] If they apply the disclosing solution on all the surfaces of the teeth of upper jaw [5] If they do not apply the disclosing solution on all the surfaces of the teeth of upper jaw [0] If they apply the disclosing solution on all surfaces of the teeth of lower jaw [5] If they do not apply the disclosing solution on all the surfaces of the teeth of lower jaw [0] 6) To evaluate whether the CHWs identify the presence / absence of dental plaque in the upper and lower jaw. [20] If they identify correctly the presence of plaque in the upper jaw after waiting for 10 minutes as per the dentist assessment [10] If they don’t identify the presence of plaque in the upper jaw as per the dentist assessment [0] If they identify correctly the presence of plaque in the lower jaw after waiting for 10 minutes as per the dentist assessment [10] If they don’t identify correctly the presence of plaque in the lower jaw as per the dentist assessment [0] Annexure 5B Practical assessment tool Dental tools used for practical evaluation Dental form A pair of disposable Gloves A Disposable Mask Disposable Wooden tongue depressor Disclosing Solution Cotton buds Annexure 5C Practical assessment tool Dental form used for practical evaluation � Previous Section: Annexures (2 of 3) Next Section: Acknowledgement � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[61]=new Array(0,1,"./paper-5-chw-training.html","2009-10-09","14K","Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009    ","",""," Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009 Font Size Validation Study of Community Health Workers Assessment of Oral Hygiene Paper Contents... Introduction Rationale for Study IKP Centre for Technologies in Public Health Objective of Study CHW Training programme Annexures Acknowledgement GEETHA LOGANATHAN, RAVIKUMAR CHOCKALINGAM CHW Training Programme (Page 1 of 2) As part of ICTPH Community Health Programme in Thanjavur, the team conducted a community based research using the CHWs to assess the oral hygiene in the village of Karambayam. The community health workers were trained for a period of two days, 27-28 April 2009 [Annexure 1 – schedule for training] at Thanjavur office, on assessment of oral hygiene and diagnosis of dental plaque, gingivitis and dental caries. Training programme title “Capacity Building of the Community Health Workers on Oral Health” Goal of training programme To develop the capacity of the community health workers knowledge on oral health and their technical skills in identifying dental caries, gingivitis. Objective of training programme On completion of the training, each CHW should be able to Discuss the anatomy and functions of teeth; Discuss the types of dentition; Discuss the common oral diseases, including the etiology, signs and symptoms; Discuss the interventions for prevention of common oral diseases; Able to identify common oral diseases; and Bring about a change in the oral health seeking behaviour of the community Specific objective of training programme Discuss the anatomy and functions of teeth and be Able to describe the anatomy of the teeth and the surrounding structures Able to describe the different parts of the teeth Able to describe the different types of teeth and their functions Discuss the types of dentition and be Able to explain the two different types of dentition Able to explain the number of milk teeth and permanent teeth Able to explain the age at which the milk teeth erupt and exfoliate Able to explain the age at which the permanent teeth erupt Discuss the common oral diseases including etiology, signs and symptoms, and be Able to list the common oral diseases Able to list the causes for the common oral diseases Able to list the signs and symptoms of the common oral diseases Able to list the different stages of the common oral diseases Discuss the interventions for the prevention of common oral diseases, and be Able to list the different methods for the prevention of common oral diseases Able to tell about oral hygiene, brushing techniques Able to tell about healthy balanced diet Able to tell about the importance of visit to dentist Able to tell about adopting healthy habits Able to Identify common oral diseases and to identify gross dental caries and gingivitis without any dental instruments to apply disclosing solution 16 and identify the presence of dental plaque and create awareness about oral hygiene The trained CHWs will bring about a change in the oral health seeking behaviour of the community Create awareness about the oral diseases among the community Create awareness about the different preventing measures to be taken for good oral health Able to identify the population at risk for the oral diseases and implement a referral to a dentist Framework of training programme The training programme was divided into three sections, developing the theoretical knowledge on oral disease and prevention, the practical/technical skills in identifying the oral disease and evaluation of the CHWs on identifying the oral diseases post two day training programme. 16 Disclosing solution is a red disclosing agent to diagnose dental plaque. It contains Erythrosine dye which stains the plaque into a red stain on topical application (Continue reading) � Previous Section: Objective of Study Next Section: CHW Training Programme (2 of 2) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[62]=new Array(0,1,"./paper-5-chw-training-2.html","2009-10-09","20K","Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009    ","",""," Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009 Font Size Validation Study of Community Health Workers Assessment of Oral Hygiene Paper Contents... Introduction Rationale for Study IKP Centre for Technologies in Public Health Objective of Study CHW Training programme Annexures Acknowledgement GEETHA LOGANATHAN, RAVIKUMAR CHOCKALINGAM CHW Training Programme (Page 2 of 2) Section Programme Section 1 Theoretical training The CHWs’ knowledge about the oral health, diseases and prevention was developed: Method – Class room training; Medium – Tamil; Tools – lectures, power point presentations, experience sharing, group discussions, video clippings, denture models. The theoretical training was based on the syllabus prepared in-house [Annexure 2] Section 2 Practical training The CHWs’ technical skills in identifying the oral diseases were developed: Method – Class room training; Medium – Tamil Tools – practical demonstration on oral examination of the subjects with the help of tongue depressor for identifying dental caries, gingivitis and identifying dental plaque using disclosing solution16. The practical training was based on the protocol for study prepared in-house [Annexure 3] Section 3 Post-training evaluation of CHWs Post-training the CHWs were evaluated both on theoretical knowledge and practical/technical skills in identifying dental caries, gingivitis, dental plaque using disclosing solution16: Medium – Tamil; Tools – Using the theoretical assessment tool [Annexure 4] and the practical assessment tools prepared in-house [Annexure 5a,5b,5c] Figure 3: Results Assessment scoring system Theoretical Evaluation (25x4):100 MARKS Practical Evaluation:100 MARKS Total:200 MARKS Less than 100:Below average 100 – 120:Average More than 120:Above average To be part of the oral hygiene study the CHWs have to score >100 in the assessment tests. Interpretation Overall, all the CHWs scored above 60% and all have the eligibility criteria to be part of the oral hygiene study. As many as four CHWs got above 90%, nine CHWs got above 80% and only two CHWs got above 60% but less than 70%. Though overall, all the CHWs scored above 60% when individual score for theory and practical scores were assessed, almost all the CHWs’ theoretical knowledge and practical skills gained were same. But in some CHWs there was quite a more difference between the theoretical knowledge and the practical skills. One CHW’s theoretical knowledge was only 56% but she gained more practical skills where she scored 76%, and also one more CHW’s theoretical knowledge was only 76% but she gained more practical skill where she scored 93%. At the same time one CHW whose theoretical knowledge was 80% did not gain much of practical skills where she scored only 59% and one more CHW whose theoretical knowledge was 96% did not gain much of practical skill where she scored only 68% and one more CHW whose theoretical knowledge was 92% did not gain much of practical skill where she scored only 73%. Conclusion It is evident from the results above that, post-training, the CHWs gained knowledge on oral diseases and prevention and technical skills in identifying the common oral disease to a significant extent. Recommendations Periodic training - The CHWs should be given periodic training on both the theoretical knowledge on oral health and the technical skills in identifying the common oral diseases. It is evident from the post-training evaluation that not all the CHWs were consistent in scoring. Some of them scored more in theoretical evaluation and some scored more in practical evaluation. This shows that their knowledge on oral health and technical skills in identifying oral diseases were not equal. Strengthening of the Referral System - The CHWs can be further trained [other than oral health education] to identify the levels of oral disease and to refer to corresponding health care. For example, if a person has gingivitis due to poor oral hygiene, it can be treated by scaling. Scaling can be done by an oral hygienist who can be hired or posted at RMHC 17 or PHC 18. If the person has periodontitis, it needs more specialized treatment which can only be treated by a dentist. So a dentist can be hired or posted at RMHC or PHC or can refer to a dentist at Tertiary Dental Hospital. Likewise if a person has dental caries, depending on the stage of dental caries, the treatment varies from filling or RCT 19 or extraction of tooth. These treatments can only be done by a dentist. So, the CHWs were trained to identify the level/stage of the disease and trained to refer to the particular level of health care, either RMHC or PHC or Tertiary Dental Hospital, depending on the facilities available and the type of treatment need. Expansion of role of CHWs – The CHWs can be trained further for identifying other oral diseases like Oral cancer, Malocclusion. India has the highest prevalence of oral cancer in the world (19/100,000 population), and constitutes 13 -16% of all the cancers, and of all the oral cancers 95% are due to the use of tobacco4. Tobacco products, either smoking or smokeless, are extensively prevalent in our country. Oral cancer has a high morbidity and mortality. Hence early diagnosis is very important. Since oral cavity is easily accessible for examination and the oral cancer is always preceded by some pre-cancerous condition like white or red patch, an ulcer or restricted mouth opening, it can be easily prevented by oral health education which can be easily done by the community health workers4. In India the prevalence of malocculusion is estimated to be 30% in school-age children. Malocculusion may vary from mild to severe, causing aesthetic, functional problems and also predisposes to dental caries and periodontal diseases4. If the recommendations are followed effectively, the community will have knowledge about the oral health, oral hygiene and dietary practices and will be able to maintain good oral health. 