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.

In most other countries, the constitution requires the government to provide some form of healthcare. The implementation, however, suffers from deficit of policy, government or resources even in the countries that consider healthcare as a part of social justice. The Author talks about how India can lead with innovations in legislation, policy, governance and finance to provide health for all.

Adequate healthcare is both, a prerequisite and a consequence, of the growth of a country. A health system can deliver public health and medical services, if its solid foundation includes skilled workforce, information systems, medical products, technology, adequate financing and governance. While technology can provide innovative tools to improve health, it is the regulatory framework whichcan provide the enabling ecosystem. It is important that Innovations not be limited to drugs and devices but also include regulations.Ultimately,it is laws that determine financing and structure of healthcare.

The nations of the world have included healthcare in their legal framework in some form.Almost all countries are signatories to one or more international human rights or health rights declarations.

One third of the countries include healthcare as a constitutional right for individual citizens. Russiaand former countries of the Soviet bloc Italy, Spain, Brazil, Philippines and South Africa have maintained health as human right in their constitution. On the other end of the spectrum are countries like the USA, which have no individual constitutional right to healthcare.

In most other countries, the constitution requires the government to provide some form of healthcare. The implementation,however, suffers from deficit of policy, governance or resources even in the countries that consider healthcare as a part of social justice.

India extrapolates health rights from other parts of the constitution.The right to health in India is outlined the Directive Principles of State Policy- Articles 42 and 47 and the fundamental right to life as stated in article 21.

Article 42 states that the State shall make provision for securing just and humane conditions of work and for maternity relief.

Article 47 states that the State shall regard the raising of level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties and, in particular, the State shall endeavor to bring about prohibition of the consumption, except for medicinal purposes, of intoxicating drinks and of drugs which are injurious to health.

Article 21,“The Fundamental Right to Life” guaranties individual life.

The Indian judiciary has interpreted the “Right to Life’ in many ways. It has held that humane working conditions, health services and medical care are an essential part of Article 21. Public interest litigation, as well as litigation arising out of claims made by individuals,has generated substantial case law showingright to health is an integral part of the Right to Life.

For technological innovations to flourish in its current stage of development, India needs more proactive regulations to progress towards universal healthcare.

Currently the Indian government spends about 1 percent of GDP on healthcare. Compare that to 3 percent in China and 8.3 percent in the USA. Private expenditure on healthcare is in addition to public expenditure; approximately 70% of health expenditure in India is from private sources.

A study done by PGI Chandigarh, suggests that universal health care services for entire 1.2 billion population, the annual cost of providing preventive and curative services will be INR 2415 billion (USD 54 billion). This would amount to increasing the allocation to health sector from current nearly 1% to 3.8% of GDP.

Indian business association, FICCI and consultants EY, estimated in 2012 that universal health cover would require government health spending to increase to 3.7-4.5 percent of GDP.

The current government, under the National Health Assurance Mission, would provide all citizens free drugs and diagnostic treatment and insurance cover to treat serious ailments. It would cost an estimated $11.4 billion annually.

In 2010, a High Level Expert Group on Universal Health Coverage recommended increasing public financing from 1% of the gross domestic product to at least 2.5% to provide essential health care package through tax funding and employer-provided insurance.

The Lancet published an India focused issue on health in Jan 2011. The lead authors (K SrinathReddy, Vikram Patel, Prabhat Jha, Vinod K Paul, A K Shiva Kumar, Lalit Dandona),summarized the recommendations of various working groups as ‘call to action’ as follows. They propose the following targets to be achieved by 2020 through the creation of the Integrated National Health System with three overarching goals: ensure the reach and quality of health services to all in India; reduce the financial burden of health care on individuals; and empower people to take care of their health and hold the health-care system accountable.

Service delivery

• The entire population should be covered by an entitlement package of health care with

financing from a combination of public, employer, and private sources. Full range of relevant diseases need to be included in the entitlement package of health services with cost-effective interventions that include health promotion and disease prevention.

• All health practitioners and facilities in the public and private sectors have to be registered with the Integrated National Health System.

Health Financing

• Public spending on health should be increased from 1% to 6% of the gross domestic product, and 15% of tax revenues—including new taxes on tobacco products, alcohol, and food with little nutritional value—should be earmarked for this purpose.

• Reduce the proportion of out-of-pocket spending from 80% to 20% of the total health expenditure.

• Increase spending on health research to 8% of the health budget.

Human resources for health

• Establish the Indian Health Service with guidelines developed through an autonomous National Council for Human Resources in Health.

• An updated training curriculum should be fully in place for medical and allied professions that is relevant to the situation in India.

• Establish suitable incentive structures to retain health providers in underserved areas.

Health information system

• Have in place comprehensive health information and surveillance system that covers all major diseases, health-system issues, and key social determinants, which also facilitates assessment of public health interventions.

• Establish adequate research capacity in India to investigate and report key issues that affect the health system and policy for further improvements.

• Have in place a fully functional autonomous council that compiles and synthesizes relevant information to develop guidelines for evidence-based health care and its assessment.

Drugs and technology

• Implement a national network of pharmacies for generic low-cost drugs for the entire population.

• Establish mechanisms for bulk purchase of patented drugs at low cost.

• Have in place mechanisms to check and control the use of perverse incentives by pharmaceutical and biotechnology companies for health-care providers.

Governance

• Have in place mechanisms to make functional the components of the National Health Bill.

• Have a system in place that requires all middle and senior functionaries in public health to have relevant training in public health.

• Ensure devolution of responsibility for health care to district management systems along with accountability mechanisms and explicit community participation (The Lancet, Jan 2011).

India, at current stage of development needs more healthcare in every form and not less. Multiple studies have confirmed the fiscal feasibility and for technological innovations to flourish we needs a progressive enabling ecosystem.

Opposition to right to health emphasizes that it could increase the fiscal deficit;it could create shortage and increase the wait time for medical services, which would lead to rationing and lower the quality. It could also cause people to overuse health care resources. While appreciating valid opposing view, human development is not possible without guaranteed healthcare. Financial burden of a single episode of disease pushes millions of Indians into poverty, which stifles the market for technological progress.

Health and longevity have improved as never before in human history. And with explosive growth in the knowledge of human biology and genetics, it is likely that the life span will increase exponentially. It may even change the very definition of health to include happiness, intelligence and aesthetics as components of a new paradigm. It is imperative that innovations in legislation, policy, governance and finance will have to stay ahead of the burgeoning technologic innovations and not fall behind to irrelevance. It is important to have innovative strategic thinkers in the leadership positions that understand biology, healthcare, governance and finance.

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