ZEENA JOHAR

India,

Zeena Johar is reinventing the rural primary care system from being government-run and heavily subsidized to being viable and economically sustainable. By recognizing and addressing the core challenges of the rural primary care system in India as talent, infrastructure, and finance, Zeena is changing the system.

This profile below was prepared when Zeena Johar was elected to the Ashoka Fellowship in 2013.

INTRODUCTION

Zeena Johar is reinventing the rural primary care system from being government-run and heavily subsidized to being viable and economically sustainable. By recognizing and addressing the core challenges of the rural primary care system in India as talent, infrastructure, and finance, Zeena is changing the system.




THE NEW IDEA

Zeena believes that primary care in India requires a sustainable solution to ensure that trained medical practitioners are available in the most remote areas. To provide proper care, rural doctors require readily accessible information and technology infrastructure. To tie all of these elements together, Zeena has created a rural health enterprise that acts as a gate keeper by proactively identifying and addressing a wide scope of health issues in the closest proximity to patients and at the lowest cost. 

To address the absence of doctors in rural areas, Zeena is tapping into a large pool of trained traditional medicine practitioners that are already available in rural areas. To be able to recruit them as physicians, Zeena developed a new concept in the country that qualifies them for allopathic practice. To ensure consistent positive health outcomes, the work of the doctor is governed by specific treatment protocols. To provide quality services and to enable remote monitoring at every stage, from registering patients to follow-ups, the entire process is bound together through a technological platform. The clinic also conducts population level screenings for the early identification of diseases and provides on-going medical support for pregnant women, and people with chronic conditions, among other groups. 

By implementing all of these solutions, Zeena is setting a new standard for comprehensive primary care in rural areas. Presently, the government is the single largest provider of primary care, but farsighted private players are beginning to see this critical market as an opportunity. In this context, the solutions developed by Zeena become tools that show others the how to’s of providing quality primary care. Zeena is in the process of building several partnerships to implement her strategies through citizen organizations (COs), companies, and the government. 




THE PROBLEM

India, like many developing countries, can be characterized by a shortage of resources for healthcare and a high burden of infectious diseases. More recently, the rates of chronic non-communicable diseases have also started to grow in urban and rural areas. However, access to healthcare services is severely skewed toward urban areas. With 70 percent of the population residing in rural areas and 70 percent of medical infrastructure only available in urban locations, about 700 million people are left without access to primary care. The public health system relies on 1 percent of India’s GDP, or $10 per capita, a minuscule amount, which results in an underperforming healthcare system and the worsening of population level health indicators. 

There is an overall average shortage of 600,000 doctors in India. As a result, close to 40 percent of the government Primary Health Centres do not have doctors. Unfortunately, most doctors do not choose to work in remote rural areas due to an increased number of challenges they face, one being low pay. It is not an aspirational choice for young medical professionals to become rural doctors and operate in isolation with no professional support and a lack of transparency. From a macro-perspective, such isolation of rural doctors leads to poor public health planning and implementation. 

The lack of doctors is an issue faced by many countries. Some countries have made steps toward upgrading existing trained talent to the level of primary care providers to fill that gap. For example, in the US, a person with a life-sciences degree can become a nurse after just one year of additional training. It then takes another 11 months of training to become a qualified nurse practitioner allowed to independently practice medicine. Unfortunately, there is no similar system in India to fill the demand. There are 750,000 medical practitioners of the traditional medical systems of Siddha, Unani, Ayurveda, and Homeopathy (AYUSH). These medical practitioners receive five and a half years of medical training, and about 70 percent are legally permitted to offer allopathic services. As the degree in AYUSH is more accessible and affordable than an MBBS degree, many people from smaller towns and rural areas opt for this degree. While most are based in rural areas (unlike their MBBS counterparts), there are few professional options for them and little effort has been made to streamline AYUSH practitioners into the primary care level, which could fill the gap of doctors practicing in these areas. 

