Editor’s note: Demand: ASME Global Development Review shuttered after six years of publishing in-depth coverage of the most interesting manifestations of design, engineering and social ventures in global development. The biannual magazine was a premier source of global development writing and a sister publication to Engineering for Change. As an homage to Demand and the work of the experts whose voices it disseminated, we are reprinting the magazine’s articles on this site.
Healthcare for the Long Haul
Lacking the infrastructure and skilled manpower to provide high-quality, basic healthcare, India is struggling against the urgent and costly burden of non-communicable, chronic diseases. Indeed, chronic diseases like diabetes and hypertension, are the leading cause of death in India, and are projected to cost the country trillions of dollars in economic loss in the coming decade. A team from advisory services firm Intellecap is working to change that with a new health intervention model built around frugal technologies and low-cost services. Its focus is an ultra-high-risk, hard to reach group: India’s long-haul truck drivers.
Many professionals working in demanding city jobs may feel like they live at their workplace, but that is nothing compared to Avtar Singh who cooks, eats, sleeps, and socializes in his workplace. Singh, who is from the northern Indian state of Punjab, was featured in a recent article on India’s truck drivers in the travel and food magazine Roads and Kingdoms. The writer, Rajat Ubhaykar, paints a sympathetic portrait of Singh and India’s two million other truck drivers, who collectively represent the second-largest employment group in the country, after agriculture.
Trucking accounts for six percent of India’s GDP. Eight million trucks transit goods across India’s 4.7-million-kilometer road network at any given time. Of those, 70 percent are controlled by small operators who own between one and five trucks. The drivers’ lives are not easy. They get paid poorly—roughly US$100 per month, give or take—work grueling hours, and contend with all varieties of physical and security dangers on the road.
“Despite their crucial role in the smooth conduct of the economy, truck drivers are stigmatized by conventional society and popular culture as peripatetic good-for-nothings, rash drivers, hard-drinkers, people who frequent brothels [and] contribute to the spread of AIDS,” Ubhaykar writes.
They are also a high-risk group for noncommunicable diseases, owing to their unhygienic living conditions, poor diets, heavy alcohol and drug consumption, and exposure to vehicular exhaust and other forms of air pollution. India’s truck drivers are not the only population at risk. Non-communicable diseases, or NCDs, are the leading cause of death worldwide. This loose group of chronic illnesses, which includes diabetes, hypertension, and cardiovascular and respiratory disease, are defined by their non-infectious nature. According to the WHO, of 56.4 million global deaths in 2015, 39.5 million, or 70 percent, were due to NCDs, and over three quarters of those deaths occurred in low- and middle-income countries.
The overwhelming majority of India’s NCD burden afflicts poor Indians, but 30 to 40 percent of those with one of more such disease will remain undiagnosed.
In India, it is estimated that 20 percent of the population has an NCD, and 10 percent has more than one. By 2030, India will represent a quarter of the world’s NCD cases, which will cause $4.6 trillion in economic losses economic losses—22 times India’s current GDP—in addition to the human toll. India’s poor and rural middle-class are disproportionately affected by the NCD burden because of their lack of health knowledge and access to quality care. Thirty to 40 percent of the chronic disease-afflicted in disadvantaged communities will remain undiagnosed, and 80 percent of the total NCD burden will fall on them. As dire as that sounds, risk factors for acquiring an NCD are only rising. Air pollution regularly spikes to dangerous levels in cities like Delhi and Gwalior, while occupational and economic
constraints lead to unhealthy diets and addictive habits, like smoking. The urgent question facing India and many other fast growing economies is how to tackle a problem so invisible and diffuse, yet ubiquitous and deadly. That problem became a clear target for Bangalore-based Intellecap Innovation Labs when it launched in 2016. The Innovation Labs divisions functions like a startup within its parent organization, Intellecap Advisory Services, a social sector firm that supports entrepreneurs serving disadvantaged communities in India and other emerging markets. Innovation Labs focuses on fundamental problems like health, livelihoods, and food security, with the goal of implementing and scaling products, technologies, services, and platforms with high impact potential.
