Working with a government body to digitise their offline hospital quality assurance system

What’s the problem?

The NRHM (National Rural Health Mission) is an initiative undertaken by the Government of India to address the health needs of under-served rural areas. The NRHM was initially tasked with addressing the health needs of 18 states that had been identified as having weak public health indicators.

In an effort to better this setup, the Government of India setup the NHSRC (National Health Systems Resource Centre), under the NRHM, to serve as an apex body for technical assistance. The goal of this institution is to improve health outcomes by facilitating governance reform, health systems innovations, and improved information sharing among all stakeholders — at the national, state, district and sub-district levels — through capacity development and convergence models.

One of the areas that the NHSRC works in is the provision of universal healthcare services. Universal access to good quality services — services that are effective, that are safe and satisfying to the patient; services that are patient and community centred, and services that make efficient use of the limited resources available.

The approach for achieving these objectives involves ensuring that every single health facility is scored against pre-defined standards with periodic supportive supervision for ensuring continual improvement.

There are three main components to conducting an assessment,

- Facilities
- Assessments themselves, and
- Facilitators

Facilitators conduct Assessments for Facilities.

Facilities are hospitals or other healthcare systems that exist at different levels,

• National level
• State level
• District level
• District Hospital level

Based on their level, facilities would be eligible for a particular type of assessment.

There are two main types of assessments in the system,

• National Quality Assessment System (NQAS): Is a system which has incorporated best practices from the contemporary systems, and contextualised them for meeting the needs of Public Health System in the country
• Kayakalp assessment: To complement the government’s ‘Swachh Bharat Abhiyan’ (cleanliness in public spaces campaign), the Ministry of Health & Family welfare, Government of India launched a National Initiative to present awards to public health facilities that demonstrate high levels of cleanliness, hygiene and infection control

Assessments are a set of pre-defined standards against which facilities are scored. Assessments happen periodically throughout the year under supervision to ensure continual improvement.

Facilitators are people with varied experience, who are picked based on the type of assessment. For instance, National level assessments would require facilitators with a certain set of requirements as compared to a State level assessments. For instance, national level facilitators will consist of representatives from the programme divisions (maternal health, child health, family planning, etc.) of the Ministry of Health and Family Welfare, Government of India and National Health Systems Resource Centre.

How does the assessment process work?

The assessment process requires Facilitators to give a Score (of 0, 1 or 2) to a Measurable Element (ME).

Each ME belongs to an Area of Concern (AoC) and an AoC belongs to a Standard.

Standards: These are broad thematic areas with respect to cleanliness & hygiene, and can be termed as the “pillars” of the system.

Area of Concern: Each theme (Standard), has a fixed number of criteria that cover specific attributes.

Measurable Element: Is the lowest and most tangible unit of an assessment. MEs are specific requirements that the facilitators are expected to look for in a facility for ascertaining the extent of compliance and award a score.

Checkpoints: In the NQAS type assessment, MEs are broken down further into Checkpoints. Checkpoints are departmental checklists.

This is how the above-mentioned elements exist in the Assessments,

Assessments for Facilities are done via Checklists, which encapsulate all of the above (Standards, AoCs, MEs and Checkpoints).

How were assessments conducted prior to the app?

Facilitators were handed sheets of paper with all the Standards, AoC and ME on them. Facilitators would traverse back and forth through this list, assign a compliance score to a ME until they were done with all AoC and subsequently with all Standards.

Advantages of the offline system,

• Easy and fast scanning of Standards, AoCs and MEs
• This medium requires little to no training

Disadvantages of the the offline system,

• Hard to keep track of progress. Facilitators have to scan and do this themselves by repeatedly going through the list
• Force facilitators to conduct their assessments by the list, rather than what is convenient
• Unobliging towards writing comments for scores awarded to MEs
• Can’t generate reports immediately
• Submitting Assessments as a physical copy and manually syncing the results across the entire district/state/nation

What is Gunak?