Despite multiple interventions by the state, ranging from community health workers to state funded tertiary care insurance schemes, citizens are left spending close to $40 per capita out-of-pocket. Much of this money is spent at the local level. However, due to a complete absence of modern healthcare facilities at the primary level, large parts of it are handed over to quacks. As many as 800 out of 1,000 people receive primary care from medical imposters. 

Another important factor to consider in high healthcare costs is the lack of initiative taken by the general population to seek preventative healthcare. There is a tendency among even the highly educated to postpone care until they are seriously ill. With limited economic resources available to a rural household, the priorities are always on immediate needs, such as food, education, and marriage, unless they are struck by a sudden and necessary health expenditure. This results in an unnecessary financial burden on the patient and a high service cost for the providers at the secondary care level. Therefore, developing a rational model for primary care requires both improvements in the access of healthcare as well as mobilizing citizens to be proactive about seeking preventative care. 




THE STRATEGY

To create a sustainable primary care model, Zeena started SughaVazhvu Healthcare, which promotes local primary care clinics. These clinics are staffed with physicians and are equipped to provide a wide scope of primary care at the local level. They deliver the broadest possible range of services, including dental fillings, cervical cancer screenings, vision screening and dispensation of glasses, and management of chronic diseases. Zeena also founded the IKP Centre for Technologies in Public Health (ICTPH) to consolidate knowledge and spread the ideas developed at SughaVazhvu nationally and globally. 

To fill the gap of medical talent in rural areas, Zeena found a way to streamline AYUSH practitioners who are legally permitted to practice allopathy. To evaluate their competence in providing allopathic care, she compared the curricula of the AYUSH practitioners and MBBS doctors. In all four disciplines (Siddha, Unani, Ayurveda and Homeopathy), the first three years of training are structured around concepts of biochemistry, anatomy, physiology, pharmacology, pathology, and microbiology. The rest of the courses are devoted to hygiene and community medicine, forensic medicines and toxicology, general medicine, special medicine, surgery, obstetrics, and pediatric medicine. With enough similarities to make it possible to equip AYUSH practitioners for allopathic practice through a bridge course with more pharmacological training, relating to the behavior and compatibility of modern drugs. In addition, training in areas such as mental health, geriatrics, ophthalmology, dentistry, maternal care, cervical screening, and emergency care was also required. 

In collaboration with the University of Pennsylvania School of Nursing, Zeena developed a course that provides AYUSH practitioners with a joint certificate from UPenn and ICTPH to practice allopathic medicine. So far, this course has only been used to prepare doctors in SughaVazhvu clinics, however, ICTPH is now launching it as an open course. Zeena expects to demonstrate the success of this approach, which could lead different states to start encouraging AYUSH practitioners to requalify. 

To ensure a standardized quality of care in rural clinics, Zeena developed a technological platform driven by the evidence based on treatment protocols. Thus, individual patient management follows a defined pathway through screening, disease diagnosis, treatment regiments and medication dosages, and follow-up schedule. A cloud-based system allows a real-time remote audit of all patient cases. 

To encourage people to access care at the early stages of illness, the clinic conducts rapid risk assessments at the community level. A health extension worker (equipped with a smartphone), assesses all households in the catchment area using basic parameters such as body mass index, waist-hip ratio, blood pressure, and family history to map disease prevalence. It provides a public health profile of the community and allows for the early identification of at-risk patients to take preventive measures. For example, individuals with indicators for cardiovascular conditions are counseled to seek care and are given additional discounts for confirmatory tests. A comprehensive care management protocol, inclusive of medications, is then prescribed. Similarly, young mothers and pregnant women are identified and counseled for iron supplementation. All married women within the ages of 30 to 50 years are recommended to undergo cervical screenings; a simple test conducted in minutes yields results. Through this exam, other reproductive tract infections can be diagnosed and managed locally with antibiotics.

