Month: July 2019

Five Families. Five Stories. Five Ways We Can Improve the Healthcare System.

Left - Intelehealth Director of Programs, Vibha Bhirud Right - Intelehealth CEO, Neha Goel
Left – Intelehealth Director of Programs, Vibha Bhirud Right – Intelehealth CEO, Neha Goel

Globally, the public healthcare systems have monitored and planned several targeted (vertical) interventions for specific diseases like tuberculosis, malaria, anemia and for certain disadvantaged groups like women and children through primary healthcare programs. These vertical programs have resulted in a number of big wins, one such example being a global reduction in maternal and child mortality. However, health systems have become more complex over time with a number of such selective programs for many health areas – like maternal health, child health, non-communicable diseases, communicable diseases. Often there is very little connection between these health programs and each operate in its own way. Several groups of people are also frequently neglected like those with disabilities, needing mental healthcare and the aging (geriatric) population.

We at Intelehealth, do our bit by using/developing technology to deliver comprehensive primary health care to underserved communities in remote and far-flung areas. We work to integrate technology and comprehensive primary healthcare supported by digital health tools. Last week, a part of our team visited Umerga and a few other villages in Osmanabad (Maharashtra, India). It was a routine baseline survey but in the end, what we experienced in these rural areas, deeply moved each one of us. Here are five of the most touching stories from the field that, in a way, shaped our thinking of what introducing comprehensive primary health care here would mean to them.

1. Comprehensive care means addressing the underlying social issues that lead to poor health

“Can you tell me what’s wrong with her?” pleaded an upset middle-aged woman as she pulled her daughter closer to come and sit with us. “Take a look at her. She can’t even walk properly and she gets irritated so easily. We couldn’t even send her to school, let alone make her stay there. She has been like this since she was born”. The hapless young girl, who looked to be around 16 years old, seemed to have some kind of developmental disability. However, the family simply wasn’t aware of what to do and where to go and get help for her. They had sought advice from their relatives, some doctors, and even faith healers. But in the end, they did not know what to do, condemning the girl to a life of isolation.

The problem solved- Social issues like lack of awareness of stigmas prevalent about mental illnesses is a major barrier to seeking care. Health promotion and awareness is a part of CPHC that would have positively impacted the life of such people with disabilities

2. Comprehensive care means focusing on early diagnosis and prevention and not just cure

“My wife has a lump in her breast from the past 3 years. But I think the treatment will be too expensive and tedious. From where do I get the money? And who would look after my wife in the hospital? So we haven’t gone to see any doctor,” said a poor farmer as his wife curiously peeked in from the kitchen.

Just a few houses away, a young woman, we interviewed, shared how she recently attended a screening camp for cervical cancer and menstrual abnormalities. She was screened positive for a possible lump in her uterus and was referred to a hospital for further investigation. “My family didn’t want me to go. They said there was no need as I was perfectly fine. But I didn’t listen to them and went anyway.” Further tests showed she did not have cancer and the lump was benign. But she was proud that she stood up for herself.

The problem solved- Women usually face a lot of social and cultural barriers and because of which they don’t speak up for their health. Screening programs, part of CPHC, can help promote positive health-seeking behavior in disadvantaged communities.

3. Comprehensive care is sensitive to the needs of all age groups, including neglected groups like the elderly

An 80-year old lady sat down next to us, and not realizing we weren’t doctors, began to pour out her heart on her ailment, i.e. how she was having a lot of difficulties during swallowing. “I even went to a big hospital in Pune. But the doctor said he would have to put a big tube down my throat and check! I got so scared I never went back. Now I am finding it so hard to swallow.”

Screen Shot 2019-06-20 at 12.31.59 PM.png

The problem solved- Lack of education and awareness often hold people back from seeking the treatment they need, and especially in the elderly. Additionally, it becomes very difficult for them to travel far and they are dependent on other family members for tending to their needs. Also, being uneducated, having deep-seated cultural biases and the dearth of public health programs for the geriatric population, makes matters worse. Health education and promotion helps such people to understand their ailments and how to help themselves out.

4. Comprehensive care includes lowering out-of-pocket expenses for patients

“I had kidney stones, and we spent close to Rs. 18000 for my treatment, but I still have a lot of discomfort and still sometimes in pain. I may have to go back but I am worried about the toll it would have.” The farmer we were talking to, ran inside his house and came back with a new insurance card under the Pradhan Mantri Jan Arogya Yojana (Ayushman Bharat scheme). “I made this new card. But I do not understand it. What do I do with this? Can I use this for my treatment? I went to a hospital but they said they don’t accept this card. Can you help me understand this?”