Based on the disadvantages mentioned above, Nikhil (senior member of the NHSRC) thought it’d be best to use technology to make the process of conducting and syncing assessments easier. Gunak is the app that aimed at doing this.

Minimum feature list we aimed to launch the app with,

• Conduct NQAS and Kayakalp assessments
• Motivate facilitators to enter comments for the scores they give
• Allow assessments to be conducted offline
• Sync assessments once facilitators were in an area with active internet connection
• View detailed reports across all Standards, AoCs and MEs for finished assessments
• Sync reports of finished assessments for peers/superiors to view/review

The challenges we faced,

• Maintain familiarity while transitioning facilitators from an offline to an online system
• Translating a multi-tier architecture to mobile

Navigation

Usage: For an assessment to be complete, facilitators have to finish all MEs across all AoCs.

Usage Pattern: Facilitators, physically visit facilities to conduct assessments. The offline medium sometimes forced the facilitators to finish Measurable Elements in a sequential order (as displayed on paper) since it would be easier to keep track of the progress of the assessment.

Notes:

1. MEs are specific department-wise questions for a facility. Since most facilities aren’t built the same way, following a sequential pattern wasn’t the way to go ahead.
2. The assessments are usually carried out over a period of 3–5 days.

We wanted to design a system that would be flexible and not dictate facilitator behaviour. A system that would always keep the facilitator aware of where they are and their progress. In addition to this, we had to ensure that readability and usability were the main focus since facilitators moved around a lot while conducting assessments.

The bottom navigation for an ME, allows facilitators to know the progress of the AoC these MEs belong to. It works as a navigation system where facilitators can jump forward to answer an ME and come back to answer another ME.

Search

We wanted to find an equivalent for the ‘flip & find’ function, that facilitators perform on paper, for the app.

Search allows facilitators to find MEs, AoCs and Standards.

Our Search feature isn’t a simple text match. As seen below, it can identify that the word ‘hygiene’, could pertain to a Standard, an AoC or MEs.

Reports

One of the main drawbacks of the offline medium was its inability to generate reports. A facilitator or their superior would spend hours going through an assessment and assign a score for the same.

We took advantage of technology to provide detailed reports based on Departments, AoC and Score, which can be shared as an excel sheet or as an image.

Who did we work with?

This project would not have been possible if it wasn’t for the amazing team at Samanvay. This is our second project with them, you can read about the first one here,

Designing for Rural India — Part 1

App Launch and Reception

The Gunak app is being rolled out in phases. Its first launch was in August 2017 by the Ministry of Health and Family Welfare, the app has a 4.8* rating on the play store.

Thank you so much for reading this. If you found this interesting, don’t forget to 👏 👏

If you have questions or thoughts about the post and/or would like to reach out to us outside of Medium, send us an email, moshimoshi@nilenso.com

🙏

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Gunak — Designing with the Indian Government was originally published in uxdesign.cc on Medium, where people are continuing the conversation by highlighting and responding to this story.

Designing for Rural India — Part 1

Journey of designing OpenCHS with Samanvay

India does not have a National health insurance or universal health care system for all its citizens. This has propelled the private sector to its dominant position in the healthcare market. Private companies provide the lion’s share of healthcare services in the country.

Despite the structures in place to ensure equality and funding from government and non-government sources, we still observe a visible gap in access to healthcare in rural areas compared to cities. A staggering 68% of the population lives in rural areas and has no or limited access to hospitals and clinics. Consequently, the rural population mostly relies on alternative medicine and government programmes.

If one had to paint a picture of rural India, it would be people living in mud houses in small villages. These villages have next to no electricity supply. There are setups of solar power stations which people use to charge their cellphones. Travelling to these villages is not always easy. One would require to change at least three different modes of transport to reach many of these villages. The residents seek out healthcare in cases of pregnancy and severe illness like Tuberculosis, Dengue, etc. However, villagers often do not seek treatment for early symptoms which appear less dangerous. This is not always due to lack of awareness. It is often also the case that infrastructure to support the long tail of healthcare is simply not that accessible in rural India.

