Change Ag ents Bring Hope and Health to Rural India

Rural India faces an acute shortage of healthcare professionals. In an innovative initiative called “Addressing the Base of the Pyramid” (BoP), Novo Nordisk A/S teamed up with community partners to bring diabetes services closer to people in remote areas while supporting health activists’ microbusiness. This initiative is now integrated with the Changing Diabetes Barometer® program in Bihar, India, to increase the level of outreach.

Sangeeta Devi sits on the dusty ground outside a small, rural home. In front of her sits a middle-aged woman, to whom Sangeeta asks a series of questions. The woman complains of feeling tired. Sangeeta takes out a glucometer and tests the woman’s blood sugar.

Sangeeta is an Accredited Social Health Activist (ASHA) in Sampatchak, a town of 112,000 people in the east Indian state of Bihar. In a country with a severe shortage of healthcare professionals, ASHA is a pillar of the National Rural Health Mission’s strategy for improving the proximity and affordability of basic healthcare services in rural India. Armed with knowledge and a supply kit, people like Sangeeta bring hope and healing to millions of Indians who still struggle with fundamental public health issues and infectious diseases that have been nearly forgotten about in the West.

Those problems command the focus of India’s health system. As such, few ASHAs have the skills to address non-communicable diseases. To improve ASHAs’ capabilities and the health of the communities they work in, Novo Nordisk A/S piloted a Base of the Pyramid initiative in Sampatchak and trained 32 ASHAs in basic diabetes knowledge and counseling. The initiative proved so successful that it has been integrated with the Changing Diabetes Barometer® program of the Novo Nordisk Education Foundation (NNEF). NNEF last year signed a memorandum of understanding with the Bihar state health society to train 300 more ASHAs in the basics of diabetes care who will be deployed to 10 primary care diabetes centers in the state.

“This will help diabetes patients from my village get good care closer to their homes,” says Deepa Sinha, another ASHA worker in Bihar. “They can get easy access to diabetes care, for which currently they have to travel far.”

Scarce resources

In India, there is not even 1 doctor for every 1,000 people, which is less than half the global average. In some primary care clinics, a doctor might see between 20 and 100 patients a day, depending on the season. Overwhelmed by such conditions as malaria, leprosy, tuberculosis, and HIV, “manpower is low for handling diabetes,” says Dr. Rebha Krishori, medical officer at a primary care center in Dahod, Gujarat.

Not only are there too few doctors, many remote primary care centers struggle with too few drugs. Some do not have insulin, forcing them to refer people with uncontrolled diabetes to a hospital that is often far away. That compounds the problem – patients who cannot afford to travel or take time off of work either settle for suboptimal care locally or take a risk of buying counterfeit drugs on the open market.

And then there is the lack of awareness. “We run a diabetes outpatient department every Saturday. The challenge is that patients with diabetes are not coming for treatment,” says Rebha. “If a dedicated person could follow up with these patients, we would be able to provide them with quality care – just like with tuberculosis and malaria. The ASHA workers can play a big role in increasing awareness of diabetes.

Meet the ASHA

Appropriately, asha means “hope” in Sanskrit. The ASHA is a link between the public health system and the community, and often is the first point of contact in underserved populations. Selected from their own villages, ASHAs are women between the ages of 25 and 45, literate, and with some formal education. They promote and deliver immunizations, make referrals for maternal health, and teach patients about nutrition, sanitation, and self-care techniques. They bring basic medications to people’s doorsteps to help them stay healthy.

Each ASHA has responsibility for 1,000 people. “She knows every household in the village and can be an effective aid for creating awareness about diabetes,” says Dr. Bharathi Bhatt, Senior Medical Advisor of Novo Nordisk’s India affiliate.

But ASHAs themselves face several barriers to promoting better awareness about diabetes, treatment, and complications, says Bharathi. They are often inadequately compensated, reducing their incentives to mobilize the patients as best as possible. They are perceived as maternal health and vaccine providers. Their lack of training in non-communicable diseases perpetuates misconceptions about their competence. “But with the right training and empowerment, ASHA workers can be agents for change,” says Bharathi.

Base of the Pyramid pilot

In March 2013, Novo Nordisk A/S operationalized the BoP pilot based on the concept of social entrepreneurship. As part of this initiative, training was provided for 32 ASHAs to improve their diabetes care skills, and economic support was provided in the form of starter kits.

Novo Nordisk India affiliate’s medical advisor taught ASHAs about types of diabetes, complications, how to recognize signs and symptoms, and monitoring of blood glucose levels. ASHAs were trained to handle glucometers, counsel patients on diet and exercise, and on insulin storage and injection techniques.
Classroom sessions concluded with a written test. To combat questions about ASHAs’ competence and to provide them with future employment opportunities, ASHAs who passed the test successfully received certificates as “lay diabetes facilitators.”

An ASHA carries her new skills into the village. There, she promotes healthy lifestyles, refers people at risk of diabetes to a primary care diabetes center for screening, and motivates patients to stay adherent to treatment and to visit clinics regularly – not just when they experience symptoms.