“PROBLEM FORWARD” APPROACH
Introducing new ideas into markets where they can impact people and communities is often a long journey. The number of competitions, awards programs and funding initiatives designed to ease this process has exploded in recent years. But many of them operate in silos, which is inefficient and creates gaps in the entrepreneurial ecosystem, explains Chandana Kiran, associate vice president at Intellecap. The mission of Innovation Labs is to bridge the current gap between the social innovation sector’s robust pipeline of ideas and lack of forums for testing those ideas.
“There are many great ideas coming out of these hackathons, but how many are leaving that competitive environment to be implemented in the field?” Kiran told Demand in 2016, around the time of the Innovation Labs’ launch. “Right now, no one is taking ownership of the process for [innovation] commercialization.”
Innovation Labs is hoping to propel that transition for start-ups, corporations, and partnerships alike.
“A lot of innovations fail to launch or scale because they aren’t piloted in real conditions with real customers,” Kiran says. “The Labs’ intent is to provide test beds for piloting both new and mainstream technologies for new demographics.”
Its approach is to incubate pilot projects in what it calls “µLabs,” or “micro-labs.” “We first identify [a] problem and then we ask, how do we start systematically solving the problem in an economically viable way?” Kiran explains.
Then Innovation Labs’ team begins assembling a network of thought leaders, including scientists, innovators, governmental and non-governmental representatives, and entrepreneurs, united in trying to solve that particular challenge. These “unlikely alliances,” as the Innovation Labs’ website puts it, are fundamental to the work it does in terms of rapid testing, iterating, and refining of technology, business models, and operating models to arrive at solutions that will work at scale. It is an open model in the way that the µLabs share their design, data, and insights with other members of the global community for feedback and dissemination of information. “To promote bigger, more sustainable impact,” Kiran says, “it has to be an ecosystem-level approach.”
Technology, whether simple or complex, doesn’t really percolate down to low-income populations. Innovation Labs’ intent is to bring technology to these communities.
Technology plays a critical role in that ecosystem, and part of µLabs’ approach is to facilitate the adoption of new technologies meant for low-income communities. Often communities’ access to such technologies is one of the main barriers.
“When we look at low-income populations, we find that technology, whether simple or complex, doesn’t really percolate down to them,” observes Kiran. “The whole idea behind [the] Innovation Labs was to bring some of this technology to these communities and [use it to] solve community problems in a commercially or economically viable way.”
The Innovation Labs aims to do this through a “problem-forward” approach, rather than a “product-forward” approach.
“We don’t look at a device and ask, how might we fit it in the community?” Kiran says. That is because the ultimate goal of the µLabs is to turn each project over to local communities to manage and operate, and this can only happen successfully if all of the elements of the project intrinsically fit.
TACKLING TRUCKER HEALTH…
Intellecap Innovation Labs has several projects in the works, but its decision to launch the NCD µLab was the result of trend analysis the team conducted, which indicated that India’s disease burden was increasingly linked to environmental and lifestyle factors resulting from the country’s industrialization. The incidence rate of hypertension is a good example. A survey of hypertension’s trends in the Journal of Human Hypertension describes “a strong correlation between changing lifestyle factors and increase in hypertension in India,” with about 25 percent of urban Indians developing the condition compared to 10 percent of their rural counterparts. When developing the µLab, the Innovation Labs team decided to focus on two things: first, how to use data on environmental conditions and demographics to identify high-risk communities; and second, how to cheaply, rapidly, and effectively screen and monitor at-risk subjects.
To the first point, the NCD µLab team decided to target Bangalore’s long-distance truck driver community for its pilot. They settled on a population of around 14,000 drivers—of which 90 percent are men—because of the community’s high-risk for developing NCDs. As mentioned, long-haul truck driving does not lend itself to a healthy lifestyle. Most drivers own their own vehicles, so for both security and financial reasons, they are reluctant to leave their trucks. “As you can imagine, the conditions inside are quite unhygienic,” Kiran says. Also, being poorly paid and often in debt, they try to drive as much as possible.
“If they leave the workplace, someone else might get the next job, which impacts their income,” Kiran adds. “Plus most transport perishables and have to reach their destinations on time, so they don’t take many breaks.”