17 Rural Micro Health Centre (Continue reading) 18 Primary Health Centre (Continue reading) 19 Root Canal Treatment (Continue reading) � Previous Section: CHW Training Programme (1 of 2) Next Section: Annexures � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[63]=new Array(0,1,"./paper-5-ictph.html","2009-10-09","12K","Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009    ","",""," Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009 Font Size Validation Study of Community Health Workers Assessment of Oral Hygiene Paper Contents... Introduction Rationale for Study IKP Centre for Technologies in Public Health Objective of Study CHW Training programme Annexures Acknowledgement GEETHA LOGANATHAN, RAVIKUMAR CHOCKALINGAM IKP Centre for Technologies in Public Health (ICTPH) Profile ICTPH (www.ictph.org.in) is a Section-25, not-for-profit Company; registered under the Companies Act, 1956. ICTPH aims to improve the health of poor populations by focusing on designing, developing and delivering innovative solutions in healthcare concerning India and the developing world. This is achieved through an inclusive process that scientifically integrates knowledge of factors influencing health and diseases in India, regular evaluation and impact assessment of existing health systems and integration of appropriate technology for optimal healthcare delivery. ICTPH aims to research provisioning enhanced accessibility to health-care services for rural populations through a three pronged focus on Epidemiology, Human Capacity and Healthcare Solutions. ICTPH Role ICTPH had conducted a baseline study of 3 villages in the Thanjavur district of Tamil Nadu which consisted of an extensive household survey and a study of different variables using invasive and non-invasive methods. Karambayam was one of the three villages surveyed in Thanjavur. Karambayam belongs to the Pattukottai Taluk in Thanjavur district of Tamil Nadu. The population of Karambayam figures a little more than 3600 people with 907 households. ICTPH has mobilized 20 volunteers from the community as CHWs 14 (ICTPH – Nala Oli) 15; most of them involved in self help groups. They have been undergoing training for preventive and promotive healthcare to collecting information about the community on health related problems in the region as facilitated by the CHW training team at ICTPH. ICTPH primary objective is to make a strong case to show the potential of CHWs in identifying manifestations of poor oral hygiene such as plaque, dental caries and gingivitis and to study the impact of CHWs in improving oral hygiene in the community. 14 Community Health Worker (Continue reading) 15 Nala Oli means “ Health Light.” The term was coined by ICTPH - CHW training team. (Continue reading) � Next Section: Rationale for Study (2 of 2) Next Section: Objectives of Study � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[64]=new Array(0,1,"./paper-5-introduction.html","2009-10-09","14K","Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009    ","",""," Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009 Font Size Validation Study of Community Health Workers Assessment of Oral Hygiene Paper Contents... Introduction Rationale for Study IKP Centre for Technologies in Public Health Objective of Study CHW Training programme Annexures Acknowledgement GEETHA LOGANATHAN, RAVIKUMAR CHOCKALINGAM Introduction Geetha Loganathan holds a Bachelor’s degree in Dental Surgery from the Saveetha Dental College and Hospital under the Dr.M.G.R. Medical University in Chennai, and a Master of Public Health from the SRM School of Public Health, SRM University, Chennai. She has been awarded several Certificates of Achievements including one from the Queensland University of Technology, Australia, for her outstanding performance in the ‘Introduction to clinical classification ICD-9-CM and Advanced clinical classification ICD-9-CM’ course conducted by them. She has worked as a clinical coding specialist at the Changi General Hospitals, Singapore, and has tutored in the Department of Pedodontia at the Saveetha Dental College and Hospitals, Chennai, prior to which she was an assistant dental surgeon at the Jagir Dental Center, Chennai. Ravikumar Chockalingam graduated from Madras Medical College, one of the oldest in India, in 2003. He has five years of post-graduate clinical experience including training in Surgical Laparoscopy and Intervention Gastroenterology in Buffalo, NY. He worked as a Registrar in the Critical Care unit in Apollo Hospitals for a year and a half after which he joined ICTPH as Assistant Vice-President – Human Capacity. Dr. Chockalingam is the founding member of the CHW (Community Health Worker) focus at ICTPH, looking at alternate disease focus areas e.g. mental health, oral health and sexual health. Dr. Chockalingam also played an instrumental role in operationalizing the CHW pilot in Tanjore district of Tamil Nadu – from coordinating field teams for mobilizing the CHWs to designing and implementing the in-house three phase training programs. Dr. Chockalingam is currently pursuing his Masters in Public Health (MPH) at the Warren Brown School of Social Work, Washington University, USA. Health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity 1. This includes oral health as well. Oral health is a state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity 2. However, Dental caries and Periodontal diseases have historically been considered the most important global oral health burdens 3. Figure 1: Share of oral disease burden Priority non-communicable health conditions in India, by share in the burden of disease, 1998. COPD: Chronic obstructive pulmonary disease Source: Peters et al. 2001 1 WHO definition of Health [online] Available from: http://www.who.int/about/definition/en/print.html (Continue reading) 2 Oral Health [online] Available from: http://www.who.int/topics/oral_health/en/ (Continue reading) 3 Oral disease burdens and common risk factors [online] Available from: http://www.who.int/oral_health/disease_burden/global/en/index.html (Continue reading) Next Section: Rationale for Study � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[65]=new Array(0,1,"./paper-5-objectives.html","2009-10-09","10K","Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009    ","",""," Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009 Font Size Validation Study of Community Health Workers Assessment of Oral Hygiene Paper Contents... Introduction Rationale for Study IKP Centre for Technologies in Public Health Objective of Study CHW Training programme Annexures Acknowledgement GEETHA LOGANATHAN, RAVIKUMAR CHOCKALINGAM Objective of Study Project Title “Validation Study of Community Health Workers Assessment of Oral Hygiene in Karambayam, Tamil Nadu” Objective of study To understand the role that CHWs can play in diagnosing poor oral hygiene specifically looking at dental plaque, dental caries and gingivitis and validate their assessment through re-examination of the random sample by a certified dentist. � Previous Section: IKP Centre for Technologies in Public Health (ICTPH) Next Section: CHW Training Programme � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[66]=new Array(0,1,"./paper-5-rationale.html","2009-10-09","19K","Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009    ","",""," Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009 Font Size Validation Study of Community Health Workers Assessment of Oral Hygiene Paper Contents... Introduction Rationale for Study IKP Centre for Technologies in Public Health Objective of Study CHW Training programme Annexures Acknowledgement GEETHA LOGANATHAN, RAVIKUMAR CHOCKALINGAM Rationale for Study (Page 1 of 2) Oral health status in India Oral diseases are widely prevalent in India. Dental caries and Periodontal diseases are the two leading oral disease burden of the World. India is no exception to this problem. Epidemiological studies over the Indian population also show that dental caries and periodontal disease are widely distributed throughout the country. The other common oral diseases in India are Oral cancer, Malocclusion and Fluorosis. Dental Caries: It is a microbial disease resulting in the gradual destruction of tooth. It is the second most common cause of tooth loss and is found universally irrelevant of age, sex, caste, geographic location and socioeconomic status. In India the prevalence of dental caries is found to be 50%-60% 4. Periodontal disease: It is a microbial disease which affects the supporting structures of the teeth [gingival, periodontal ligament, alveolar bone and cementum]. It is the leading cause of tooth loss and is more common among the adults than children. It is found that in Indian population periodontal diseases affect 90% of the population, but most of them have mild gingivitis which is reversible by good oral hygiene. But more advanced periodontal disease with pocket formation, bone loss, ultimately resulting in tooth loss, is found in about 40%-45% of the Indian population 4. It has been projected that these diseases will increase by 25% in the next decade 5 Impact of oral diseases Oral health is an integral part of general health. Though oral diseases are not life threatening, they are very painful and very badly affect the day to day activities. Moreover, the treatment of dental diseases is expensive and time-consuming. When the person suffers from pain due to the oral diseases he may not be able to work properly or may not be able to work at all, leading to loss of working hours. It is estimated that the disability adjusted life-years [DALYs] lost in India during 1998 due to Oral disease alone accounts for 12,47,000 years 5. This is especially important in a country like India where 27.5% of the population is below poverty line and 75% of the population depends on daily wages 6. Besides that poor oral health affects mastication [chewing] of food leading to change in the dietary habits resulting in nutritional deficiencies. Poor oral health causes difficulty in speech, affects the aesthetics, leading to loss of confidence and overall well-being of the individual. Oral health and systemic health Oral health and general health are interlinked. Oral infections have an adverse effect on other organs of the body. There are number of studies also explaining that oral diseases in particular periodontal disease have an adverse effect on many of the systemic diseases. Effect of periodontal disease on diabetes Periodontal disease is often considered the sixth complication of diabetes. Studies show that diabetic patients are at 2-4 times higher risk of getting periodontal disease 7. Periodontal disease and diabetes are considered as two-way relationship, because, as said, diabetic patients are at increased risk of getting periodontal disease and, once periodontal disease sets in a diabetic patient, this in turn makes it more difficult to control the blood sugar. Effect of periodontal disease on pregnancy outcomes Studies have shown that pregnant women with periodontal disease are 7 times 8 more likely to give birth to premature babies. Periodontal disease triggers high level of subjects that induce labour, and this is further more exacerbated in women with diabetes. Effect of periodontal disease on heart disease Studies show that people with periodontal disease are twice more likely to suffer from cardio-vascular diseases 9. Studies propose two hypotheses for the occurrence of heart attack in person with periodontal disease. One is that periodontal pathogens enter the blood steam, invade the blood vessel wall and cause atherosclerosis and the second one is that periodontal disease increases the plasma levels of inflammation like fibrinogen, c-reactive proteins. Effect of periodontal disease on cerebrovascular disease [stroke] Studies show that subjects with severe periodontitis have 4.3 times increased risk of getting stroke than those with mild periodontitis or no periodontitis 10. This may be due to the bacteria found in the periodontitis develop blood clots increasing the likelihood of stroke. Effect of periodontal disease on respiratory disease Studies show that bacteria found in the periodontal disease are aspirated into the lungs, causing respiratory diseases like pneumonia 11. 