About the author

Simran Sachdeva, a class 11 bright student, hails from Karnal, India. She has keen interest in analytical research in the field of healthcare. She won the prestigious Hindustan Times essay contest 2017-18 and was also the Chief Writer for the special edition of the Times Of India in 2018-19. Her areas of keen interest include Science, Research & Technology and wishes to be a scientist in future.

SAM selects the target population on the following criteria:
Targeting vulnerability: SAM works with the poor and vulnerable communities who lack education, income, assets, status and access to healthcare.
Targeting pregnant, infants and children: SAM follows all pregnant women, infants and children under 5 years in the community.
Targeting reproductive age: For population stabilisation, SAM targets reproductive age group women and married couples between ages 18 and 49 years and adolescent girls from 10 to 19 years.
Targeting disease: SAM targets the families and contacts all TB patients, malnourished children and high-risk pregnant women.
SAM-ESP Innovation: SAM has developed a cost-effective platform for changing health behaviour ofa community. Health activists, in partnership with local public and private healthcare stakeholders, convert awareness to actionable knowledge. SAM has successfully used its Effective Social Persuasion Platform (SAM-ESP) in multiple locations. ESP relies on seven assumptions.
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Behaviour modification is the least expensive way to reduce disease burden.

Health is an individual and community responsibility; ownership of this responsibility empowers a community to demand healthcare rights. A campaign to push health information may improve awareness but is not sufficient by itself. Awareness is just one of many steps to change behaviour. Other essential steps include: a sustained, intensive, repetitive campaign without a predefined end time-point, encouraging peer to peer nudge and a methodical transfer of ownership to the community leaders.

Messages scripted by the community encourages their ownership. Trained volunteer activists can lead and sustain the ESP without external help.

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An established SAM-ESP platform can be used to address multiplehealth problems. SAM-ESP is not yetanother awareness building program. Awareness is often assumed to be equal to behaviour change. In practice, it is not true. Communication programs and prevalent awareness programs merely touch the surface without translating into significant behaviour change. SAM-ESP is a multi-step process, where awareness in just one of many steps for a sustainable behaviour change.

SAM promotes community ownership of both health and healthcare. SAM believes, that health is an individual and community responsibility and getting healthcare, as a right, has to be learned. SAM-ESP is a peoples’ program, which ensures that the health system is responsive and accountable.

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SAM trains volunteer health activists who lead the program and develops a cadre of social entrepreneurs, who sell contraceptives, sanitary pads and nutritional products. SAM field workers are from the community where they live and work. They are available 24/7 and take health to the doorstep of the recipients. The program sets no predetermined end date; repetitive training continues till SAM meets the objectives.

The following steps describe its execution:

Organize, create structure and build leadership capacity: SAM has well-trained field staff and managers;the voluntary directors of the organization are professionals from healthcare and management. Each district has a manager, trainers, and supervisors who are selected from the local population. They receive intensive training not only in health issues but also in motivational techniques, training methods and leadership.

Develop messages: SAM believes that a good message should be simple without technical jargon, short with less than five points, easy to understand without explanation and emotionally connected with a local need. For better retention, a message could be in the form of a story, song or a slogan. Some messages should be created by the community to feel ownership.

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Train health activists: Master trainers train volunteer health activists to be responsible for village health issues. Training is repetitive and intense.

Teach people: SAM organizes the village into a healthcare community. Field supervisors motivate and mobilize villagers and discuss each topic of healthcare with a specific training module. SAM uses local community resources to create training material and health leaders script their own songs and slogans. Activists meet villagers repeatedly to discuss best practices. Repetitive training of health activists and villagers is essential.

Cooperation with public and private health systems: SAM establishes linkage with the local private and public health system. Utilizing all available public health resources is an essential component of the program. Public health workers are invited to all meetings. This linkage creates awareness, which improves demand of healthcare and encourages accountability.

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Evaluation and improvement: Programs are monitored by community involvement and by participatory research action. Results lead tocourse correction.
Replicate: Solutions are validated and replicated in other locations.

Measuring impact: Each program starts with a baseline and finishes with an end-line evaluation. SAM defines objectives, activities, outputs and outcomes before the start of the program. They measure monthly progress against all these parameters.

Process of measuring impact is a four-step process:
Data Collection at community level: The field workers collect data during house visits and community meetings. They upload it on a smartphone.
Data review at block level: Field officers collate and review data every month at a block level. They validate it through client interaction.

Data validation at district level: SAM validates data through a monitor and evaluation protocol which includes field visits, focus groups and comparison with public health data. SAM compares outcomes and impact with similar programs run by the government and other private organisations.

External agency evaluation: Periodically, SAM engages external agencies to evaluate its work. The funding partners also send external evaluators to check the progress and impact.