The problem solved- Often financing schemes do not reach beneficiaries or they may not know how to access them or in this case, how to use it. A health system that focuses on comprehensive care also looks into how care can be made affordable. However, education regarding insurance have still not percolated through the rural masses and could be a training point.

5. Community health workers (CHWs) can be a powerful medium to deliver comprehensive care

Screen Shot 2019-06-20 at 12.50.08 PM.png

“I saw this young pregnant woman who was very weak. While she had been at her mother’s home, she was being well taken care of. She would regularly come to the Primary Health Center for her checkups during pregnancy,” said a midwife (a type of CHW in India). “But after she came to her mother-in-law’s home, she was prevented from coming for her regular checkups. I went to her house and told her mother-in-law that she needed to care for her daughter-in-law like her own daughter. I told her I would bring the village elders to her home and make sure she was held responsible if anything happened to her daughter-in-law.” We realised that CHWs can be a powerful force to address underlying social issues like these.

The problem solved- Health seeking behaviour i.e. preventive medicine is usually not a part of the treatment process and the patients usually approach the doctor after exhausting all home remedies and out of fear. The CHWs can effectively promote positive health-seeking behavior through screening, raising health awareness and home visits. CHWs bring the health system to the doorstep of patient, and are an agent for change in the way the community perceives healthcare.

Other Blogs

We look forward to partnering with you

Together we can make telemedicine reach the last mile

Contact Us

Doctors’ Safety – A physician’s perspective

True Story: A few years ago, I was a lone Medical Officer for a health related CSR project in remote rural villages in Gujarat. One day, as usual, more than a hundred patients and their relatives were sitting outside my make-shift clinic, braving the hot sun. All of a sudden, a man stormed in midst of my consult and accused me of taking too much time (I was seeing >20 people in 1 hour, with one health worker and one nurse to assist me). People started to gather around, curious to know what was happening and how events would pan out. I had heard stories of attacks on doctors. I knew about the mob mentality. I was frightened! What was better, fight or flight? How do I approach the situation?

But what happened next changed my perspective forever. Read on.

The safety of doctors has been an issue since time immemorial. Earliest studies of violence against doctors from the USA date back to the 1980s. 57% of emergency care workers in the USA have been threatened with a weapon, whereas in the UK, 52% of doctors reported some kind of violence.[2] In India, according to the IMA, at least 75% of doctors have reported as being exposed to assault (verbal, physical and psychological) [3] during duty hours. The incident that recently happened in Kolkata was a (yet another) wake up call in this direction. In India, where the allopathic doctor-patient ratio is low (1:11082) and not many doctors want to practice in the government or rural sector, doctors could be considered as a rare commodity and every effort should be made to protect them! [4]


Source: Wikipedia
Source: Wikipedia

So let us see what exactly happens. When a patient is no more, it is very natural that the patient’s relatives would grieve and try to console and counsel each other and form a support system. Some of the patient’s close relatives also look outward for support and to make sense of the profound loss. A popular theory about stages of grief according to the Kubler- Ross model are denial, anger, bargaining, depression and acceptance. Another popular theory (see pic) shows two possible outcomes of grief or a life-changing event – shock and denial or anger and bargaining. [4]

So when necessary support is not received by the patient in the first three stages phases, it leads to a crisis in grief management which can then lead to a violent outburst by the patients or their relatives. Also, there are several other factors leading to frustration which in turn cause violence. Few are listed here and may include:

Patient frustration factors

Doctor-Patient interaction times around the world. Source: Times of India
Doctor-Patient interaction times around the world. Source: Times of India
    1. Long queues and wait times
    2. No proper sitting, toilet or canteen facilities
    3. After hours of waiting to meet the doctor, only 2 minutes or less time with the doctor
    4. Inability to understand the doctor’s notes or their own condition
    5. Expensive tests or medications prescribed by doctors they consider to be ‘money minded’.
    6. Out of pocket expenditures forcing people to empty their savings or utilize money kept aside for a better life.
    7. No sympathy or empathy and a very mechanised ‘assembly line’ delivery of healthcare.

Doctor frustration factors

    1. Long working hours
    2. Poor resources and infrastructure
    3. Organizational pressures to accommodate more patients in a fixed amount of time
    4. Better job opportunities, facilities and incentives elsewhere (in urban areas and private setups)
    5. Patients doubting their ability and prescription and violent outbursts from relatives

Other causes include irrational behaviour and personal vengeance. Also politically or economically motivated violence against healthcare institutions and doctors is not uncommon. For instance, Yi Nao, which literally means healthcare disturbance, started in China and is now a worldwide phenomenon, where self-proclaimed ‘do-gooder’ gangs extort money from hospitals alleging malpractice and share the profits with the patients.

