Jaroka Project -- A bridge

Web based healthcare solutions are usually termed as Telehealth care projects, where as mobile based application software solutions fall under the label of "mobile-telehealth care"

Jaroka Telehealth care Project -- contrary to its name is not only a we based solution but infact it is a bridge between the telehealth care and mobile telehealth care.

Today numerous software solutions exist in Pakistan , but either they require dedicated special equipment / hardware, or they are web based or solely mobile based (very rare). But Jaroka telemedicine employs both technologies, it combines the benefits of large screen, easy data entry through computers with easily available , ubiquitous growth of mobile phones and already deployed networks of cellular services.

Long term potential benefits of Jaroka Tele-healthcare Project

Jaroka Telehealth care project can impart following long term potential - benefits to Pakistan.

[1] It ensures the Millenium Development Goals are met at a lower cost.

[2] It will make local network of Lady Health Workers [LHW] and Basic Health care units [BHU] effective and efficient.

[3] It provides a system that can be replicated , as infrastructure exists , we just need to make it effective.

[4] It will impart skill to the local public, especially women which can contribute to women empowerment.

[5] It will change the trend of the doctors of preferring the urban hospitals, by providing attractive job opportunities in rural areas.

[6] It will change the trend of people of rural areas of working in big cities and towns, by providing attractive job opportunities in home town/village.

[7] It will result in availability of better health care services and patient - crowd reduction in government hospitals.

Psychological Benefits of Using a Network of LHWs

Apart from other benefits Jaroka Telehealth care Project also imparts psychological benefits and mental relief to its patients.

As Jaroka Project provides medical aid at door step in the form of Lady Health Workers which gives the patient flexibility of receiving healthcare at home . It is a source of mental relief for the patient which results into rapid recovery due to enhanced social support from family members, friends, relatives and colleagues.

It provides a more frequent and consistent contact between patients of remote areas and healthcare providers which results in increased patient satisfaction and early diagnoses and prevention from diseases.

Patient care at home has several advantages such as proper care, cleanliness and attention from family members, which is difficult to get in government hospitals, which are flooded with patients and hence degraded in service.

Care at home also builds up an increased will in the patient to get well soon. It also helps patient's family members to avoid the conflicts between family and work responsibilities. It also helps a patient to avoid a long journey travel and high charges of hospital beds and other associated expenses, thereby relieving the patient's mind from the worries of total cost and stay, away from home, which often helps the patient towards faster recovery.

Home care , monitored by LHWs also helps elderly and physically challenged patients to receive health care without visiting the clinic.

Through auto send SMS , patients are also reminded about their medicine dosages, appointments and camps being held in the area, making the system more patient friendly.

Since LHWs are females from local community , women can discuss their problems openly, and at an initial stage which can save them from costly complications and hospitalization at a later stage. Being ladies, these LHWs can easily comprehend the problems faced by the women. LHWs also suitable practitioners in rural Mardan, due to the preference of local women to be treated by female practitioners.

Being from the local community also gives LHWs the advantage of gaining the community trust easily, and convincing them effectively and without any language barrier, which is also a plus point from patient's point of view as , he/she does not have to put extra efforts in defining the problem to LHW. In this way , Jaroka helps patients of Mardan, while keeping their cultural norms intact.

Jaroka project, not only empowers women but it actually empowers patients, helping them to manage their disease for long term health. It also helps them in management of chronic diseases like asthma, diabetes etc, and creates awareness in local community.

Disadvantages of telemedicine and How Jaroka Project is overcoming them

Some of Disadvantages of telemedicine or challenges involved are breakdown in the relationship between health professional and patient; a breakdown in the relationship between health professionals; issues concerning the quality of health information and responsibilities and accountabilities on the providers behalf; and organizational and bureaucratic difficulties. Use of expensive equipment, making project is sustainable.

But the question is then why to employ it , if we are even not sure about the quality of information imparted by the practitioners. Answer is simple solution even simpler.

Telemedicine is good but as long as it is used properly, that is to say, proper specialists and doctors provide medical advise , secondly that we keep a check , on the performance of the specialists as well, considering no. of cases correctly and incorrectly solved.