Healthcare in Rural India

The public healthcare in rural areas has been developed as a three-tier structure based on predetermined population norms.

1. CHC (Community Health Centres)

Community Health Centres form the uppermost tier and are established and maintained by the State Government. Community health centres are staffed by four medical professionals supported by twenty-one paramedical and other staff. Surgeons, physicians, gynaecologists and paediatricians provide comprehensive care in each CHC.
Each CHC has thirty indoor beds, an Operating Theatre, X-ray, Labour Room, and Laboratory facilities. The community health centre provides expert facilities in obstetric and other care for patients referred to them by the four primary health centres within their jurisdiction.

2. PHC (Primary Health Centres)

Primary Health Centres (PHCs) comprise the second tier in rural healthcare. PHCs provide integrated, curative and preventive healthcare to the rural population with emphasis on preventive and promotive aspects. Activities include promotion of better health and hygiene practices, tetanus inoculation of pregnant women, intake of IFA tablets and institutional deliveries. A medical officer is in charge of the PHC supported by fourteen paramedical and other staff. Each primary health centre has four to six beds. Patients are referred to the PHCs by six sub-centres.

3. Sub-centres

A sub-centre is the most peripheral institution and the first contact point between the primary healthcare system and the community. An Auxiliary Nurse Midwife (ANM) is in charge of six sub-centres each of which provides basic drugs for minor ailments. A sub-centre provides services in relation to maternal and child health, family welfare, nutrition, immunisation, diarrhoea control, and control of communicable diseases. ANMs also use Anmol Tablet, a product that aids in maintaining and collecting data, specific to primary health.

4. Non-government Infrastructures

Apart from the government bodies there are other players in the system, which are closest to the villagers (bottom most in this tier). There are private hospitals, which run to provide special services or even basic healthcare.

Accessing health support is not that easy for village residents. They have to travel long distances to visit public hospitals spending money, and time that could be spent doing their daily chores. That’s when community health services come to play.

There are non-profit NGO Hospitals which run Community Health Services (CHS). They hire and train health workers who work closely with villagers in providing health services and education.

Health Workers who work as a part of the Community Health Services are known as VHWs (Village Health Workers), as a part of CRHP (Comprehensive Rural Health Programme). Jamkhed is a programme run under CRHP.

Jamkhed is centered around mobilising and building the capacity of the community, empowering the people to bring about their own improvements in health and poverty-alleviation. This is one of the better known and appreciated community health systems.

Role of VHW ( Village Health Workers )

VHWs are individuals selected by the villagers. They are responsible for providing consultation and prescription on basic health care. Their appointment by the community helps establish villagers’ trust in them.

VHWs typically take care of a single village, but if required, they can be responsible for up to five villages. They are trained in basic healthcare, understanding symptoms and personality development. Since they are only trained in basic healthcare, they escalate severe cases and recommend the patients to visit hospitals. Quite often these volunteers are women.

Apart from this, VHWs also bust widely held superstitions by providing elementary health education.

Health workers use their considerable interpersonal communication skills to bring about important behavioural changes with respect to reproductive and hygiene practices in their rural communities.

How do they operate now?

The infrastructural support that these health workers get is mostly via Community Health programs and some inventory support from the government.

Here are some highlights about their daily operations -

Use of Paper:

The health workers still use paper for most of their work. They are provided with a chart that maps various symptoms to common ailments and relevant medication. While this may enable the health workers to swiftly treat common ailments, the strict mapping unfortunately severely restricts their ability to correctly identify edge cases or more subtle health issues.

Inventory List:

Procurement of medicines is also done using paper. Health workers also track the need for medicines, availability and expiry dates of the medicines. Medicines are procured from Sub-centres where the health workers visit often to give reports to ANM’s about their respective villages.