4 Naseem Shah. “Oral and dental diseases: Causes, prevention and treatment strategies”, NCMH Background papers – Burden of Diseases in India,(2005), 276-298 (Continue reading) 5 “Disease burden in India:Estimations and causal analysis”, NCMH Background papers Burden of Diseases in India,(2005), 1-6 (Continue reading) 6 Poverty in India [online] Available from: http://en.wikipedia.org/wiki/Poverty_in_India (Continue reading) 7 Helping Patients with Diabetes Understand the 2-Way Relationship Between Diabetes and Gum Disease [online] Available from: http://www.azmoudehdental.com/images2/diabetesgumdisease.pdf (Continue reading) 8 Gum disease and pregnancy problem [online] Available from: http://www.perio.org/consumer/mbc.baby.htm (Continue reading) 9 Gum disease links to heart disease and stroke [online] Available from: http://www.perio.org/consumer/mbc.heart.htm (Continue reading) 10 Gum disease and stroke link [online] Available from: http://www.medicalnewstoday.com/articles/5982.php (Continue reading) 11 Gum disease and respiratory disease [online] Available from: http://www.perio.org/consumer/mbc.respiratory.htm (Continue reading) � Next Section: Introduction Next Section: Rationale for Study (2 of 2) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. 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array_files[67]=new Array(0,1,"./paper-5-rationale-2.html","2009-10-09","16K","Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009    ","",""," Validation Study of Community Health Workers Assessment of Oral Hygiene | ICTPH - Global Internship Programme 2009 Font Size Validation Study of Community Health Workers Assessment of Oral Hygiene Paper Contents... Introduction Rationale for Study IKP Centre for Technologies in Public Health Objective of Study CHW Training programme Annexures Acknowledgement GEETHA LOGANATHAN, RAVIKUMAR CHOCKALINGAM Rationale for Study (Page 2 of 2) Table 1: Oral health care system in India In India oral healthcare is delivered mainly by the following establishments 12. As per Dental Council of India there are more than 79,000 dentists for population of about 1090 million with dentist population ratio of 1:10,000 in urban areas and 1:1,50,000 in rural areas. There are 240 approved and recognised dental colleges in the country among which 17 dental colleges are in Tamil Nadu 12. The number of dental colleges in the country increased to 240 in 2007 from three at the time of independence and the number of dental surgeons in the country increased to more than 79,000 in 2007 from a few hundreds. With the increase in population of about 3.5 times since then with the number of dentists increasing to more than 3000 times, it did not have any significant impact in reducing the prevalence of the oral diseases 12. This is event from the graph given below 12. It shows that with increase in the number of dental surgeons in the country, the prevalence of the oral disease are also increasing rather than decreasing. DMFT - it is an index to provide the estimate of the severity of the caries attack on each tooth, in this each carious surface is counted. DMFT is applied for permanent teeth. The deciduous teeth denote by small letters as dmft. D - decayed: it indicates the number of permanent teeth that are decayed M - missing: indicates the number of missing permanent teeth due to decay F - filled: indicates the number of permanent teeth that have been attacked by caries, due to which they have been restored to keep them in a healthy condition in mouth Inference It is well understood that there is a large gap in the dental service available for the community especially at the rural area which constitutes about 70% of India. It is evident from the uneven distribution of dental colleges and hospitals between the government and private sector. Among the 240 colleges in India only 32 [13.3%] colleges are owned by government and the remaining 208 [87.7%] colleges are owned by the private sector. Even in Tamil Nadu among the 17 colleges only one college is owned by government and remaining 16 colleges are owned by the private sector. There is also a large gap in the dentist population ratio available at urban areas [1:10,000] and rural areas [1:1,50,000]. Moreover in India the dental procedures are more towards restorative and rehabilitative dental procedures than preventive dental care and the majority of dental services are provided by the private dental practitioners. Also the impact of oral diseases on the systemic health of the population and the impact of poor oral health on the economy of the individual, family and ultimately on the country is well understood. Therefore with increasing dental problems, limited manpower resource and the impact of the oral diseases on the systemic health of the population and the economy of the individual, family and country, it is essential that preventive dental care be taken at all possible levels which is more cost effective, economical and beneficial way of preventing the oral diseases. Preventive care including health education and promotion should be given prior importance to implement oral healthcare in India. This can be effectively done by a combination of community, professional and individual actions. Early detection of oral diseases is more crucial for the control of oral disease. A thorough naked eye examination with adequate light can identify many oral diseases in the early stage. Since many oral diseases can be detected with thorough oral examination, it is possible that community health workers can be made use of as an alternate human resource. Alternate human resource One of the strategies considered by the developing countries to explain the preventive measures and in identifying oral disease is by making use of the community health workers and other health auxiliaries of the primary healthcare system. Oral cancer is one of the few human cancers with high possibility of prevention. In one of the studies conducted in India and Sri Lanka it indicates that it is possible to train the community health workers in the primary prevention and early detection of oral cancer and precancerous lesions. Although the study did not show any evidence in the efficacy of the community health workers in reducing the incidence and mortality due to oral cancer 13, the role of community health workers in early diagnosis and referral was illustrated. Thus Community Health Workers who when given sufficient training on oral disease and its prevention and identifying these diseases, will help in the prevention and control of oral diseases. 12 Hari Parkash et al., “Guidelines for Meaningful and Effective Utilization of Manpower at Detnal Colleges for Primary Prevention of Oro-Dental Problems in the Country”,GOI-WHO collaborative programme,(2007),12-22 (Continue reading) 13 Sankaranarayanan R., Health care auxiliaries in the detection and prevention of oral cancer, oral oncol 1997 May 33(3):149-54 (Continue reading) � Next Section: Rationale for Study (1 of 2) Next Section: IKP Centre for Technologies in Public Health (ICTPH) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[68]=new Array(0,1,"./paper-4-appendix.html","2009-10-09","14K","Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009    ","",""," Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009 Font Size Prevalence Study of Oral Hygiene and Dental Health Paper Contents... Introduction The Prevalence Study Appendix References FATIMA A HUSSAIN, RAVIKUMAR CHOCKALINGAM Appendix (Page 1 of 3) Appendix A Detailed DMFT methodology Methodology 8 - DMFT is a numerical expression of the prevalence of dental caries lesions in a patient, obtained by counting the number of decayed, missing, and filled teeth that a patient has. We will be considering all 32 teeth, as recommended by the third edition of “Oral Health Surveys - Basic Methods”, Geneva 1987. For children under 15 years of age, only 20 primary teeth will be considered and data will be designated in lower case (DMFT). The DMFT score is a sum of the number of teeth with complete 9 caries lesions (D), the number of extracted teeth (M), and the number of teeth with fillings or crowns (F). If a tooth is both filled and has a caries lesion, it is considered a decayed tooth only, thus the highest possible DMFT value is 32 (or 20), where every tooth is affected. Data presentation 10 %PP (%pp) - percentage of population affected with dental caries %D (%d) - percentage of population with decayed teeth DT (dt) - mean number of decayed teeth FT (ft) - mean number of filled teeth MT (mt) - mean number of missing teeth MNT (mnt) - mean number of teeth %Ed (N/A) - percentage edentulous (toothless) Appendix B Details of periodontal disease scoring systems NPDI Methodology 11: According to the Universal Tooth numbering system, the following six teeth will be examined: (1)3 (2)9 (3)12 (4)19 (5)25 (6)28 If numbers 3, 12, 19, or 28 are missing, the next most posterior tooth will be examined. If 9 or 25 is missing, substitution of the nearest incisor will be made, if the incisors are missing, a cuspid will serve as the substitute (See Appendix A). The Gingival Score is on a 0, 1, or 2 point scale 12: 0 refers to a gingival tissue that is normal in color and tightly secured to the tooth with no exudate fluid present, and no obvious problems. For a score of zero, routine dental care will be recommended. 1 refers to inflammation of the gums, periodontal pockets that are present but do not completely surround the tooth, caries without accompanying signs or symptoms, spontaneous periodontal bleeding, and/or suspicious white/red soft tissue areas. For a score of one, a dental visit is recommended within the next several weeks. 2 refers to inflammation completely circulating the tooth, signs or symptoms that include pain, infection, swelling, and/or ulcerations lasting for more than two weeks (determined by questioning). For a score of two, immediate dental treatment is recommended. 8 World Oral Health Country/Area Profile Programme: Caries Prevalence (Continue reading) 9 Partial caries lesions are ignored in the DMFT model (Continue reading) 10 WHO Global InfoBase: India: All Data - Dental Caries Prevalence and Severity (Continue reading) 11 Institute for Algorithmic Medicine: 2007 (Continue reading) 12 Association of State and Territorial Dental Directors: 2003 (Continue reading) � Previous Section: The Prevalence Study Next Section: Appendix (2 of 3) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[69]=new Array(0,1,"./paper-4-appendix-2.html","2009-10-09","10K","Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009    ","",""," Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009 Font Size Prevalence Study of Oral Hygiene and Dental Health Paper Contents... Introduction The Prevalence Study Appendix References FATIMA A HUSSAIN, RAVIKUMAR CHOCKALINGAM Appendix (Page 2 of 3) Appendix C 13 ICTPH’s baseline survey did address tobacco habits of the population. It may be repetitive to have it in the oral health survey as well. 14 ICTPH’s baseline survey did address tobacco habits of the population. It may be repetitive to have it in the oral health survey as well. � Previous Section: Appendix (1 of 3) Next Section: Appendix (3 of 3) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[70]=new Array(0,1,"./paper-4-appendix-3.html","2009-10-09","13K","Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009    ","",""," Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009 Font Size Prevalence Study of Oral Hygiene and Dental Health Paper Contents... Introduction The Prevalence Study Appendix References FATIMA A HUSSAIN, RAVIKUMAR CHOCKALINGAM Appendix (Page 3 of 3) Appendix D Dental numbering systems Tooth numbering systems are used by dentists and researchers to refer to specific teeth individually. Two main systems are used today: The Universal Numbering System