Direct impact: Since inception, SAM has trained 37,000 volunteer health activists who live in the villages and are available to the community. SAM has directly impacted over 1,150,000 million people through maternal, child health, population stabilisation and TB control programs.

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Through maternal, child health and population stabilization programs, SAM has directly impacted: 530,000 women and over approximately 100,000 infants. SAM follows all (100%) pregnant women in the villages and has reduced maternal mortality by 90% and infant mortality by 60%. In some places, SAM has done even better. In the past 6 years, in 167 villages of Gadag, Karnataka; maternal mortality rate has decreased to 15.8 from 364 and the Infant mortality rate has decreased to 5 from 46.

Through population stabilizations program, the marriage of girls under 18 years of age has decreased to almost zero. Contraceptive use has increased from 28% to 62% and supplychain management has reduced the unmet need for contraception from 10.8 % to 2% been running in 700 villages. 287,042 people have participated in 14,552 community meetings. 13,973 people have had sputum tested. Sputum was positive for TB in 1329 people and 14 had multiple drug resistant TB. All received supervised treatment. SAM has directly helped with education and surveillance of 130,000 contacts of TB patients and helped another 317,000 community members with awareness program. TB detection rate has improved 3.7 times.

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Indirect impact: SAM estimates that approximately 0.9 to 1 million people, who did not actively participate in its programs, became aware of the benefits from those who attended our programs.

Women feel empowered, which has opened their minds to many choices in life. They express their opinions freely. Men and elderly women, who were suspicious and objected to their women attending public meetings, have mellowed their resistance and have even become enablers. Girls attend school more regularly and the number of girls attending college has increased. Adolescents participation has increased. Public health system and their workers are more responsive to public demand.Local elected politicians are responsive.

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Discussion: Multiple theories have attempted to explain the health behaviour of individuals. The most popular is the Health Belief Model (HBM), which was developed about 40 years back. It postulates that people make healthcare decisions based on perceived susceptibility to disease and consequences. The response is tempered by perceived benefits of action and with a belief that benefits outweigh risks. While this theory, like other theories, builds a plausible reference point to explain behaviour, it gives no guidance for modification of individual behaviour.

Theory of Planned Behaviour suggests that a person should be empowered with ability (self-efficacy) to change behaviour. The person should believe that the behaviour will improve his health and is socially approved. It has also been recommended that principles of marketing could be applied to a social cause, where the product to be sold is behaviour change.

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SAM model comes close to a hybrid variety of HBM, building self-efficacy and social marketing. SAM tries todevelop social efficacy through the agency of health activists by using techniques similar to social marketing. SAM Effective Social Persuasion is a people’s platform, which needs further elucidation and expansion. SAM is looking to use entertainment education or gamification for behaviour modification and use of technology in early detection of noncommunicable diseases. SAM seeks collaboration with others for mutual learning, sharing resources and scaling-up the program in vulnerable population.

About the author

Dr. Shiban Ganju is the Chairman of Atrimed Pharmaceuticals and Founder of Save A Mother Foundation, USA. He has dedicated his life to healthcare. Dr. Ganju graduated from AIIMS New Delhi and received advanced training in Internal Medicine and Gastroenterology both in India and USA. He is a consultant specializing in gastroenterology, liver disease and nutrition in hospitals in the greater Chicago area. His commitment to and understanding of how to drive improvements in health outcomes has benefitted big strata of society.

About the author

Mr. Amit Chopra, Managing Director India and, Middle-East, Thermo Fisher Scientific
Amit joined Thermo Fisher Scientific India in May 2007 as Managing Director for their Laboratory Products Group in India, and was named Managing Director & VP/GM for Thermo Fisher’s India operations in March 2011. Amit has taken on additional responsibility for the Middle East region w.e.f. 2017.

As of now, they have identified a staggering 233 unique chemical compounds from 82 types of chewing tobacco products sold in nine countries including US and Sweden. Of the 233 chemical compounds, 69 are known carcinogens as classified by the International Agency for Research on Cancer (IARC). Among the chemical compounds, major categories present in smokeless tobacco products include polycyclic aromatic hydrocarbons (PAHs), followed by radionucleotides, metals and metalloids as well as additives.The database is called SLTChemDB and is developed at the National Institute of Cancer Prevention and Research (NICPR) of the Indian Council of Medical Research (ICMR). This is supposed to be the first such comprehensive database of smokeless tobacco products globally, according to scientists.

“It will function as a reliable resource for stakeholders including policymakers, scientists, researchers and tobacco control advocates globally to better understand smokeless tobacco products and the industry manufacturing the products,” explained Dr. Ravi Mehrotra, Director of NICPR, while speaking to India Science Wire.

