Context:
India’s rural healthcare is tiered, with patients being referred upward to more advanced medical institutions depending on the severity of their ailment. This system ends up being fragmented, and hence has problems related to motivation, inefficiency and tracking that result in patients not getting the care they need.
The process:
This project was done as part of my final year thesis in design college, and was one of the award winners in the 2016-20 batch.
The research phase of the project was intensive, including multiple field visits to health centres in rural Maharashtra
Defining a scope, brainstorming, card sorting and creating a visual design took place after research.
The background
Besides doctors, India's rural healthcare system has several other workers, all with different levels of qualification and training.
Accredited Social Health workers (ASHAs) visit homes to increase awareness and provide basic medication, while Auxillary Nurse Midwives (ANMs) manage immunisations, prenatal and antenatal programs at primary health centers, and Anganwadi workers (AWWs) work in schools, focussing on childrens health.
The rural healthcare system is tiered, as shown here. Each village has ASHAs and AWWs, every Sub Centre (SC) has an ANM, and each Public Health Centre (PHC) has a doctor. ASHAs and SCs refer patients to their PHC, and PHCs further refer upwards.
A large part of primary research took place thorugh field visits to PHCs, to observe different stakeholders actions and conduct informal interviews with the different healthcare workers.
Here is how a typical PHC in Maharashtra looks like, serving around ~1,00,000 people from 16 villages. It has IPD facilities, and performs deliveries, treatment, medication and screening.
Main problem areas
Key themes that emerged from primary and secondary research
Inter-entity communication
Currently, ASHAs, sub centres and PHCs share information about a patient through a referral chit sent with the patient outlining the prognosis. The ASHA has to manually follow up with each patient / relevant PHC to find out about referral completion, outcome etc
Floating population
These issues rise seriously when it comes to the floating population (labourers, temporary workers etc), as their frequent travelling makes it difficult for their ASHA workers to keep tabs on them if they leave the village, they lose referral chits while moving etc.
Planning and forecasting
PHCs often have no way to plan for patient inflow on a particular day, especially in surge situations. Doctors also may not always have context on a patient's prior care journey, often leading to repeated procedures that waste effort and resources.
Patient motivation
Women tend to seek care only in the second trimester mainly to confirm pregnancy, and need constant reminding for follow ups, ANC etc. The main drop offs rise when referred to higher centres.
Potential interventions
FOR PATIENTS
FOR health workers
two way form filling
Additions in
ASHA, ICDS software
Revamp referral chit
Online repository of records
Inter hospital communicat ion system
misc
wearable vitals monitoring
Tracking devices
Initial concept exploration
Learnings
The lack of motivation stems from percieved inaccessibility, concern about finances, opposition from family and inability to take time off work. In this case a more personal touch in the form of an ASHA worker who works better to explain to and convince the women and their families, assuage their fears and suggest more flexible options is a better alternative.
Hence, a solution that supports and bridges gaps in the current system would be more effective, rather than one that works isolated from the current system.
Who are we designing for?
Doctor at PHC
Arrives early at the PHC to prepare. Brief appointments with people from nearby villages, provides referrals. Also visits nearby anganwadis, immunization camps, and attends policy meetings.
pain points
Lack of context on why a patient is at the center at times.
No coordination with the hospitals patients are referred to.
Rushing appointments
Nurse at PHC
Opens the PHC along with other MOs. Checks referral chits, guides patients on where to go for testing, medicine collection, next steps in treatment. Crowd control and management.
pain points
Crowd, disorder, no space in centres.
Patients losing their referral chits.
lack of context unless local ASHA worker has briefed them in advance.
ASHA worker
Visits existing patients homes, meets people new to the village, gives basic fever medication. Meetings with supervisor to monitor work progress and nurses at local PHC to discuss patients.
pain points
Bulky files and notebooks are the only means of tracking.
Manual follow ups needed for referrals
Long and uncertain travel times
The care journey can roughly be divided into three sections from the perspective of an ASHA worker - pre-referral, during the referral and post referral. During the referral, the stakeholders involved increase to cover the PHC staff. This journey was mapped out to determine the different points at which Kramati would assist.