and the FDI World Health Federation Notation. The CHW model gives preference to the Universal Numbering System because it is straightforward in its numbering, chronologically increasing from back right around to bottom right (See Figure D1), and is identical to the numbering system used in the initial validation study and CHW training. The FDI notation is a bit more confusing as it divides the oral cavity into four sections and numbers the teeth in each section chronologically from the centre out (See Figure D2). Figure D1: Universal Numbering System (Patient’s view) (http://users.forthnet.gr/ath/abyss/dep1151_1.htm) Figure D2: FDI World Health Federation Notation (Dentist’s perspective) (http://users.forthnet.gr/ath/abyss/dep1151_1.htm) Appendix E Periodontal disease indexes The Community Periodontal Disease Index is the most common scoring methodology used to analyze periodontal disease. It will not be used in the ICTPH CHW model, however, because of its need for instruments and technical skills. CPI Materials and Methods 15 The indicators used include: gingival bleeding, calculus, and periodontal pockets. A specific CPI probe is used to measure the periodontal pocket size. Many are available, but the Williams model has been proven to be the most accurate (Estela, 2002) 16. The probe is specially designed with a 0.5mm ball tip with a black measuring band from 3.5 to 5.5mm along the probe and measuring rings at 8.5 and 11.5mm. The mouth is divided into sextants. Originally following the FDI index, the tooth ranges are 18-14, 13-23, 24-28, 38-34, and 33-43. Examinations are conducted by using the CPI probe to determine the pocket depth, gingival bleeding and sub-gingival calculus. The probe is placed parallel to the tooth root and inserted with a force not to exceed 20 grams. A patient should not experience pain in probing. In addition to the complexity of the CPI methodology, the scoring system does not seem to fit in the financial scope of the CHW model. The Williams Periodontal Probe is available with 7 replacement zips from Hu-Friedy (manufacture code: PCVWKIT6) by Colorvue for US 52.99 (approximately Rs.2,500). 12 replacement tips run for about 77.50, or Rs.3,700. CPI will be referred to the primary healthcare giver (dentist/Nurse Practitioner/Trained Village Health Nurse). 15 WHO CAPP Community Periodontal Index (CPI) (Continue reading) 16 According to the Technical Assessment of WHO-621 Periodontal Probe made in Brazil by Estela et al, the Williams Periodontal Probe is accurate with a standard deviation of 0.08mm. This is twice as accurate as the WHO design. (Continue reading) � Previous Section: Appendix (2 of 3) Next Section: References � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[71]=new Array(0,1,"./paper-4-introduction.html","2009-10-09","16K","Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009    ","",""," Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009 Font Size Prevalence Study of Oral Hygiene and Dental Health Paper Contents... Introduction The Prevalence Study Appendix References FATIMA A HUSSAIN, RAVIKUMAR CHOCKALINGAM Introduction (Page 1 of 2) Fatima A Hussain is a candidate for a Bachelor of Science in Environmental Engineering at the Massachusetts Insitutute of Technology. She has worked as an undergraduate research laboratory intern at Pre-UROP (Material Science and Engineering), MIT, as a laboratory intern at the National Cancer Insitute, Ft. Detrick and at the CVS Pharmacy as a pharmacy service associate. She has also worked on a Potable Water System Project in Santa Ana, Ecuador, led by the MIT Public Service Center through which she gained experience in international development work and public health. Ravikumar Chockalingam graduated from Madras Medical College, one of the oldest in India, in 2003. He has five years of post-graduate clinical experience including training in Surgical Laparoscopy and Intervention Gastroenterology in Buffalo, NY. He worked as a Registrar in the Critical Care unit in Apollo Hospitals for a year and a half after which he joined ICTPH as Assistant Vice-President – Human Capacity. Dr. Chockalingam is the founding member of the CHW (Community Health Worker) focus at ICTPH, looking at alternative disease focus areas e.g. mental health, oral health and sexual health. Dr. Ravikumar also played an instrumental role in operationalising the CHW pilot in Tanjore district of Tamil Nadu – from coordinating field teams for mobilizing the CHWs to designing and implementing the in-house three phase training programs. Dr. Chockalingam is currently pursuing his Masters in Public Health (MPH), at The Warren Brown School of Social Work, Washington University, USA. Executive summary Oral health is a rising concern for the Indian population. The IKP Center for Technologies in Public Health (ICTPH) has taken an initiative in oral health from a public health systems perspective. ICTPH is a research-based, not-for-profit, organization aiming to improve the health of poor populations in India. It aims to accomplish this goal by integrating the scientific knowledge of factors influencing health and disease with regular evaluation and impact assessments of existing health systems, and appropriate technologies for optimal healthcare delivery (ictph.org.in). The overall aim of ICTPH’s dental health initiative is to create a framework for public oral healthcare by integrating preventative and primary care models with alternative human resources. In this context, the Human Capacity Vertical of ICTPH has completed a validation study to assess the utility of Community Health Workers (CHWs) in identifying dental caries and periodontal disease at the Karambayam field site. This study was based on a representative sample of the population. The next phase in the ICTPH initiative is to determine the burden of disease in Karambayam, and to examine the oral healthcare seeking behaviors within the community. For the Prevalence Study, the CHWs will be trained to use different scoring systems to evaluate the oral health of the community as part of establishing a baseline, and for follow up studies. The Prevalence Study will use the Decayed, Missing and Filled Tooth (DMFT) index (See Appendix A) and the Navy Periodontal Disease Index (NPDI)/Basic Screening Survey (See Appendix B) in conjunction with a door to door survey to gauge modifiable risk behaviors and existing knowledge, awareness, and practices of oral hygiene (See Appendix C). The study itself is scheduled to be carried out in the second half of the year 2009. Introduction The Burden of Disease and ICTPH’s Role Thus Far Oral healthcare problems and the Indian perspective Poor oral hygiene and dental health have a profound impact on the overall health of an individual. Oral health problems such as pain, missing and discolored teeth, along with dental and gum disease, affect the ability to eat, communicate, and perform other daily activities. The impact of poor oral hygiene is observed at school and the workplace, with the loss of millions of work hours world wide (Petersen et al. 2005). Oral health often receives lower priority than other health concerns such as HIV/AIDS and maternal healthcare. This is largely due to the false notion that oral health does not lead to serious diseases and other illnesses. ICTPH’s literature review on oral illnesses revealed: There is increasing evidence linking impaired oral hygiene to various health conditions such as pancreatic cancer in men, role of periodontal disease as a risk factor for stroke/TIA, greater prevalence of severe periodontal disease among individuals with type I and II diabetes among individuals in the age group 15-24 years of age. There is also increasing evidence that periodontal disease has been associated with low birth weight and pre-term deliveries (Chockalingam et al. 2009). In addition, the four most prominent non-communicable diseases – cardiovascular disease, diabetes, cancer, and chronic pulmonary disease – share several common risk factors with oral diseases (Petersen et al. 2005). Community dentistry in India There is no specific allocation of funds for oral health in the Indian health budget (Tandon, 2004), and there is a substantial lack of human resources in public dental health. The overall ‘dentist:population’ ratio in India is 1:30,000, and, there is a significant geographic imbalance. While the ratio in the urban setting is roughly 1:10,000, in rural regions it averages about 1:250,000 (Tandon, 2004). For comparison, in most developed countries, the ratio is about 1:2,000 (Peterson et al. 2003). This disparity is illustrated below, in Figure 1. Figure 1: Number of patients per dentist Furthermore, in India, only about 2% of specialists in dentistry are trained in community dentistry (Tandon, 2004). With 72% of the Indian population living in rural areas with no access to the private dental health sector (IJCM, 2004), there is an acute need to develop public dental initiatives. The first access to dental care is only available beyond the community health center level; there is no dentist or dental technician at the Sub-centre, PHC, or CHC level (IJCM, 2004). This lack of access to dentists in the rural setting is a major concern. However, if the oral healthcare needs can be switched from surgical treatment and tooth removal to more of a preventative methodology (Tandon, 2004), the lack of access to dentists could be addressed via dental auxiliaries. Next Section: Introduction (2 of 2) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[72]=new Array(0,1,"./paper-4-introduction-2.html","2009-10-09","18K","Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009    ","",""," Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009 Font Size Prevalence Study of Oral Hygiene and Dental Health Paper Contents... Introduction The Prevalence Study Appendix References FATIMA A HUSSAIN, RAVIKUMAR CHOCKALINGAM Introduction (Page 2 of 2) ICTPH’s oral hygiene and dental health initiative The Human Capacity Vertical’s Plans: The Human Capacity limb of ICTPH has conceptualized and implemented a Community Health Worker (CHW) program with a primary objective towards educating the community and improving the overall health seeking behavior. We [HC] envisage integrating field research, community understanding through feedback from the community as well as from our community health workers to address key issues in public health through a process of organizing training and dissemination at the community level. ICTPH’s efforts to study and improve oral hygiene at the community level, the Human Capacity vertical program has a three-pronged strategy: (1) Studies conducted at various levels, (2) the community health workers efforts to disseminate information, and, (3) community-based interventions based on training through didactic and practical learnings (Chockalingam et al. 2009). The Oral Hygiene and Dental Health Initiative consists of a Validation study, Prevalence study, and Impact Analysis. The Validation study aims to assess the ability of the CHWs to diagnose oral disease following an interactive training session. The Prevalence Study will evaluate the burden of disease in Karambayam by means of a selected oral health scoring system and survey analysis. Finally, the impact analysis will study the role of the CHWs in improving oral hygiene and dental health at the community level. This paper describes and discusses the Prevalence Study. Focusing on Dental Caries and Periodontal Disease Throughout the oral hygiene and dental health study, ICTPH is focusing on dental caries and periodontal disease. Cavities and periodontal disease are the two most prevalent oral diseases in India, followed by malocclusion and oral cancers (Tandon, 2004). About 45% of people above the age of 15 suffer from periodontal disease (Mahal, 2006), and 80% of children suffer