Zeena chose several districts in the state of Tamil Nadu to start her operations. SughaVazhvu is currently operating seven clinics serving a population of 70,000 people. To date, they have serviced 16,000+ patients. Since 2011, most of the clinics have adopted a fee-based structure. Zeena sees a lot of room for creating a sustainable financial model around primary care. In some clinics they are trying an insurance-based full coverage model, in others, patients’ pay for individual services. While more reiteration is required to make the cost work for patients and the clinics, Zeena is raising investment to increase the number of clinics to 25. 

More importantly, the processes and tools developed at SughaVazhvu tied together in the technology platform have the potential to act as a blueprint for primary care. SughaVazhvu demonstrates how to provide consistent care to patients in scattered and remote locations. Zeena is in conversations with various partners to explore ways to replicate this model. For example, secondary care providers may choose to adopt the model to extend their care to the primary level. Zeena believes this could ensure a captive market and serve as a gateway for the patients who do not require hospital care. It can also be replicated as an independent social enterprise and taken up by the government to run the PHCs. One of the board members of SughaVazhvu was elected as a member of the High Level Expert Group for the Planning Commission of India; created to come up with strategies to address the Indian healthcare crisis in order to create more avenues for this idea to spread. As a result, a lot of the ideas developed at SughaVazhvu are influencing planning at the national level. Zeena believes such a system could make primary care in India more reliable and transparent while delivering quality healthcare to India’s most remote populations. 




THE PERSON

Zeena grew up in a traditional and modest family. Her parents expected her to perform exceptionally well in her studies, and she recollects spending most of her time studying. Zeena was gifted in the sciences and pursued a degree in chemistry. After completing her bachelor and master degrees, Zeena was keen to pursue an academic career. She received a full scholarship to do a PhD in biochemistry in Switzerland. 

Zeena’s family didn’t support her leaving home, and she had to stand up for her decision. Living in Switzerland was a difficult adjustment. After a time of loneliness and despair, she decided she had to make it work. Zeena started to play an active role in the Indian Student Organization and made it a platform for cultural exchange and learning. She organized events, talks, cooking shows, and film screenings. It was a noteworthy time for her, meeting people from all over the world and creating opportunities for them to learn more about India. 

Completing her PhD at 27, Zeena returned to India. She realized that the academic path was not actually fulfilling to her. She recalls her PhD journey as “stroking a fire” within her to seek avenues to make her research methodology a medium to catalyze a real change in people’s lives and translate basic science research into actionable business plans. At this time, Zeena was offered a position at IKP Knowledge Park, founded by the ICICI Bank Foundation. Its mandate was to promote business driven research and development. They wanted to expand their operations in the field of health and Zeena led the effort. It was a completely blank canvas and an open mandate, and Zeena had to start by defining the problem. Though challenging, she felt it was a meaningful cause.

Zeena’s big supporter from these initial stages was Nachiket Mor, the former head of ICICI Bank and one of the promoters of IKP. Zeena spent a year travelling around India meeting people and looking at different initiatives, discussing her ideas with Nachiket, and trying to pin down the problem. Through this process, Zeena came to understand that in India, the biggest unaddressed issue in healthcare was primary care. Although it has been the responsibility of the government to provide it, she felt that there had not been any significant effort from the private sector and COs to change this. Zeena realized that the low quality of service and the high expenses at the primary care level were disrupting the healthcare chain. She went on to define the critical elements that had to be delivered at the primary level: an available qualified doctor, essential drugs, laboratory services, early detection, and disease management. Zeena then created the strategy of a healthcare enterprise that could deliver on all these parameters. 

Zeena chose areas where there was no primary care delivery, so that their work would not overlap with the work of the government primary care centres. She also realized that she had to watch the process on a daily basis to constantly reiterate, change, and make this idea accepted by the communities. In 2008, Zeena moved to a small town in rural Tamil Nadu and started SughaVazhvu Healthcare to put her dream to work.