Patient History

The health workers aren’t equipped to look at patients history at the time of consultation. They keep manual records which are too comprehensive to look into at the time of visits.

How does OpenCHS help?

OpenCHS strives to fill this gap and provide a decision support system that helps a health worker perform diagnoses. The system also provides the health workers with the steps for treatment.

What is OpenCHS?

OpenCHS is an Open Community Health Service platform that works in collaboration with NGO Hospitals. OpenCHS is a mobile app that is used by Village Health Workers (VHW) in the field or in their clinics when patients visit them.

OpenCHS helps VHWs to record patient data, perform diagnoses and manage programme statuses. The app also enables the health workers to consider individual patients’ medical histories during their diagnoses.

Our challenges while designing the product

1. Physical Constraints: Data is not recorded as someone on a desk job would. Health workers not only collect data with the app but they also have to use health equipment to take measurements. This requires the health workers to keep switching their attention between the patient and the application.
2. No Electricity and Network Connectivity: VHWs don’t have access to electricity. They use basic cellphones (not smartphones), which they charge using solar charging stations located at central areas of villages. There is also next to no network connectivity which makes it difficult for an application to work in the field.
3. Localisation & Multi-lingual Support: The application is intended to be used throughout multiple states of India. Each state has their own language. Some villages within a state may even use multiple dialects. We focused on providing multi-lingual support and localisation, in particular with regard to specialised medical terminology and concepts.
4. Ease of Use: VHWs live in remote villages of India, where there is very little or no access to technology. They are used to basic cellphones, i.e. no smartphones. We had to be cautious about not having a higher learning curve for the application for them, so they don’t face issues when they are in the field.

What did we do?

Considering the challenges and constraints that we were working with, this is how we approached the design of the application.

It works offline:

We were aware that the user is not going to be connected to a network 98% of the time, so we made the app work offline. We store all data locally on the device. The app only connects to a server when synchonising data. Typically health workers visit a sub-centre or another place with internet connectivity monthly. Recorded data is reported to the hospitals as part of the synchronisation.

Decision Support:

The application provides decision support based on the recorded data and suggests treatment. We built our algorithm in collaboration with medical practitioners and took into account common health procedures. The algorithm even helps the health worker identify emergencies and provide appropriate medical care. When a patient needs medical attention from a trained medical professional, the application suggests them to inform the patients of the details and visit a hospital.

Localisation and Multi-lingual Support:

The application will be implemented with multi-lingual support. For each implementation, there will be localisation for specialised medical terminology used by the residents of the villages. Currently, we have an implementation in Marathi, which can be downloaded from here.

Ease of Use:

Ease of use was our major focus while designing this application.

• Keep it simple, focused: We tried to understand different activities that a Health Worker performs, and based on those use cases, created focus in the application, instead of going by one interface for all flows, like a dashboard.
• Attention on Iconography: We experimented with iconography using various styles and even with contextual icons. This quickly proved infeasible given that our users were stretched through rural India.
  We followed these simple rules of iconography:
  - Keep it simple and schematic, i.e. avoid details
  - 5 second rule, if you can’t think of that icon in five seconds then that icon probably is not a good choice
  - Memorability, making the icons distinct enough that they are remembered even after prolonged usage.

• Understand Behaviour: We tested an alpha version of the application with Health Workers to see if they are comfortable with data entry and understand input fields as concepts. To our surprise, the first thing the health worker did was swipe on the screen. It was most interesting because we knew that our users don’t use smart phones, so how did this come up as a first interaction in this person’s head? Perhaps media has been reaching them through means which one can’t imagine.

So, What’s next?

The application is yet to be released. The plan is to implement it at one village first and then scale accordingly.
We are looking forward to two types of feedback. After the implementation of the application, the health workers will be trained. At this stage will be able to get quick feedback about usability and other challenges.