from dental caries (IJCM, 2004). In addition, dental caries and periodontal disease are the two leading causes of tooth extraction and removal (Upadhyaya, 2009). Dental caries has been referred to as a pandemic; it is globally distributed, affecting all populations (Edelstein, 2006). Developing countries, including India, have shown an upward trend in DMFT 1 (Decayed, Missing, and Filled Teeth) values (See Figure 2) due to an increase in the prevalence of processed foods in the diet (Petersen et al. 2005). Figure 2: Changing levels of dental caries experience (Decayed, missing and filled teeth (DMFT) index) among 12-year-old in developed and developing countries 1 DMFT is a severity indicator of dental caries calculated by summing up the number of decayed, missing, and filled teeth a person has. (Explained in detail in the prevalence study) The developed countries have the reverse trend in dental caries severity due to increasing availability of dental care and education. The DMFT score for Tamil Nadu is 3.94, which is well above the accepted value of 3 or less (WHO, 2009). Periodontal disease affects 90% of the population above the age of 30 (IJCM, 2004) in India. Periodontal health is correlated with the other non-communicable diseases mentioned above and is of primary concern due to HIV/AIDS oral manifestations and relations to oral cancers. The World Health Organization (WHO) has developed a Global Oral Health Program that targets common dental diseases by focusing on modifiable risk behaviors. Professor Shobha Tandon, Dean of Manipal College of Dental Sciences, recommends that, “Human resource planning and utilization should be based on the aim for sustained development along with a system of monitoring and evaluation programs” (Tandon, 2004). This recommendation is reflected in ICTPH’s Validation and Prevalence Study. Validation Study 2 The aim of the oral hygiene validation study is to understand the role community health workers can play in preventative oral healthcare at the community level. The study focused primarily on the CHW’s ability to detect the presence of dental plaque, caries and gingivitis. Their assessment was validated by means of reexamination by a certified dentist. From the three villages in Thanjavur, Tamil Nadu, included in the ICTPH baseline survey, Karambayam was chosen as the model for the oral hygiene and dental health initiative. Karambayam has a population of 3600 people and 907 households. For the validation study, a random sample size of 92 citizens between the ages of 19 to 64 was selected. 20 volunteers were mobilized from the community by ICTPH to work as CHWs. A group of 5 CHWs was randomly selected for the validation study. The CHW training was completed over two days at the ICTPH field site office by trained specialists. Training methodology included didactic tools and practical sessions on diagnosing dental caries, gingivitis and dental plaque. The CHW’s diagnosing capabilities were evaluated using assessment tools developed by ICTPH that included theoretical as well as practical components 3. The CHWs were prepared to conduct the prescribed dental examinations according to an in-house developed protocol. Due consent was obtained from each subject and documented according to the Institutional Review Board approved consent form. Results from the validation are currently pending. Preliminary findings comparing only one CHW to the professional dentist evaluation (See Figure 3) revealed an ability to correctly identify the number of teeth present in both upper and lower jaws 90% of the time 4. Caries were accurately detected only 55% of the time, and on average .75 caries were missed by the CHW. Gingivitis was correctly detected 83% of the time. The reexamination, as per the validation protocol, is scheduled for completion by the end of July 2009. Until that time, ICTPH will continue with the Oral Hygiene and Dental Health Prevalence Study. If necessary, ICTPH will reevaluate and re-administer the validation study training. 1 DMFT is a severity indicator of dental caries calculated by summing up the number of decayed, missing, and filled teeth a person has. (Explained in detail in the prevalence study) (Continue reading) 2 A detailed report of the Validation study is available through ICTPH (Continue reading) 3 The CHWs were evaluated immediately preceding the training session and have not been reexamined for verification. (Continue reading) 4 Findings were collected by intern Fatima Hussain on a field site visit on 12 June 2009 and include 10 evaluation samples chosen at random. (Continue reading) � Previous Section: Introduction (1 of 2) Next Section: The Prevalence Study � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[73]=new Array(0,1,"./paper-4-prevalence-study.html","2009-10-09","17K","Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009    ","",""," Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009 Font Size Prevalence Study of Oral Hygiene and Dental Health Paper Contents... Introduction The Prevalence Study Appendix References FATIMA A HUSSAIN, RAVIKUMAR CHOCKALINGAM The Prevalence Study Objective The aim of this study is to understand the prevalence of oral health issues in Karambayam, Tamil Nadu. The study utilizes surveys and statistical analysis and is conducted by trained Community Health Workers (CHWs). In addition, ICTPH will evaluate the CHW model as a means to diagnose and deliver preventative healthcare by addressing issues of life style and education. The oral health screening will be used as a surveillance system with follow- up screenings to track improvements. Research question The prevalence of dental caries and periodontal disease can be assessed by use of the Decayed, Missing, Filled Tooth (DMFT) Index, Basic Screening Surveys (BSS), and the Navy Periodontal Disease Index (NPDI) Gingival Scoring System in conjunction with a door to door survey. Such an assessment can provide an effective means for addressing gaps in oral health seeking behavior and to gauge the existing levels of knowledge, awareness, and practices of the community. Research protocol Karambayam, with population 3600, will be divided into index ages and age groups as designated by the World Health Organization (WHO) methodology for Basic Oral Health Surveys (OHS, 1987). Stratified sampling of ages 12, 15, 35-44, and 65-74 years will be used. CHWs will use the modifiable risk behavior survey (See Appendix C) to assess the oral health seeking behaviors of the population and to measure the prevalence of oral disease by use of the suggested oral health scoring systems. The CHWs will focus on dental caries and periodontal disease for the prevalence study, as these are the two most prevalent indicators of oral disease (Tandon, 2004). Epidemiological studies in Indian population show that dental caries and periodontal disease are widely distributed regardless of age, sex, socio-economic status and geographical location (Mahal, 2006). Dental caries prevalence After an extensive literature review on detection methodologies, the dental caries scoring system suggested 5 for the Community Health Workers in Karambayam will be the Decayed, Missing, Filled Tooth Index (DMFT) (See Appendix A). DMFT is the most recognized detection methodology for dental caries (WHO). It is used by the World Health Organization for dental health detection and is much simpler to use than its alternative, the DMFS index, which accounts for every tooth surface. The DMFT index looks at each tooth in order, using the Universal tooth numbering system (See Appendix D). This is preferred for the CHW model and it provides a means to validate the effectiveness of the training methodology as well. DMFT can be and has been used in previous studies by the WHO for follow up purposes and thus is perfect for the CHW preventative healthcare model. Periodontal disease prevalence Periodontal disease is highly prevalent and hazardous. Periodontal disease has been correlated with health problems such as diabetes, cardiovascular disease, stroke, pancreatic cancer, low birth weights and premature deliveries 6 and thus cannot be ignored. The methodologies in testing for periodontal disease, however, are not in the scope of the CHW model. All gum disease indexes involve the use of specific dental equipment and skilled methodologies that are suited for dental professionals only (See Appendix E). It is thus proposed that the CHWs will diagnose periodontal disease more qualitatively, using only the NPDI gingival score and by determining the urgency for dental care on a 0-1-2 point scale, as indicated by the Basic Screening Surveys (BSS) Manual (indicator #6) (See Appendix B). This screening and rating methodology can also be used for improvement tracking purposes. Seeing what households move from 2 to 1 or from 1 to 0 over time will be of great interest. Modifiable risk behavior surveys In addition to measuring the burden of oral disease, the prevalence study will involve a survey (See Appendix C) to analyze the dental hygiene behaviors, modifiable risk behaviors, and oral health perception of Karambayam. A separate survey will be used for the 12 and 15 year age groups and the 35-44 and 65-74 year age groups. The surveys are modeled after a similar geographical survey conducted in other parts of India, and address issues of brushing and cleaning methodology, tobacco and dietary habits, and oral care seeking behaviors. Trained CHWs will administer the surveys and at the same time note the oral health scores for caries and periodontal disease. Discussion and recommendations The Prevalence Study will develop an understanding of the oral disease burden in Karambayam, Tamil Nadu. In addition, modifiable risk behaviors that will need to be addressed in the community can be identified. Based on this study, ICTPH may be able to design an education program to meet well-defined needs assessment. Following the findings of the Validation study, ICTPH will be able to outline and define the role for the CHWs in preventative oral healthcare. The hypothesized role of the CHWs is one that is able to diagnose oral diseases and refer individuals to the Public Health Centers where primary care facilities and resources will be available. ICTPH is organizing for a dentist, village health nurse, or nurse practitioner 7 to be available at the PHC once a week to treat the referred patients. The Oral Hygiene and Dental Health Initiative has many opportunities to further expand its outreach. In the future, oral cancers and fluorosis should be examined as well. As oral health is greatly affected by behavioral changes and increase in education, the ICTPH study has great potential to improve the oral health of the Karambayam community. It can also lay a foundation for other public health initiatives. It is the first study of its kind and will be of great use in future research. 5 All suggestions and recommendations present in this report are made by intern Fatima Hussain (Continue reading) 6 See references in ICTPH Oral Hygiene Proposal under the Human Capacity Vertical (Continue reading) 7 ICTPH is working on forming a nurse practitioner model to help fill in human resource gaps at the primary healthcare level. More information is available on their web site (ictph.org.in) (Continue reading) � Previous Section: Introduction (2 of 2) Next Section: Appendix � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[74]=new Array(0,1,"./paper-4-references.html","2009-10-09","11K","Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009    ","",""," Prevalence Study of Oral Hygiene and Dental Health | ICTPH - Global Internship Programme 2009 Font Size Prevalence Study of Oral Hygiene and Dental Health Paper Contents... Introduction The Prevalence Study Appendix References FATIMA A HUSSAIN, RAVIKUMAR CHOCKALINGAM References Association of State and Territorial Dental Directors. (2003). Basic Screening Surveys: An Approach to Monitoring Community Oral Health. Estela, G. (2002). Technical Assessment of WHO-621 Periodontal Probe Made in Brazil. Brazilian Dental Journal. 