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.

Conductive gels and patch sensors resembling fashion accessories are also being developed to record cardiac, brain and muscle activity which could complement the traditional blood analysis and clinical examinations. Mechano-acoustic skin sensors that measure speech patterns and internal body sounds, like swallowing, are being explored to quantitatively measure the impact of rehabilitation in patients, such as those recovering from a stroke.

In treatment, miniscule implants placed inside the body can cross the blood-brain barrier and deliver the drug directly at the target site, even in hard-to-reach internal organs. Such devices have shown promising results in laboratory settings in reducing side effects and toxicity while increasing overall drug efficacy. This could also ensure patient compliance, a step further to the recently approved digital pill, especially in patients on long care and those with compromised cognition.

Certain implants can also electrically stimulate cardiac or brain tissues to treat conditions like irregular heartbeat, certain motor disorders, and cognitive impairments. Other implants like artificial retina and cochlear implants, restore functionalities of damaged tissues. These interventions, being referred to as ‘Bioceuticals’, could restructure conventional therapeutic options for more efficient outcomes.

In India, a lot of work has now started in this sphere. Results from a few studies have started trickling in, with most of them in development or early stages of testing. Research findings in the journal Scientific Reports by researchers from IIT Kharagpur earlier this year reported bio impedimetric analysis of cancer cells that efficiently distinguishes their aggressiveness by measuring electric field impedance in laboratory conditions. In another study published in the journal Sensors earlier this year, researchers at IIT Delhi developed a novel low-cost prosthesis based on sensors to enable normal gait kinematics, i.e. motion analysis, for lower limb amputees.

IIT Kharagpur is setting up a Bioelectronics Innovation Laboratory that aims to develop battery-free implantable miniaturized engineering systems for treatment of brain, nerve, muscle or spinal cord disorders by restoring missing neural functions. The proposed coin-sized implant will be powered wirelessly and will combine brain activity testing like electrical simulation, bio-potential recording and neuro-chemical sensing for use in rehabilitation and prosthesis.

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Round-the-clock data collected from bioelectronic devices could replace the present time-point investigations and lead to better management of the health condition of patients. In addition, data from multiple people can help develop artificial intelligence algorithms and predictive tools. Such tools have already started showing analytic performance similar, and sometimes better than manual inspection by a specialist physician. In countries like India, that suffer from a shortage of qualified doctors in remote areas, such devices have immense potential. However, data standardization, data security, and privacy protection must be addressed and regulated before rolling out such interventions.

In the next few years, health monitoring, neural prosthetics, and biochemical prosthetics are expected to drive major developments in this space. Although the monitoring devices have already started testing the market in niche patient segments, it may take the implants another 5-10 years to reach health centers as they make their way through developmental and regulatory checkpoints.

SYMHEALTH, an annual mega event with an academically rich legacy attracts over 1200 delegates from all verticals of healthcare such as doctors, medico-legal experts, insurance & IT professionals, NGOs, hospital administrators & clinical research professionals from all over India and abroad.

SYMHEALTH 2019 is a two days’ event organized by the Faculty of Health and Biological Sciences (FoHBS), Symbiosis International (Deemed University), SIU which is being hosted at the university campus, Lavale, Pune on 19th & 20th April 2019. It is an event that marks the significance of integrating ideas and information from across many disciplines. This is in consonance with our mission of contributing towards knowledge generation & dissemination. The conference provides a platform through which various stakeholder groups can discuss and proffer practical and workable solutions to the challenges of healthcare.

The Conference will provide an opportunity for stakeholders beyond academia and industry, to exchange insights, present emerging opportunities, make networking connections, and to share resources. The two thought-provoking days of the conference results in deciphering knowledge both in the sessions and during the many planned opportunities to build rapport and alliances, share advice, stories, case reports and socialize throughout the conference.

The highlight of this year’s conference is the incorporation of ‘Connexions’ – a unique event on the first day of the conference. Connexions presents an opportunity for students to attend grooming and skills transfer sessions which prepares them to face interviews. A placement assistance drive is conducted after Connexions which facilitates interested enrolled candidates to interact and get interviewed with prospective recruiters and employers in the healthcare sector.