Over 350 million people consume smokeless tobacco globally and about 0.65 million die every year due to its consumption. “The chemical profiling of these products available in a user- friendly database will help in taking a timely policy action on the prevention and control of smokeless tobacco globally and also address diseases induced by their use,” he added.

The information for the database was sourced from already published scientific literature and was curated from different chemical web servers and databases.One can search for any tobacco product and retrieve information relating to its chemical composition, pH, moisture, nicotine free and tobacco content, besides biological, toxicological and physicochemical information of chemical compounds.

India Science Wire

Q1. When the Lal Path Labs started 68 years back, what was the scenario of Indian healthcare industry? How do you see the market now? And how has been the journey?

My late father Dr. Major S.K Lal started this lab in April 1949. He was a displaced person from the partition and came to India from Rawalpindi in 1947. After coming to Delhi he worked in a government lab for one-and-a-half years and then started the first pathology lab in North India. At that point of time there were hardly any pathology tests as we know neither there were any routine tests like, HP, TLC, ESR, Urine Test, Blood sugar Test, Cholesterol test. So there was not any competition then.

Q2. What is your future business plans both at National and International level?

We are running 1700 laboratories in India and about 1600 collection centers. In addition we take another 5000 collections of blood samples from our pick up points. For example Medanta, Fortis, Moolchand and Apollo are some of the pick-up points we have.

Last year we tested about 1.35crore patients, so the average of the samples we can test is about 55000 in a day. We are the biggest Histopathology Biopsy Centre in the world.

Histopathology Biopsy is a test basically to detect cancer. Suppose if a lady has a lump in her breast, so she feels something has to be done about the lump, a part of the lump is surgically taken out which is known as the biopsy, it is the biopsy we test and find out the results. There is a possibility of two things either the tumor is benign (Non-Cancerous) or malignant (Cancerous). If the lady has malignancy she under goes with further tests, chemotherapy and radioactive therapies as per clinical requirement. We are the largest Histopathology in the world. We test about 1000 biopsies in one day and we are the second largest kidney biopsy center in the world. We are the only laboratories in India which have their own electro-microscope for very high end testing. We have our centers in all the major cities of India.

Our next step would be to set up another comprehensive laboratory in Lucknow. We have such research center in Kolkata and next year we will make one in Lucknow. With this we will provide high end services for the people in the region for whom the services are not available.

Q3. With so many market players why people should opt for Dr. Lal? What additional value you bring to the table?

We have many reasons, first of all people know that we are not fly by night operators and also they have faith in us since last 70 years plus people come to us for their pathological tests because 70% of all the medical decisions are nbased upon the pathology test of a patient, hence if the pathological tests result aren’t in place 70% of the medical decision can’t be taken. Gone were the days when people used to visit the “vaids” and doctors and they felt the nerves and pulse gave medicines, now it is evidence based medication. If someone has fever the doctor would suggest the person to get a blood test because it could be malaria, chikungunya, dengue or it could be anything. And if the person is diagnosed with anything she or he will get the treatment for the same. Now the medicines are completely evidence based, there is no hit and trial. These are the reasons why people come to us.

Q4. With Dr. Lal Path labs entering into the international market with operations in countries like Middle East, Malaysia, Bangladesh, Nepal and many more, where do you see the potential for growth of your organization?

The first reason is, India is not having the kind of quality labs that it should have. There is a demand and supply problem. That is because there are no large laboratories. There are lots of facilities that claim to do testing, but they are not testing laboratories but testing shops. This is what is to be changed and people give the example of our establishment and say that “they should be like Dr. Lal’s laboratory.” All these countries you have mentioned, we are getting their samples for testing but only one lab is set up in Nepal and next would be in Bangladesh and then we will go to other countries. The reason we are slow on this is because our own country is huge. I usually say to people that if we will take out Uttar Pradesh and put it in the Indian Ocean, India would be the 5th largest country in the world. So this is the reason that we want to look at our country first and then look at the outside market.

Q5. What kind of environment does your organisation provide to patients?

Our organisation provides a very sterile kind of an environment, it doesn’t smell, and blood is not spilled around, there are no flies buzzing around the surroundings. This is a kind of a place where anyone would like to go to.

Q6. Now days there so many machines available in the market for test like sugar, BP etc, which we can be used by the patients themselves. How good is that? What are your views?

These are known as point of care testing and people can test a few things but in India people can only test blood sugar. For which we suggest the patient to check his or her blood sugar on a regular basis of 15 or 20 days, so these are called Point of Care Testing (POCT).