13(1): 61-65. Chockalingam, R. et al. (2009). Validation Study of Community Health Workers Assesment of Oral Hygiene in Karambayam, Tamil Nadu. Edelstein, B. (2006). The Dental Caries Pandemic and Disparities Problem. BMC Oral Health. 6(1). IKP Centre for Technologies in Public Health. (2009). About Us. Retrieved July 15, 2009, from http://www.ictph.org.in/about.htm. Indian Journal of Community Medicine (Editorial). (2004). National Oral Healthcare Programme (NOHCP) Implementation Strategies. 3-10. Mahal, A. (2006). Implications of the Growth of Dental Education in India. Journal of Dental Education. 70(8):884-891. Petersen, P. et al. (2005). The Global Burden of Oral Diseases and Risks to Oral Health. Policy and Practice: Theme Papers. Tandon, S. (2004). Challenges to the Oral Health Workforce in India. Journal of Dental Education. 68(7):28-33. Tooth Numbering Systems. Retrieved June 14, 2009, from http://users.forthnet.gr/ath/abyss/dep1151_1.htm. Upadhyaya, C. (2009). The Pattern of Tooth Loss Due to Dental Caries and Periodontal Disease Among Patients Attending Dental Department (OPD), Dhulikhel Hospital, Kathmandu University Teaching Hospital (KUTH), Nepal. Kathmandu University Medical Journal. 7(1): 59-62. World Health Organization. (2009). Dentition Status and Criteria for Diagnosis and Coding (Caries). WHO Oral Health Country/Area Profile Programme. World Health Organization. (2009). Community Periodintal Index (CPI).WHO Oral Health Country/Area Profile Programme. Institute of Algorithmic Medicine. (2009). Dentistry and Oral Medicine: Navy Periodontal Disease Index. The Medical Algorithms Project. � Previous Section: Appendix (3 of 3) Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[75]=new Array(0,1,"./paper-3-analysis.html","2009-10-09","19K","Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre | ICTPH - Global Internship Programme 2009    ","",""," Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre | ICTPH - Global Internship Programme 2009 Font Size Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Paper Contents... Introduction to Telemedicine Processes Involved in Setting up a Telemedicine Centre Standards and Protocols Software Data Interchange/Exchange Standards Security Telemedicine Process Guidelines Protocols at the Telemedicine Centre Employment of Telemedicine in India Issues & Challenges Analysis Annexures References MANU MANAMEL, ARIJIT SARKAR Analysis Telemedicine has immense potential to influence the delivery of healthcare services at the primary level. If optimally utilized, telemedicine can effectively lead to better healthcare services even at the tertiary level also. The employment of telemedicine at the primary level can have a cascading effect on the healthcare system as a whole since the patients who do not require specialist services can be referred back at the primary level itself and the consulting time of the specialists can be optimally dedicated to the deserving patients. The immediate challenge remains to equip the public health services with the necessary infrastructure. Ideally, all the public healthcare centres including the primary health centres and the peripheral centres should be equipped with internet connection with the required bandwidth either through broadband or through satellite connectivity. This would bring in a drastic difference in how the primary health centres operate. Each primary health centre can double up as a consulting centre as well as a specialist centre. The doctor at the PHC can connect to the secondary centre or a super specialty centre and seek specialist’s opinion on the patient’s condition. In this regard, the PHC would be acting as a consulting centre. The PHC doctor can also give advice to paramedical personnel who are manning the peripheral centre. The peripheral centres are not run by doctors but instead by the trained paramedical staff who are proficient in identifying and diagnosing the common illnesses. The PHC would be taking up the role of a specialist centre in this instance. The patient from a peripheral centre would be referred to higher centres only after consultation with the doctor at the primary health centre. Infrastructure The report tries to identify the technological requirements and medical diagnostic devices that should be made available at different hierarchy for a viable telemedicine programme. This is only an attempt to improvise the system and not to belittle the existing system. The suggestions that have been put forward have been made after studying the environment, seeking guidance from experts and exercising discretion to reach our own conclusion. The report does not talk about the rest of the infrastructure that is needed to make the system a functional one. This report is only an outline of what needs to be done and the exact requirements may vary on a case to case basis Secondary health centre The secondary health centre holds more promise in the ability to be transformed into an ideal telemedicine centre where the potential with regard to the community health can be tapped. It requires less effort to set up a telemedicine centre at the secondary centre because the investment needed to set up a telemedicine centre is less due to the existence of better diagnostic facilities as compared to the primary level. The following are the diagnostic devices that are required by which a secondary health centre can easily be upgraded/ transformed into a well performing telemedicine centre. 1)X Ray digitizer / Scanner – Most of the secondary health centres have X Ray machines to which a digitizer/scanner can be added. 2)Ultrasound scan 3)12 lead ECG 4)Telepathology microscope with camera 5)Pulmonary Function Test Machine 6)Tele otoscope 7)Tele ophthalmoscope Primary health centre The primary health centres need to upgrade themselves from the present situation if the public health system is to become stronger. A robust telemedicine system can improve the confidence level of the doctors in the periphery. The diagnostic devices at the primary health centre which should be connected to the telemedicine system: 1)12 lead ECG 2)Ultrasound scan 3)Tele otoscope 4)Tele ophthalmoscope Peripheral centre run by paramedical personnel Peripheral centres can effectively blend with the public health system as is done by the ANMs and ASHAs today. Suggestions for the diagnostic devices which should be installed at the peripheral centre and connected to the telemedicine system: 1)Electronic stethoscope 2)12 lead ECG 3)Digital BP apparatus which may or may not be controlled by the remote doctor 4)Pulseoxymeter The above machines can be easily operated by the paramedical persons and the results can be analysed by the doctor at the primary health centre who decides whether the patient needs referral services or not. Some of the above suggestions may seem infeasible due to the capital that is involved. On closer analysis, we feel that the benefits that can be reaped on investing in the capital are very high. In the long run, it is quite likely that the investments may pay off in terms of the wellbeing of the community and the monetary benefits to the patients. The patients and the doctors do not seem to be convinced about telemedicine. This has to be addressed by spreading awareness and by conducting hands-on trials using telemedicine. Setting up a telemedicine centre calls for a lot of discretion on the part of the client. Although there are no rules that are laid down, the guidelines might take the form of an Act in the near future. The guidelines for standardization do not lay down the standards for all the human resources that are involved in running the telemedicine centre. The selection of the candidates for the operation of the telemedicine centre and their training, therefore, rests solely upon the client. As the fixed costs involved are very high, it might act as a deterrent to the private players from setting up telemedicine centres. The government, therefore, has to intervene actively and encourage public private partnership in the sector. Telemedicine is an amalgamation of the developments that take place in other fields such as communication, information technology, healthcare and diagnostics. These fields are evolving constantly and consequently the standards are also bound to be raised. Therefore it is necessary that the client keeps himself abreast of the developments happening in these fields and install the equipment that are not likely to become obsolete in the near future. Any technical instrument is prone to failure and breakdowns which can result in the loss of information if there are no alternatives already set up. A right balance has to be struck between the usage of human mind and electronic solutions in the field of healthcare. It is imperative that all the centres be enabled with internet connection and the bandwidth for the successful implementation of the telemedicine programme. Usage of web camera and open source software would be the easiest and the most cost effective option for videoconferencing while satellite connectivity provides the highest reliability. The implementation of telemedicine would neither solve all the problems that plague the public health system presently nor does it come without pitfalls and drawbacks. Technology should be used as a means to attain the goal and not as a goal in itself. It would be a small step in the right direction which can act as a harbinger for multiple benefits for the community as a whole. � Previous Section: Issues & Challenges Next Section: Annexures � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[76]=new Array(0,1,"./paper-3-annexures.html","2009-10-09","36K","Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre | ICTPH - Global Internship Programme 2009    ","",""," Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre | ICTPH - Global Internship Programme 2009 Font Size Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Paper Contents... Introduction to Telemedicine Processes Involved in Setting up a Telemedicine Centre Standards and Protocols Software Data Interchange/Exchange Standards Security Telemedicine Process Guidelines Protocols at the Telemedicine Centre Employment of Telemedicine in India Issues & Challenges Analysis Annexures References MANU MANAMEL, ARIJIT SARKAR Annexures (Page 1 of 3) Annexure I (As per the report of the telemedicine working committee for standardization of telemedicine) Specifications for typical PC-based telemedicine consultation centre system configuration 1.0 Ghz or above processor speed system or equivalent with appropriate mother board. Appropriate number of Serial, parallel & USB ports. 10/100 Base-T LAN/Ethernet interface with Wake-On-LAN (WOL). Appropriate clinical device interfaces, ex. Interface for ECG and pathology camera 40 GB (minimum) or more HDD 1.44 MB FDD 128 MB DD RAM, upgradable to 1GB CD Writer, with 8X (minimum) re-write speed. Graphics with 32 MB (minimum) RAM & PAL-B composite (minimum) video output. 24-bit image capture hardware with image resolution of 720 x 576 (minimum) with appropriate video interface. High-resolution (1280 x 1024) 17 color monitor, for displaying medical data/images is advisable. But 15 color monitor with 1024*768 resolution can also be considered. Audio interface with speakers, (20W minimum) & a microphone. Web camera (640~)*(480~) Maximum resolution. Frame rate:30fps@VGA (640*480);Optical system; CCD; Progressive 330K effective pixels Standard Windows 101 US Key board. Scroll two-button mouse with mouse pad. Preferred two spare PCI slots. Auto shutdown facility. Optional Video switching unit. ISDN interface up to 384 Kbps. Specialized interface for clinical devices & communication. SCSI Camera Link IEEE 1394 Blue tooth IEEE 802.11 (b) Specifications for typical PC-based telemedicine specialist centre system configuration Intel Pentium-IV, 1.8 GHz with Intel chipset mother board or AMD Athelon, 1.8 GHz or equivalent, with appropriate mother board Appropriate number of Serial, parallel & USB ports. 