In turn, they smoke or chew tobacco or worse to stay awake. “Official figures are unavailable, but the truck drivers we spoke with said more than three-fourths of their compatriots in Punjab were opium addicts,” Ubhaykar reported in his article for Roads and Kingdoms. “A driver addicted to ‘bhukki’ [opium husks] can’t possibly drive without it [and] a longer unsupervised withdrawal period can even be fatal.”
In terms of how to build an effective intervention, Innovation Labs had to consider India’s shortage of skilled medical professionals and readily accessible health facilities. Instead,
it sought to construct its pilot around point of-care screening technology deployed by community health workers. The pilot’s design included four steps:
- Partnering with the local ministry of health, to guide the µLab in terms of how a program might be integrated into the existing public health-care infrastructure.
- Training health workers and hire support staff.
- Sourcing existing technologies to screen drivers for diabetes, hypertension, cardiovascular disease, and respiratory disease.
- Choosing an implementation partner to help run the clinics. In this case, the NCD µLab team chose to work with Hindustan Latex Family Planning Promotion Trust, a national not-for-profit health services organization that deals with reproductive health and HIV prevention and control.
The organization has a clinical presence at major trucking terminals to perform HIV screenings for drivers, whose HIV incidence rate is 10 times higher than India’s average population, according to India’s national AIDS Control Organization. To meet the technology needs of the NCD µLab, Intellecap Innovation Labs identified 12 parameters for the tools it needed, including ease of use, ease of integration with existing systems and mobile technology, an ability to run without a continuous source of power, and portability. The team then cast a wide net—a worldwide net—to find the right products.
“All of the technology we choose must be integrated onto a single platform, and minimal [skills and power] are required in order to do the screenings. In these communities we cannot, for example, carry a huge ECG system, which requires a power backup and a skilled person to use it,” Kiran explains. “We look at how an unskilled or minimally skilled worker could potentially use the technology in the field and also collect data that would be a guiding parameter for [how to assess and manage NCDs].”
Using these parameters, the NCD µLab team boiled the program’s core technologies down to three pieces of equipment from a large group of product contenders. They include:
- From the Indian start-up Cooey: A diabetes and hypertension screening and monitoring system comprised of a blood-pressure monitor, a glucometer, and a “smart body analyzer” that calculates percentage of body fat, among other things, integrated with a mobile IOT framework. This system allows health workers to manage their patients’ vitals and it also automates the creation of patients’ health records.
- From Swedish company NuvoAir: A handheld “Air Smart” spirometer that measures lung health across four parameters—forced vital capacity (FVC, i.e. the amount of air a person can forcefully and quickly exhale after taking a deep breath); forced expiratory volume in one second (FVC1, i.e. the amount of air a person can forcefully exhale in one second of the FVC test); and the ratio between the two, which, when taking into consideration a patient’s age, height, and weight, can indicate the presence and type of disease.
- From U.S. company AliveCor: A single-channel heart monitor that consists of a “Kardia” device about half the size of a credit card, and an app, that enable patients to record and review electrocardiograms. The device, which costs about $100, attaches to the back of most mobile devices and communicates wirelessly with the Kardia app. The NCD µLab is also exploring a fourth potential device from Israel.
…WHERE THE TRUCKERS ARE
Intellecap Innovation Labs is running its NCD µLab out of 29 satellite clinics in truck terminals in and around Bangalore. In determining where to set up these clinics, the Intellecap team collected multiple sets of data and came up with an algorithm that gives a “risk” score of any geographical location. This information is being incorporated into a “risk propensity map,”
which enables geographical targeting based on local concentrations of air pollution. Right now, air pollution data collected by government air quality monitoring stations is the only variable being used in the map, as pollution is closely correlated with NCD incidence rates, says Kiran. The risk propensity map will become more robust as Innovation Labs continues to add more data sets, she adds.
While the Innovation Labs team may have taken a methodical approach for how to structure the NCD µLab, it was less prepared for the practicalities of launching the lab in the field. A hard lesson came early: after setting up the satellite clinics, few truck drivers took advantage of them.
“We had to change the equation completely,” says Kiran.