Coming back: I gathered courage and informed the people that I am doing the best with the resources and the infrastructure available and empathized with them for their patience, which was seconded by the community health worker. When the man refused to budge and stood towering before me, I politely informed everyone, the reasons why further consults are not possible due to the looming danger. What happened then surprised me! The health worker and the local people told me not to worry, got together and ushered the gentleman out. He was asked to seek healthcare for himself and his family elsewhere. They even involved the local bodies to keep the entire family away from me and the premises.


Several legislations, including state bills, both for and against the doctors and the patients, are already in place [6]. But even with stricter laws in the advanced countries, assault on doctors still happens. Also, in spite of several laws being present on the patient’s side, there is a perception that the doctors are well connected and often get away unscathed. Also, certain media sources present sensational stories where gangs have beaten doctors and have got away with it. All these instances embolden the people to take the law in ones own hands.


As patients

Doctors enter the profession with a spirit of helping others and always use their best judgement in the interest of the patient. Also, a doctor is just another human being, constrained by his knowledge and experience, trying his best not to make any mistakes, as in this field there are no second chances. Also, you may be dealing with a doctor who is as frustrated and helpless as you (reasons described above). Thus, ideally, in times of distress, one should approach and handle the situation in a calm and dignified manner and take help from higher authorities if things don’t turn out as per expectations or if you suspect any foul play.

As healthcare providers

Doctors should understand that the patient is a stressed person with heightened emotions and is probably worried about the personal, professional and financial toll this ‘mysterious’ disease would bring. Doctors should involve the patient in their diagnosis and treatment process i.e. shared decision making and given the times, take due consent and properly document the case irrespective of severity. Empathy is currently not taught as a subject at med school, and being so important in our daily practice, we should cultivate it along the way.

As healthcare organizations

Healthcare organizations have a statutory responsibility to commit to the safety of patients and healthcare providers, and ensure that their premises are safe and free from looming danger. Periodically reviewing safety protocols, quicker response by authorities, training security personnel and senior officials in managing escalations, using counsellors and better community engagement to build trust, are few of the instances that the institutions can undertake to manage and reduce harm during a crisis.

As policy-makers

Stricter enforceable laws could be implemented. For example, one thinks over a few times before assaulting a police officer as it is against the law to lay hands while he’s ‘on duty’. An extreme example is lifetime punishment, recently given to a South-Mumbai businessman for a hijacking prank on a popular airline. Such laws and its enforcement may deter people from even thinking of hurting doctors as the consequences of their actions are severe.

However, none of these solutions is sufficient by itself, but by working together we can all play our part in improving the safety of physicians.


A community health worker trained by Intelehealth in rural Odisha evaluating a patient.
A community health worker trained by Intelehealth in rural Odisha evaluating a patient.


Violence in any form towards anyone is deplorable, as is inciting one towards it. Doctors, patients and policy makers should be aware of the problems faced and initiate a course correction in a dignified and respectful manner. Additionally, such situations highlight the importance of having a trusted community health worker (CHW) by ones side (i.e. as a doctors’ or peoples’ advocate) and it goes a long way in calming down such people or events, as they are at a better advantage since they belong to the same community and the people place their trust and full faith in them to work diligently and have their communities’ best interests at heart.

A happy ending: A few weeks later, I saw a young boy arguing with some of my patients and his toddler brother crying outside my clinic. The health worker informed me that they were the children of the angry man, and the father refused to take them to a physician as he had to go to work, and they were asked to go away. The elder brother had enough of his little brother’s sickness and had tried to sneak him in. He pleaded with me for help. I couldn’t punish the children for their father’s mistakes, I was no judge here, I was just a doctor!

After cajoling the crowd, I managed to let the toddler in, consult and send a note back with a neighbor. I sent the small boy home with a local sweet and a smile on his face that was sweeter



  2. Goodman RA, Jenkins EL, Mercy JA. Workplace-related homicide among health care workers in the United States, 1980 through 1990. JAMA 1994;272:1686-8.

  3. Nagpal N. Incidents of violence against doctors in India: Can these be prevented?. Natl Med J India 2017;30:97-100

  4. Human Resources in Health Sector. National Health Profile 2018. New Delhi:Central Bureau of Health Intelligence, Directorate General Health Services, Ministry of Health and Family Welfare, Government of India; 2018:219



Other Blogs

We look forward to partnering with you

Together we can make telemedicine reach the last mile

Contact Us