Dr. Balram Bhargava, Secretary, Department of Health Research, (Ministry of Health & Family Welfare) has kindly consented to be the Guest of Honor on 19th April 2019.

Dr. Sanjay Zodpey, Vice President Academics, Public Health Foundation of India, New Delhi will enlighten upon the Public Health Agenda for India wherein the Indian government has adopted the National Health Policy to “attain the highest possible level of health and well-being for all at all ages through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face financial hardship as a consequence”.

A panel discussion will be conducted on the perspective of varied stakeholders like Insurance companies, Hospitals & Govt. of Maharashtra on “Ayushyaman Bharat”.

The chairperson for this panel discussion will be Mr. Dinesh Arora, Dy. CEO National Health Agency, (NHA), representative of Insurance companies will be Mr. Bhaskar Nerurkar, Head, Health Bajaj Allianz ltd, Pune, representative of hospital will be Dr. Ashutosh Raghuvanshi, Vice Chairman, Managing Director & Group CEO, Narayana Health & spokesperson from Govt. of Maharashtra will be Mr. Jayant Kumar Banthia, Former Chief Secretary, Govt. of Maharashtra.

Dr. Simmardeep Singh Gill, Group COO CK Birla Group, Kolkata will shed the light upon the importance of leadership skills for healthcare professionals. He will explain how individual development, including communication skills, coaching, mentoring, negotiation, and motivation theory, works within a leadership role.

Mr. Sanjay Singh Nirwan, Healthcare Communication & Digital Strategist, Media Medic Communications, Mumbai will speak on the Digital Healthcare Advocacy. Digital technology has greatly contributed to improvements in patient care and monitoring, as well as patient communication with primary caregivers, general practitioners, and specialists. The digital world has revolutionized the accessibility of health information for people across the globe. Patients no longer must wait for doctors’ appointments to begin their diagnosis process.

Some of the other eminent national speakers include – Mr. Abhishek Agarwal, MD Strategy, MERCK, Mumbai. Mr. Badri Iyenger, MD, South Asia, Smith & Nephew HC Pvt Ltd. Mr. Vidhi Prasad K V, Head, Image Guided System, Wipro GE South Asia. Dr. Anirudha Malpani, Director & Founder, Malpani Ventures, Mumbai. Dr. Raman Gangakhedkar, Scientist G & Director-in-Charge, National AIDS Research Institute, Pune. Mr. Lalit Mistry, Director of Healthcare, KPMG. Mr. Kumar Krishnaswamy, Group Head- HR, Medwell Ventures. Dr. Col. Ajay Gangoli, Group Medical Director, Apollo Health & Lifestyle Ltd. Mr. HSD Srinivas, Head Health Portfolio Tata Trust, Mumbai. Prof. (Dr). Sudhir Kumar Satpathy, Director, School of Public Health, Kalinga Institute of Industrial Technology Deemed to be University, Bhubaneshwar. Ms. Nishi Saini, Head- North, Clove Dental Clinics, New Delhi. Dr. Avinash Phadke, President, Technical & Mentor, SRL, Diagnostics, Mumbai. Dr. Clive Fernandes, Group Clinical Director, Wockhardt Group of Hospitals, Mumbai. Dr. Sanjay Gupte, Medico-Legal Expert, Pune. The valedictory ceremony will be held on April 20, 2019. Dr. Deelip Mhaisekar, Vice-chancellor, Maharashtra University of Health Sciences will grace the occasion as Guest of Honor. The session will be presided by Dr. S. B. Mujumdar, Chancellor, Symbiosis International (Deemed University).

SYMHEALTH 2019 will continue to bet on increasing the presence of organizations, exhibitors and visitors from around the nation to keep on generating synergies, sharing knowledge, provoking discussion, reflection and inspiring new actions. It will encourage all the stakeholders to expand their knowledge horizon as well as to forge collaborative networks across disciplines and professions. The attendees will benefit enormously from the event.