That meant taking the most extreme point-of-care approach: sending the health workers from truck to truck to do the screenings, rather trying to convince the drivers to visit the clinics. The team also knew that cost would be a concern, given that the overwhelming majority of Indians do not have health insurance and pay for healthcare costs out of pocket. The NCD µLab was able to offer its four-test screening at a total price of 37 ($0.58) when it launched, and then was able to quickly reduce the price to 27.
“The more we screen people, the [cheaper it gets],” Kiran says.
You can’t just set up a health camp to test everyone’s blood sugar and never come back again. That’s not how you manage a chronic disease.
Her hope is that they can ultimately get the cost down to about 20. All of the tests are mobile phone-based, so once a driver is screened, the results can be easily digitized, saved, or shared. Drivers flagged as high risk are booked for follow-up appointments at the µLab’s satellite clinics inside the truck terminals. Health workers then come back a month later and set up a clinic in the same spot to see if there is any improvement in drivers’ conditions. Health workers also keep in touch with drivers between appointments, calling them, sending messages, and answering questions.
In the first four months of the NCD µLab, the program has screened 1,000 patients and has found that in contrast to the general Indian population, which has an estimated incidence rate of diabetes of 20 percent to 40 percent, over 58 percent of truck drivers have diabetes. Forty-eight percent have hypertension. Many of the drivers tested had no idea that they had a chronic illness. By incorporating themselves into the driver community, Innovation Labs has been able to raise awareness among drivers about NCDs. “People now understand that NCDs are [a problem],” says Kiran. There has also been a significant uptick in the use of the satellite clinics, she says.
The process has also cultivated trust between the drivers and the health workers. The Innovation Lab team discovered that, in a country where HIV is heavily stigmatized, drivers were initially reluctant to use the clinics because the program’s partner, Hindustan Latex Family Planning Promotion Trust, is a recognized name for HIV screening and care. Instead, the NCD
µLab’s workers communicated the screening services they were offering to drivers in terms of general health and wellness. In turn, they have had success at encouraging drivers to get tested for HIV at the clinics, in addition to the other tests they perform truck-side. “We were able to talk to the drivers [about HIV] and counsel them,” Kiran says.
THE FORWARD FIGHT
The NCD µLab is now looking to replicate its pilot in Hyderabad, where Intellecap Innovation Labs has a satellite office, and in the industrial city of Pune. The team is also in discussion with the state government of Karnataka to replicate their model in the state’s public health-care infrastructure. Fighting chronic disease in India is all about management, Kiran says.
Only 11 percent of the country’s total population adheres to care routines that might help mitigate the risk of developing an NCD. “The reason that this figure is so low is that people are not aware that NCDs are a chronic condition, and the country does not cater to this kind of need,” she says. This is why the Innovation Labs’ health workers are diligent about following up with the truck drivers it screens after an initial appointment and also keep in touch with them between appointments.
“You can’t just set up a health camp to test everyone’s blood sugar and never come back again. That’s not how you manage an NCD.”
There are signs that India’s major healthcare players are beginning to think this way as well. The Union Ministry of Health in Hyderabad is reportedly setting up NCD clinics in 14 districts throughout the city, with “accredited social health activists” going house-to-house to screen people for NCDs. Those who are flagged as high risk will then be sent to a medical
facility for treatment. Kiran knows that they have a long road ahead of them, but she is quick to add that Innovation Labs is only in the first year of its pilot program, and that they have a very small office staffed with four full-time employees, one intern, and one doctor as a “subject matter” expert. The NCD µLab relies on its parent company, Intellecap Advisory Services, to fund the program for now, though Kiran says the team is actively applying for grants as they work on building scale.
Kiran is quick to point out that making money is not a goal of the program; rather, the intent is to develop a workable model to tackle India’s exploding chronic disease burden. “And not just as the problem relates to the community, but to the entire ecosystem,” she says. This is the approach Innovation Labs intends to take with its other projects as well.
“We don’t create enterprises and we don’t make money—it’s the community that will be owner of the entire process,” Kiran says. “It’s all about the power of community.”
About the Author
Adrienne Day is a writer, editor and New York native. She has written for The New York Times, New York magazine, the Village Voice, Stanford Social Innovation Review, and Wired, among other outlets, and has worked as an editor at EW and Spin magazines. Ms. Day holds a bachelor’s from SUNY Binghamton and a master’s in journalism from Columbia University.