Keeping this in mind , Jaroka is utilizing the services of reliable and experienced specialists of APPNA, Association of Pakistani descent Physicians in North America. We are providing quality primary care at minimal charges Rs. 30 (approx. 38 cents), which is enhanced with the use of telemedicine to provide second opinion to patients from experts for free. Also that although using expensive equipments will enhance the service , but often it becomes a barrier when it comes to installing a project on ground, as the cost of equipment is non-recoverable. To over come this we have a doctor at Mardan who can effectively provide primary care, so no video conferencing is required and if a case beyond his expertise shows up , he can always consult a specialist with relevant documents supported with a video uploaded.

We have to consider two important aspects while designing the fee/charge strategy for the patient visits and lab tests. First abd foremost , it has to be accessible i.e. not only physically but also financially for the local public , secondly to keep the project sustaining. Therefore, we charge a nominal fee from public to meet both of the above requirements.

Moreover, remote locations donot have proper facilities and clinics , making telemedicine an ideal choice.

Weighing pros and cons of telemedicine , concludes that its benefits out weighs its disadvantages.
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source : http://www.ncbi.nlm.nih.gov/pubmed/15829049

Tele Healthcare from Socio-Economic View

Tele-healthcare is perceived as an ICT based solution for accessible and affordable healthcare for the poor residents of rural areas. YES, thinking only with respect to the health domain in developing countries makes this definition logical and I had exactly the same view until I along with our team started working on Jaroka Project. As we are in phase of introducing and implementing Tele-healthcare project in rural Mardan, my vision on tele healthcare has broaden . I strongly believe that Tele-healthcare not only benefits the healthcare domain, but in the long run results in socio-economic benefits for the society. Following are some of the socio-economic benefits with respect to our project:

- Achieving Millennium Development Goal:

Pakistan is committed towards achieving MDG ( 4 & 5) focusing towards better healthcare by 2015. Introducing Jaroka like Tele-healthcare models at various facilities will help achieve the target.

- Employment Opportunities:

Currently two males and one female doctors (processing), one Nurse and one Network administrator from local community are hired to execute the health related needs at UM-Healthcare Trust. Two students are also working as Research Assistants for implementing the technological part of Jaroka. Expansion of the project will demand more staff and medical specialists which in other words mean more jobs and better economical conditions at the area.

The second phase of the project will give trainings and incentives to Lady Health Workers (LHWs) for patient’s data collection. This means more part-time jobs and individual satisfaction.

- Health Awareness for All :

Ignorance and unawareness on vital issues including health is common issue in developing countries. Approximately 80% of the all the deaths and 90% of all illnesses in Pakistan result from disease which are preventable. It means that disseminating/discussing the critical health related information can easily help reduce this figure.

In order to facilitate the local community various sessions such as Basic Cardiac Life Saving (BCLS), awareness sessions, medical camps etc are regularly arranged at UM-Trust facility. These sessions are dedicated for local community as well as LHWs. Number of patients visiting the facility during medical camps has dramatically increased (10,000 patients - to date) and it is interesting to learn that 50% of the patients are women.

Disseminating health awareness or disease prevention methodologies also helps in decreasing the frequency of patient visits to government hospitals which results in less burden on them and quality healthcare service.

- International and National Collaborations /Foreign Visits :

APPNA (USA side), NUST and UM-Trust (Pak side) are collaborating in making Jaroka a success. All these institutes share their knowledge/results which is critical for further development for Pakistan. For example, Patient data can serve as an input for Data mining and research on disease can be carried out, which is a great contribution toward R & D nationally and internationally. In order to give the doctors and researcher more exposure of their field and opportunity to exchange knowledge, foreign visits of doctors and researcher from both sides are arranged.

- Affordable and Accessible Healthcare:

UM-Trust charges minimal free (Pak Rupee 30) from its patients who can afford to pay. Doctors at facility are available to cater the health care needs/ guidance for the patients.