The POCT in India is not established because firstly, it is very expensive and secondly the Indian people aren’t savvy. There are seven types of care testing which is emanated by a lady. A lady can go to the bathroom and test her pregnancy by a UPT (urinal pregnancy test) in which she gets to know whether she is pregnant or not then in this case there is no need of a pathological test. When I was young we never had cats and dogs as pets but we had rabbits , so I never couldn’t understand why my father killed those rabbits and I got my answer when I was studying medicine. The reason why rabbits were killed during that time i.e, in early 1950s people used to check the pregnancy through it. A pregnant woman’s urine was injected into a female rabbit and after killing them they use to dissect the abdomen area to find ovulating ovaries. This is how pregnancy test were conducted.

Q7. Now a days Dr. Lal Path labs is focusing on inorganic growth; how beneficial it is to patients?

The growth in any sphere or in any business is either organic or inorganic, organic means when a person is creating his own set up, say if a person is doing well in Delhi so he decides to open a set up in Uttar Pradesh and then in Uttarakhand, and inorganic growth is when other person is ready to give up her or his lab to somebody else irrespective of any reason the former will give some certain amount of money to the latter in position of the lab this is called inorganic growth. We have done 10 inorganic growths till now and yes we will buy some more from south of India and west of India.

Q8. What innovations you think can bring down cost, keep quality and improve efficiency on which researchers and start-ups concentrate?

There is no start-up in my line, if one is a qualified pathologist either he can work in a pathology lab or can start his own lab. The start-up in Delhi is difficult because Delhi has become a saturated city. there are many people who are running many pathology labs and they shouldn’t run these pathology labs and the reason they are running the labs is because it is very lucrative, which is very unethical and should not be done.

So the government of India has also started the voice to our ways and they said that we are going to have a clinical establishment act which has been passed by the parliament in 2010. Since the healthcare is state subject so all the 29 states have not adopted it or implemented it. There are a chain of pathology labs which are not run by the pathologists they are run by the non-pathologists they are not even doctors they are quacks. So this brings out the quality and efficiency of the whole industry.

They are many diseases which affect the mankind these days and these diseases are called the non-communicable diseases. The non-communicable diseases can’t communicate with others, whereas malaria, chikungunya and dengue are communicable diseases because it happens through a mosquito bite. TB is a communicable disease too and if a person’s lungs are infected by TB people around them will get infected. In India we lose two patients of TB in every three minutes, India has a burden of communicable diseases which includes Hepatitis A.

But a bigger set of diseases have come out which are called NCDs (Non Communicable Diseases) and the NCDs are killing 65% of our people and if we will not control the NCDs it will also affect the two per cent of our GDP. The NCDs are headed by the high blood pressure, obesity, smoking, cardiac diseases, lung diseases, cancer, kidney diseases and stroke. Why it is becoming so important to us because it is also called the life style diseases, it changes the lifestyle of the person which has suddenly come up. India has large number of cancer patients and also large number of blood pressure patients. There is an element of genetic transfer of physical appearance of a person but some diseases are also transferred which only run in families.

The problem with Indian people is they only come in illness, but they should know that they should get their self-check on a regular basis to keep a check on their health, my main point is to make people aware of the annual healthcare which is very important for one’s health which is in between the doctor and a patient and also make them aware of the testing in wellness not in illness.

The Ministry of Health and Prevention (MOHAP) has announced the launch of a new set of innovative health services featuring futuristic technology solutions – particularly artificial intelligence (AI) during its participation at Arab Health 2017.

His Excellency Al Ketbi, has announced the launch of the Smart Mirror which is the first of its kind globally to allows patients to analyze their body’s temperature, pulse, weight, height, and their body mass index. It also features a weather forecast component that can be utilized by looking through the mirror.

The Smart Mirror is an active tool for patients suffering from diabetes, cardiovascular diseases, as well as blood pressure problems, as it monitors their weight, height, blood pressure and body temperature. The Chatbot service is driven by basic artificial intelligence software and facilitates ‘smart’ online chats that help reduce healthcare cost as well as improve the flow of health services.

The interactive AI facility can assist the Ministry by mimicking human conversations to answer questions which can also be integrated with other software platforms to allow other communication activities such as sending messages and holding telemedicine conferences via Skype with a physician.

Another smart technology, ‘Kiomatik’, will welcome patients and guests and perform other reception duties via an innovative system, motion tracking, a high-definition camera, and three-dimensional display devices embedded in a robot.

It will also provide necessary information about the health facilities, set appointments, and answer basic questions from patients.

The Kiomatik Beacon technology also operates as a wireless device with face-recognition capability. The patient is immediately recognized upon arrival at the health facility and informed about his or her schedule which will appear at the reception platform without the assistance of any hospital employee.

Kiomatik reduces the need for computers and other announcement systems as medical staff can use the apps installed on smart watches and smartphones to communicate with patients and inform them whenever they need to visit a health facility for examination.

An advanced self-registration service ‘Kiosk’ can recognize patients’ faces using a 17-inch screen that registers them upon arrival at the hospital or medical center. This pioneering technology is still currently under research and development.

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