The second feedback will have a rather longer loop, where the health workers will be using it in the field and on their return we will learn about how it went and get more qualitative feedback. Here is all the documentation, including designs of the project so far.

Want to know more?

There has been much discussion about each flow and decision, in multiple small and large sessions that we will be sharing in detail shortly so that you can better understand our efforts. Keep on the lookout :)

Thanks to nilenso and Samanvay team for the opportunity to work on this interesting problem. I also appreciate the feedback from Kenneth & Trouble in better articulating this post.
Do get in touch with me (noopur@nilenso.com) for any further questions or details. Any feedback will be highly appreciated.

Noopur wrote this story to share knowledge and to help nurture the design community. All articles published on uxdesign.cc follow that same philosophy.

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Designing for Rural India — Part 1 was originally published in uxdesign.cc on Medium, where people are continuing the conversation by highlighting and responding to this story.

*Deliberately sensationalist headline designed to grab eyeballs.

We recently concluded annual reviews at nilenso, at the end of which, Sandy, who recently joined us, asked: “Why is our process the best we can have?”

This led to a lot of reminiscing about how reviews were conducted at other companies that some of us had worked at.

One example went like this: I ask people to review me. I don’t get to read what they said, or find out if they even bothered to write anything at all. Someone from my team (a senior, usually my boss) would look at all these reports along with HR, and hold a meeting with me. The meeting basically involved my boss giving me a summary of the above, based on his/her understanding/interpretation. While I could ask for explanations and examples when I received feedback that I couldn’t relate to, they were not always forthcoming.

There was in fact a level system based on which variable pay was decided, but this was not disclosed. Since the bonuses were kept confidential, even if a person did find out what someone else made, they couldn’t question their pay relative to their colleague (maybe s/he is a better negotiator?).** There was no incremental movement between levels. Post x number of years, you either moved up or out.

Another colleague said that reviews at his previous organisation involved filling out a report, mentioning the number of bugs you had fixed (or caused), SLAs you had met (or missed), and so on, and that “regardless of all this, your appraisal merely depended on the ‘relationship’ you had developed with your manager. Nothing really came about even when you rejected whatever level the manager gave you, because in the end s/he decides it.”

While these may sound like extreme cases, they are very real (and not all that uncommon). Regardless of experience, the adjectives thrown around to describe the performance management process ranged from “random” and “unfair” to “opaque” and “senseless”.

We’ve written about how we conduct reviews before, but here’s a quick recap.

• We use an app (hey, we’re a tech company!) to write reviews for each other. This is open source, if you’d like to use it, be our guest.
• The reviews written are visible to everyone within nilenso.
• Once this is done (and we stress that reviews should summarise feedback that has already been given during the course of the year) and a “level” has been suggested, we collectively sit down to discuss, and finalise compensation for the coming year.

Stacey Adams’ equity theory, that describes how individuals perceive the distribution of resources is well documented. In order to apply this concept, however, and to determine whether one’s compensation is fair, what one needs is data on how the available resources (profits) were distributed to begin with. The approach that most organisations take in this regard is to hold back information relevant to employees. We run against that grain here.

I don’t claim that our method is perfect. In fact, it’s constantly being tweaked. I would posit, however, that the fact that the rationale behind it is completely transparent, and open to critique, makes it better than a system which keeps hidden from its participants, the thought that went into creating it.

I’m also not going to pretend that this will work for everyone. More specifically, I’ll admit that this process may not scale well, and beyond a point, will have to be adapted it to suit the needs of a company that employs hundreds, as opposed to tens of people.

In the meantime, I’ll leave you with this quote by JFK:

“We are not afraid to entrust the American people with unpleasant facts, foreign ideas, alien philosophies, and competitive values. For a nation that is afraid to let its people judge the truth and falsehood in an open market is a nation that is afraid of its people.”

**We would write down our bonuses on a piece of paper, throw them in a hat, and then read them out loud. This way, everyone knew where s/he stood, but no one knew who got what.