- Local Community Involvement

Local community in Mardan UM-Healthcare Trust is extremely cooperative in making the project credible and successful. This is not only making good health accessible to them but also giving them the confidence that have are playing an active part in a good cause.

- Empowering Women (Lady Health Workers)

Skill enhancement and empowerment of the women is directly proportional to the success of the country. In our project LHWs through regular training session are trained to provide health care at door steps of the patients. This will give more job satisfaction to LHWs and they will be able to contribute towards the betterment of the society.

- Replicable Tele-healthcare Model

The best part about Tele-healthcare model is that, once it is successful it can be easily replicated to desired areas without incurring a lot cost.

Existing Infrastructure of Health care in Pakistan

Pakistan provides healthcare to its citizens through a three-tiered health care infrastructureand a range of public health interventions. The former includes Basic Health Units (BHUs) and Rural Health Centers (RHCs), forming the core of the primary healthcare structure. Secondary care including first and second referral facilities providing acute, ambulatory and inpatient care is provided through Tehsil Headquarter Hospitals (THQs), and District Headquarter Hospitals (DHQs) which are supported by tertiary care from teaching hospitals. There are seven hospitals under the control of Federal Government located in Islamabad, Rawalpindi and Karachi.

The network of health care facilities include 945 hospitals, 5349 BHUs and Sub- Health Centers , 562 RHCs, 4755 Dispensaries, 903 MCH Centers and 290 TB Centers.

But unfortunately , the condition of health care facilities is quite worse than it can be shown through statistics. From above mentioned facilities, only the ones which are in urban areas are operative, rural areas either donot have any proper facility or if it exists its non-operational, or poorly managed. Where as about 75% of Pakistan's population resides in rural areas. A travel of several kilometers and an expense of quite an amout is needed for a patient to visit the doctor , even for mere disease dignosis, which delays a patient visit to doctor, leading to costly complications at a later stage resulting into hospitalizations

[Human Resource Available from 1995 till 2007]
Population per doctor :-

1718 ------- in 1995
1473 ------- in 2000
1350 ------- in 2003
1316 ------- in 2004
1274 ------- in 2005
1251 ------- in 2006
1225 ------- in 2007

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Source : Economic Survey of Pakistan 2007-2008
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Jaroka Telehealthcare project and Millenium Development Goals (MDG) of Pakistan

Jaroka Telehealth care project aims at providing accessible health care to rural areas of Pakistan, through clinic based facility and Lady Health Workers (LHW). Presently, Mardan is the chosen test site. Through its Mardan healthcare facility over 10,000 patients have been treated. Through this Jaroka is helping Pakistan in achieving its Millenium Development Goals (MDG) at a much lower cost. The MDGs directly targetted by Jaroka telehealth care include ;

Goal 4: Reduce child mortality,
Goal 5: Improve maternal health,
Goal 6: Combat HIV/AIDS, malaria and other diseases

The above three goals will be achieved through the provision of better health care through properly trained Lady Health Workers (LHW) and Doctors
where as other goals indirectly dealt are;

Goal 1: Eradicate extreme poverty and hunger,
Goal 3: Promote gender equity and empower women

These goals are achieved indirectly by employing local residents especially women as lady health workers, thereby reducing poverty and unemployment from the area.

Benefits of tele-healthcare to providers/doctors

As we often discuss and read about advantages of tele-health care for patients. Benefits of Tele-health care are not limited to patients only. While patients recieve 24/7 service using telehealth care, freedom from geographical barriers and free second opinion from specialist and experts.It also helps them in avoiding the travel expenses.
Providers and doctors are also benefitted from such a service equally. On one side they offer practitioners to save their time and energy from treating mild cases like mild fever, flu etc , while on the other they also provide doctors who are temporarily or permanently physically challenged due to some accident or are on vocations, to continue working and still be in contact with their patients. It also helps them in getting useful advices from experts around the world.
It also gives the doctors an opportunity to help suffering people around the world.
Just as telehealth gives patient the freedom to recieve medical care while sitting in a remote location; it also gives a doctor the freedom to extend his/her medical care services while sitting in a remote location.