10/100 Base-T LAN/Ethernet interface with Wake-On-LAN (WOL). 40 GB (minimum) or more HDD, operating at 7200 rpm (minimum). 1.44 MB FDD. 256 MB DD RAM, upgradeable to 1GB. CD Writer, with 8X (minimum) re-write speed. Graphics with 32 MB (minimum) RAM & PAL-B composite (minimum) video output. 24bit image capture hardware with image resolution of 720 x 576 (minimum) with appropriate video interface. High-resolution (1280 x 1024) 17 color monitor, for displaying medical data/images. High-resolution (1280 x 1024) 17 color monitor, for displaying medical data/images is advisable. But 15 color monitor with 1024*768 resolution can also be considered. Audio interface with speakers, (20W minimum) & a microphone. Web camera (640~)*(480~) Maximum resolution. Frame rate:30fps@VGA (640*480); Optical system; CCD; Progressive 330K effective pixels Standard Windows 101 US Key board. Scroll two-button mouse with mouse pad. Preferred two spare PCI slots. Auto shutdown facility. Optional Video switching unit. ISDN interface up to 384 kbps. Specialized interface for clinical devices & communication. SCSI Camera Link IEEE 1394 Blue-tooth IEEE 802.11 Annexure II (As per the report of the telemedicine working committee for standardization of telemedicine) The power requirements, computer interface requirements and environmental conditions are common for all. Power requirements: 230 V AC, 50 Hz Computer interface: serial port/parallel port/USB/SCSI/Ethernet with relevant and appropriate drivers Environmental temperature: 10-35 Deg Celsius Environmental humidity: 35%-70% Minimum configuration for telemedicine diagnostic equipment is as follows. Digital ECG (12 LEAD MODULE) Leads : Standard 12 Leads, with one long lead Freq. Response : 0.5 To 125 Hz Leakage Current : < 10 Micro amps CMRR : > 100 DB Input Impedance : > 4 M Ohms Filter : To suppress supply frequency fluctuations A/D Conversion : 10 bit Sampling Rate : 500 Samples/seconds Recording Speed : 25/50 mm/sec. Optional features in the PC interface software : Display and printing X-Ray digitizer Resolution: 1200 dpi/lpi ( horizontal/vertical) Color resolution: 12-14 bits/channel(gray scale) Active area: As per the application (commercially available A3 and A4 scanners can also be deployed) Computer Interface: Other than Rs-232 Backlighting optimized for X-ray application Commercially available dedicated X-ray scanners of lesser dpi (at least 150 dpi) may also be considered, as appropriate Ultrasound (Sonography machine) Scanning Method : Electronic Convex, Micro convex and Linear Array Imaging Modes : B, B/B, B/M, M Electronic Array Probes: 3.5 MHz, 5.0 MHz, Linear convex,Trans-Vaginal (for Gynecology/obstetrics applications) Display Frame Rate: 24-30 fps Depth Selection : 4.5, 6, 9, 12, 15, 18, 21CM, Scroll Function Gray Scale : 64 shades of Gray, at least Converter : 512x512x6 bits, at least Measurements : Mouse/Trackball Operations B-Mode : Distance, Area Ellipse M-Mode : Heart Rate (optional) Calculations : Fetal Parameters, BPD, HC, CRL, AC, FL, HI, GS, LV, TA as relevant Image Management Report: Patient and Measurements Summary Image Computer interface: Using Image grabber/video capture card (PAL/NTSC/Composite video) /DICOM format output Glucometer Test : Glucose in capillary whole blood Sampling size : 3 �L of whole blood Sampling : Blood is automatically drawn into the Sensor by capillary action Measuring range : 1.1 - 33.3 mmol/L (20-600mg/Dl) Test principle : Electrochemical Specificity : Sensor reacts specifically with β D-glucose This Glucometer can be either hand-held and/or standalone Optional : Computer interface Portable X-ray machine Generator : 1 Pulse, Half wave Output (max) : 60mA-70kV-0.4s;40MA-80kV-2.0s;20mA-100kV-6.0s Line Resist : Max.0.4ohm KV : 45 to 100 kV, 5 kV per step Rad. Timer : 0.04 s to 6.0 s in multiple steps X-ray Tube : Focus 2.8 x 2.8 mm, Anode capacity-40 KHU orequivalent Power Supply : Single Phase, AC, 50Hz (in addition to general supply) Suggested features Easy Mobility and steering Integrated cassette box Easy transportation, in normal elevator and narrow passages Pulmonary function test (PFT) machine Flow Measurement : Screen type Pneumotach Volume Measurement : Flow integration Flow Range : 15 L/Sec Volume Range : 0 – 8 L Flow Accuracy : + 5% of reading Volume Accuracy :+ 3% of reading Frequency Response : 0 to 30 Hz. Sampling Rate : 128 samples/sec A/D Resolution : 12 bit MeasuringParameters: FVC, FEV 0.5, FEV1, FFV3, FFV1/FVC,FEV3/FVC, FEF25-75, FEF 25%, FEF-50%,FEF 75%, PEFR,FIVC, FIV1, FIV%, PIF,MVV. Computer interface : with real time display of flow volume loops with online display of flow and volume v/s time Fetal heart rate monitor Technique : Continuous Doppler with Auto Correlation Frequency : 2.5 MHz Intensity : < 10 mW/sq. cm HR Range : 30 to 240 M Uterine Contraction Range : 0-100 Units Bandwidth : 0-0.2 Hz Scaling : 30 bpm/cm (Heart Rate (HR)),25 mmHg/cm (Uterine Activities (UA)) Range : 30-240 bpm (HR) Resolution : 1 bpm (HR),1 m/Hg (UA) Speed : 1/3 cm/min (HR) Tele-Pathology microscope including camera A compound microscope, digital camera for tele-pathology applications, microscope system with modular concept upgrade able to phase contrast, dark field contrast, fluorescence (optional), photomicrograph and analysis, Delta/infinity corrected optics. Optics :Delta/infinity corrected with harmonic components Nose-Piece : 3 or more objectives Objectives : Standard achromatic objectives, oil with phase contrast, Magnification as per application, BF/DF observations Eye Pieces : 10X 22X with harmonic components optics Illumination : 12V, 30 W stabilized a) Trinocular tube Binocular with fixed photo tube/1X with 30 deg. viewing angle with inter-papillary distance adjustment from 55mm-75mm, with constant focus and beam splitter position vision/photo 50/50% fixed, condenser sub stage: universal condenser upgradeable for phase contrast dark field and bright field 0.90/1.25. b) Filter magazine Built in the stand with day light filter, green & neutral density filter 16%. The filter changing level is near to X 1Y knob of the stage for agronomy field diaphragm built in stand. c) Camera Digital Camera system composed of a C-mount CCD camera ½” image sensor with RGB 3 prime color filter, resolution 2.1 mega pixel or better with a minimum illumination of 5 lux/F2.0 with an interface to the computer. Annexure III (As per the report of the telemedicine working committee for standardization of telemedicine) a) Stand-alone type i) Codec Interoperability : Full ITU-T H.32x Standards-compliant, H.320 for ISDN line*, H.323 for LAN/Ethernet*, H.324 for PSTN (POTS) line* Video Compression Standard : H.261 (H.263 for H.324) Video Resolution : SQCIF – 128 X 96 (H.263), QCIF – 176 x 144, FCIF – 352 x 288 Video Frame Rate : 15 - 25 fps External Video Inputs : 2 color composite CCIR PAL-B Video interface : BNC or RCA Display Mode : VGA and SVGA up to 1024 x 768, 24-bit color Video Outputs : Minimum 1 color composite CCIR,PAL-B Audio Compression Standard : G.711: 3.4 kHz @ 64 kbps G.722: 7.1 kHz @ 48 / 56 / 64 kbps G.723.1: 3.4 kHz@ 5.3 / 6.4 kbps (H.263) G.728: 3.4 kHz @ 16 kbps G.729: 3.4 kHz@ 8 kbps (H.263) External audio input : 1 (desirable) Audio Outputs : Minimum 1 Audio Performance : 100-7100 Hz frequency response Full duplex Automatic Gain Control Automatic Noise Suppression Acoustical echo cancellation Signaling Standards : H.221, H.230, H.231, H.242 Data Rates : 64 kbps to 2048 kbps. External Data Interface : Compliant to ITU –T T.120 std. (desirable) Far End : H.281 compliant * As per network requirement. ii) Camera Camera may be an integrated part of the videoconferencing unit or it can be a separate unit with proper interfaces with the videoconferencing unit. Video Standard : CCIR PAL-B Camera sensor : CCD Picture resolution : 450 TV lines, minimum Optional: Control (local end) : Remote control for pan, tilt & zoom iii) Display Minimum 21 or bigger color TV with video and audio inputs (recommended is 29 color TV) Video Standard : CCIR PAL-B Video Format : Composite color Picture resolution : 350 TV lines, minimum Video interface : BNC or RCA Audio interface : RCA b) Video conferencing - PC add-on card type Interoperability : Full ITU-T H.32x Standards-compliant H.320 for ISDN line* H.323 for LAN/Ethernet* H.324 for PSTN (POTS) line* Video Compression Standard : H.261 (H.263 for H.324) Video Resolution : SQCIF – 128 X 96 (H.263) QCIF – 176 x 144 FCIF – 352 x 288 Video Frame Rate : Up to 25 fps Video Input : Color composite CCIR PAL-B Video interface : BNC or RCA Display Mode : VGA & SVGA up to 1024 x 768, 24-bit color Audio Compression Standard : G.711: 3.4 kHz @ 64 kbps G.722: 7.1 kHz @ 48 / 56 / 64 kbps G.728: 3.4 kHz @ 16 kbps Audio input : RCA or phono-jack Audio Performance : 100-7100 Hz frequency response, Full duplex Data Rates : 64 kbps to 768 kbps. * As per network requirement. Optional: Automatic Noise Suppression Acoustical echo cancellation i) Camera (With microphone) Camera sensor : CCD Picture resolution: 400 TV lines, minimum Video output : Color composite CCIR PAL-B Video interface : BNC or RCA c) Videoconferencing - camera with built-in encoder type i) Codec Interoperability : Full ITU-T H.323 Standards-compliant Video Compression Standard : H.261 and H.263 Video Resolution : QCIF – 176 x 144 FCIF – 352 x 288 Video Frame Rate : Up to 25 fps Audio Compression Standard : G.711: 3.4 kHz @ 64 kbps G.722: 7.1 kHz @ 48 / 56 / 64 kbps G.728: 3.4 kHz @ 16 kbps Audio Performance : 100-7100 Hz frequency response Full duplex Data Rates : 64 kbps to 384/512 kbps Camera sensor : CCD Picture resolution : 400 TV lines, minimum Optional: Automatic Noise Suppression Acoustical echo cancellation d) Videoconferencing – software-based web camera Max.Resolution : 640(h)*480(v) Frame Rate : 30 fps @ VGA (640*480) 400 M-bits /sec. capable Optical System : CCD Progressive 330k effective pixels � Previous Section: Analysis Next Section: Annexures (2 of 3) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[77]=new Array(0,1,"./paper-3-annexures-2.html","2009-10-09","22K","Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre | ICTPH - Global Internship Programme 2009    ","",""," Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre | ICTPH - Global Internship Programme 2009 Font Size Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Paper Contents... Introduction to Telemedicine Processes Involved in Setting up a Telemedicine Centre Standards and Protocols Software Data Interchange/Exchange Standards Security Telemedicine Process Guidelines Protocols at the Telemedicine Centre Employment of Telemedicine in India Issues & Challenges Analysis Annexures References MANU MANAMEL, ARIJIT SARKAR Annexures (Page 2 of 3) Annexure IV Specifications of modem used for PSTN link Compliance: V.34 Interface: PC built in or PCI card or serial communication port. PSTN Line – RJ – 11. Data speed: 33 kbps (minimum), 56 kbps desirable. Specifications of PCI card used for ISDN link Compliance: (B+D) or (2B+D) Interface: S/T or U Data speed: BRI – 64 Kbps (minimum) /128 Kbps (typical)/384 Kbps. Specifications of NIC used to link to LAN Compliance: IEEE 802-3 (10/100 Base – T Lan/Ethernet) Interface: RJ-45 Data speed: 10 Mbps (minimum) Specifications of PCI card used to link to wireless LAN Compliance: IEEE 802.11 Interface: PCI/PCMCIA IEEE 802.11 series cards. Data speed: 2 Mbps (minimum) Specifications of PCI card used to link to CDMA Compliance: CDMA Interface: Serial interface PCI/PCMCIA