We hope that you will join us in, what promises to be, a ‘must attend’ event!
For Registration and further queries please contact: (+91) 88888-92258
Email: symhealthregistration@siu.edu.in,
For more details visit: www.symhealth.edu.in

Dr. Rajiv Yeravdekar
Dean, Faculty of Health & Biomedical Sciences, SIU

Read Press Release: SYMHEALTH 2019

The first session was about the ‘Challenges in the implementation of DISHA’. The panelists were happy that InnovatioCuris has taken an initiative to critically discuss the challenges a hospital will face once the act becomes the law. All the panelists agreed that the act lacks various aspects. Few concerns that bother the clinicians are, that who will give the consent if the patient is unconscious.

The ambulances have the capability that it sends the health records from the ambulance to hospital before the patient reaches the hospital for doctors to study the emergency cases. In this scenario, what should be done if a patient denies the consent for sharing the data at a later stage? Should the clinical establishments discard the already shared health record or should they handover the same to the owner (in this case, patient) or what should be done. There are no set protocols defined in the act for such cases.

A question was put forward, does the patient has the authority to edit their health record, or can they view, who have seen their health record. A healthy discussion took place where we got to know that citizens of Estonia have chip cards, where one can see their health record and can also see the logs of who has accessed their health record. This made us realize, that India as a nation state can use Aadhar card as a mechanism, where we can log in into a portal and get to see health records.

The third challenge that came forward was interoperability of health records. As the record lies with the custodian, not the patient, editing and viewing of it can be done by the clinical establishments. The health record can be shared by the clinical establishments to another, but there is no standard on how to transfer it. Data integrity is a point of concern, which is not mentioned in the act.

One of the challenges that came into light was according to ‘Clinical Establishment Act Standards for Hospital[2]’ the hospital has to keep health information and statistics in respect of national programmes, notifiable diseases, and emergencies/disasters/epidemics and furnish the same to the district authorities in the prescribed formats and frequency. The question is what if the patient does not give consent. The proposed act should have a provision where the clinical establishments are liable to take the health data.

As we have unstructured healthcare facilities in India, the act should also empower the clinical establishments by various means to keep the data safe. As of now the DISHA is a proposed act, not a law and has lots of loopholes. It also lacks in many aspects discussed earlier. This is just a start and the government should take necessary steps to improve it.

The second panel discussed on ‘Opportunities for making health sector DISHA and data protection ready’. The panelist consisted of CIO of path labs, owners of healthcare IT firms, who shared relevant thoughts and comments. The panel started the discussion on why do we need the act and what are the benefits of the act. Panelist were grateful to the government to bring the act. They told that the clinical establishments will take steps to increase the safety of the health record.

The gaps in the technology for generation, storage and transmission will be lowered down. Sectors such as banking, financing and insurance have structured their data, but this lacks in healthcare. Detailed scope of security features are missing from the act, this would help the companies to design the software from the ground up by using security as an important consideration.

The imminent threat is in the software which are already in place and have not been patched or the system has not been upgraded. The good news is that many have an audit trail in built in their system, which track any CRUD(creation, read, update, delete) of the records. The discussion contributed a fruitful thought: Data at rest is not encrypted. The question that arises is what is preventing the healthcare IT companies to encrypt the data at rest.

One of the challenge in the DISHA is that, the owner of the data must be informed of any breach of the privacy or confidentiality of their digital health record within three days. But according to IBM report it takes on an average of 197 days to detect a breach[1]. How can the Healthcare IT companies safeguard the health record and let the owner know about the breach. The solution is to encrypt the tables in the database, but that might hamper the performance.

It is a huge opportunity for the stakeholder to bring standards in the act. DISHA might have only completed its first round of comments from the public and stakeholders, it can be expected that the revisions made based on the feedback will churn out a more refined version of the act. In any case, it is evident from the draft that the government has really pushed to provide additional security, privacy and confidentiality for individuals, with respect to their digital health record.