series CDMA cards. Data speed: 128 Kbps. Specifications of card used to 3G netwroks Compliance: GSM/GPRS/3G Networks Interface: Serial interface PCI/PCMCIA cards. Data speed: > 9.6 Kbps upto 1 Mbps. Annexure V (As per the report of the Telemedicine Working Committee for standardization of telemedicine) Data Integrity check mechanisms Using Hash or MAC SHA [used in TLS] Either MD-5 encrypted with DES, DES-MAC ISO 8730 [ISCL] Secure Hash Algorithm (SHA) is the recommended scheme. Scheme for digital signature Key management & distribution based on: RIPEMD-160 MD5 or SHA-1 Signature profiles (Base, Creator) If the data is encrypted, the DES/ RSA encryption algorithms can be used Secure transport options SSL, TLS, L2TP and PPTP can be used in a VPN environment. Annexure VI Consent form (As per the report of the Technical Working Committee on Standardization of Telemedicine) The informed consent has to be obtained on the TCC letterhead Informed Consent for Telemedicine Services (For Teleconsultation within India only) Introduction Telemedicine involves the use of electronic communications to enable doctors at different locations to share individual patient medical information for the purpose of improving patient care. A teleconsultation is based entirely on the information furnished i.e. text data, laboratory values and images. This information is used for diagnosis, therapy, follow-up and/or education. The Teleconsultant cannot countercheck the reliability of the information provided. The electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data. Possible limitations Due to unanticipated technical reasons there may be an interruption during the teleconsultation or quality of transmission may be suboptimal resulting in postponement of the teleconsultation. The teleconsultant would give an opinion based on the physical examination findings of the primary doctor. The teleconsultation may be videotaped, digitally recorded, filmed or photographed and used for teaching purposes. The patient’s identity will not be revealed. Abreach of privacy of personal medical information is theoretically possible. Lack of access to complete medical records may very rarely result in judgment errors. Annexure VII Constituents of National Telemedicine Grid at various levels Level-1: Primary health center (PHC)/ community health center (CHC)/Village unit Tele-consultation room Patient engagement facilities (bed, scopes, etc.) Telemedicine Platform Selective medical and medico-IT equipment, preferably IT compatible, with interface to Telemedicine and/or other software / hardware Computer hardware / software platform (PC, switch, etc.) and IT electronics equipment Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broadband, Wireless) Point-to-Point video-conferencing system (may be portable) Level-2: District hospital Telemedicine room Patient engagement facilities (bed, scopes, etc.) Telemedicine Platform Selective medical and medico-IT equipment, preferably IT compatible, with interface to Telemedicine and/or other IT software / hardware Computer hardware / software platform (PC, server, switch, etc.) and IT electronics equipment Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broad band, Wireless) Multi-point videoconferencing system Optional telemedicine software access facility at consultant’s room through Hospital-LAN Optional secure centralized long-term electronic record storage for assigned LEVEL-1 and LEVEL-M units Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broadband, Wireless) Note that: District Hospital may act as referring/consulting unit as well and may have some medical equipment for tele-consultation with State Hospital / National Super Specialty Hospital All units will require multiple telemedicine stations for simultaneous tele-consultation with referring units Level-3: State hospital/National super specialty hospital Telemedicine room Telemedicine Platform Computer hardware / software platform (PC, server, switch, etc.) and IT electronics equipment Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broad band, Wireless) Multi-point videoconferencing system Optional telemedicine software access facility at consultant’s room through Hospital-LAN Optional secure centralized long-term electronic record storage for assigned LEVEL-1, LEVEL-2, and LEVEL-M units Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broadband, Wireless) Note that: All units will require multiple telemedicine stations for simultaneous tele-consultation with referring units Level-M: Mobile telemedicine unit * Automobile vehicle Chasis size: 5.779 X 2.188 X 1.900 mts Customized fabrication to accommodate IT and medical equipment Integrated DG set Space for tele-consultation, patient examination Space for carrying out investigation procedures like Ultra-sonography and X-ray Telemedicine Platform Selective medical and medico-IT equipment, preferably IT compatible, with interface to Telemedicine and/or other IT software / hardware Computer hardware/software platform (PC, server, switch, etc.) and IT electronics equipment Connectivity/bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broadband, Wireless) Point-to-Point video-conferencing system (may be portable) Besides vans, Mobile Telemedicine units can be customized for deployment in any of the following: Boat (e.g. for application on backwater regions in Kerala or in Brahmaputra in Assam) Chhakras (e.g. used in Gujarat) Camel Carts (e.g. in deserts of Rajasthan) Application specific mobile units can be configured: Tele-ophthalmology Tele-Cancer care Tele-Ambulance for Trauma Network and Rural Emergency system Suitcase-based Telemedicine module for Disaster-hit area, etc. Mobile hand held units to act as data harvesting point for NRHM at the grass-root level * Each state will have initially 2/4 units depending on the size and population. Alternatively, the mobile vans procured under NRHM may be made telemedicine-enabled with suitable modifications and installations. � Previous Section: Annexures (1 of 3) Next Section: Annexures (3 of 3) � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[78]=new Array(0,1,"./paper-3-annexures-3.html","2009-10-09","12K","Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre | ICTPH - Global Internship Programme 2009    ","",""," Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre | ICTPH - Global Internship Programme 2009 Font Size Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Paper Contents... Introduction to Telemedicine Processes Involved in Setting up a Telemedicine Centre Standards and Protocols Software Data Interchange/Exchange Standards Security Telemedicine Process Guidelines Protocols at the Telemedicine Centre Employment of Telemedicine in India Issues & Challenges Analysis Annexures References MANU MANAMEL, ARIJIT SARKAR Annexures (Page 3 of 3) Annexure VIII Annexure IX Facilities in the mobile telemedicine unit of AIMS Equipment Medical equipment. Water supply. Refrigerator. Generator. Pneumatic beds. Medical equipment Colour echocardiography machine. Colour ultrasonography machine. Automated cell counter. Semiautomated chemistry analyzer. Pulmonary function test machine. Vital signs monitor. Cardiac treadmill. Retinal and Slit Lamp screening. Gastroscope and colonoscope. Capabilities Cardiac screening and diagnostic testing. General ultrasonography and material screening. General radiology. Screening and diagnostic GI endoscopy. Screening and diagnostic ophthalmology. Automated biochemistry and hematology. Screening and diagnostic airways evaluation. � Previous Section: Annexures (2 of 3) Next Section: References � Contents Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu Prevalence Study of Oral Hygiene and Dental Health Validation Study of Community Health Workers Assessment of Oral Hygiene Framework of Motivations for Community Health Workers Primary Health Care Financing Systems: International Comparisons and Lessons Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Facilitating Market Entry for Technologies in Rural Health: An ICTPH Strategy Paper Building a Case for Addressing the Issue of Mental Health in Rural Tamil Nadu Website by PACE | GIP 2009 Home | ICTPH Website Home IKP Centre for Technologies in Public Health (ICTPH)  � 2009 All Rights Reserved. Top of Page     ");
array_files[79]=new Array(0,1,"./paper-3-data-interchange-stds.html","2009-10-09","15K","Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre | ICTPH - Global Internship Programme 2009    ","",""," Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre | ICTPH - Global Internship Programme 2009 Font Size Role of Telemedicine in Primary Healthcare and Practical Aspects of Setting Up a Telemedicine Centre Paper Contents... Introduction to Telemedicine Processes Involved in Setting up a Telemedicine Centre Standards and Protocols Software Data Interchange/Exchange Standards Security Telemedicine Process Guidelines Protocols at the Telemedicine Centre Employment of Telemedicine in India Issues & Challenges Analysis Annexures References MANU MANAMEL, ARIJIT SARKAR Data Interchange/Exchange Standards It is recommended to use DICOM for transfer of diagnostic images such as X Ray, USS, Doppler between telemedicine systems. For exchange of messages, HL7 is recommended. HL7 HL7 is a Standards Developing Organisation (SDO) which works in the area of clinical and administrative data. HL7 also refers to some of the standards that the organisation has laid down. HL7 is the accepted standard for transfer of messages between telemedicine systems. HL7 is the abbreviation for Health Level 7; ‘Level 7’ stands for the topmost level of OSI (Open System Interconnection) reference model. The suggested version for interoperability is version 2.3 and above. HL7 addresses the following issues: Definition of the application data that has to be exchanged. Timing of the exchange. Application-specific errors. HL7 addresses the issue of interface between the systems that exchange patient data such as registration, discharge, orders and results. HL7 prescribes the presentation of information in the text format which is laid down as ‘encoding rules’. The format consists of data fields which combine to form segments. The segments are separated by segment separator characters. The working committee group advises that it is preferable to use the TCP/IP port while communicating amongst the telemedicine systems. HL7 Data interchange The following details have to be published by each ecosystem. ADT-AO4 ADT-AO8 ORU-RO1 HL7 Data transport Any of the following could be used but it is recommended to use the first option. TCP/IP Exchanging information in files of a directory DICOM DICOM stands for Digital Imaging and Communication in Medicine. It is accepted as an all-encompassing standard for the storage and transfer of all kinds of medical images from various diagnostic devices. It was fabricated by the National Electrical Manufacturers’ Association (NEMA), along with the American College of Radiology (ACR). The aims of developing such a standard were Communication of the digital images regardless of the manufacturer. Hasten the development of a Picture Archival and Communication System (PACS) that can also interface with the other hospital information systems. DICOM file format A DICOM file would contain a header and the image. The header contains the patient details such as name, scan type, dimensions of the image etc. The image can be stored in a compressed or uncompressed format. The usual compressed format includes the bitmap (bmp) while the uncompressed formats are the JPEG, GIF etc. In this regard, it differs from the popular Analyze format where compression cannot be done. Transfer syntax These are a set of rules that allow the application entities to intercommunicate after negotiating the encoding techniques. The transfer syntax can be ‘little endian’ wh