Diabetes, Product service system, Social Innovation, Diabetics,
Chronic diseases, Self management, Rural India.
“Designing a Product Service System for diabetics in India to self manage their conditions, mainly focused upon in particular the areas of data management, education, prevention, lifestyle change, and communication between diabetics, doctors, and health workers.”
India second largest populous country in the world and out of which more than 70% of population resides in rural India. India is predominantly an agricultural nation, the literacy rate in India as a whole is still very low. And as its an highly populated country the its obvious to have a higher rate of diabetics. There are thousands of villages in India where people have to walk or travel by bullock cart for miles together just to obtain even a simple medical aid. There are no proper lavatory facilities, which are essential for diabetes patients. Remedies for diabetes prescribed by native medical men include neem tree leaves, bitter gourd juice, honey etc.
From above description it shows that there are many more problems and challenges are there related to diabetic health care in India. A community approach is necessary for planning and implementing prevention and control programs for non communicable diseases like diabetes with common underlying risk factors.
WHO estimates that there are 32 million diabetics in India, diabetes was responsible for more than 125,000 deaths in 2000 and up to 75 % of them were unknown of the fact that they are diabetic. Studies has proved that rising prevalence of non insulin dependent diabetes (NIDDM), which affects Indian earlier than west. Diabetes retinopathy the common cause of blindness in urban, middle class Indian is on the rise, although it is not at high risk. Diabetes is also the most significant cause of end stage kidney diseases. The cost of drugs for diabetes, already high for the average Indian, is expected to go up in the near future.
Diabetes health care in India
The practical management of diabetes in developing countries is often made difficult by the scarcity of health care workers, monitoring equipments and even drugs supply, especially in rural areas. Lack in general awareness of the disease due to in adequate or even absent diabetes education undoubtedly contributes to delayed presentation and misses diagnosis.
The development of diabetic complications is closely related to glycemic control, to accessibility to patient care, and to patient compliance with a rigid dietary regimen and lifestyle. These can be influenced by number of including age, co morbidity, socioeconomic status, and social health care support.
Hence the risk of development of long term complications could be avoided by improving the quality of diabetes care for patients by establishment of public health care system.
The cost of diabetes care is so high that government can not afford the medication cost. The annual estimated cost of care of one insulated treated person attending diabetes care in madras was more than Rs 25,000/-.
Out of 32 million diabetics in India, 20% that is around 7 million diabetics require insulin treatment. The government is unable to provide proper health care, so most of the people depend on private hospitals for better care. There are number of voluntary organization and private clinics and outpatient services to pay the individual attention, patient education towards diabetes.
Current Healthcare Associations active in India
Diabetes association of India was founded in Mumbai in 1955, the aims and objectives of this association are as follows:
Study of the causes and treatment of diabetes.
Promoting of patients education through various media such as lectures, discussions and publications.
Promoting plans for early detection of diabetes.
There are 25 branches distributed all over India. The association works in co-ordination with WHO. The association takes active part, in international congresses on diabetes and organizes national congress on diabetes every three years.
Some other institutes like,
AIIMS- All India Institute of Medical Sciences.
Apollo hospitals are also actively connected with the Association.
Problems of Diabetes in Rural India
The rural sector is suffering from poor socio economic conditions, low health awareness and limited access to medical facilities. Within these circumstances rural diabetics are always diagnosed with severe level. Hence it shows that implications for the provision of healthcare service throughout the Indian subcontinent are clearly essential. These includes both the finances make comprehensive and acceptable diabetes care service to the people, and more important the consideration of capacity of people to afford this service. Indian government spends 1.2% of its annual budget on health and money routinely allotted to no communicable diseases and especially diabetes is sparse.
For planning health care of Diabetes for a District in India, we will take a sample district Kandhamal from state Orissa.
The Dream Land of Nature
The district Kandhamal a part of erstwhile district of Boudh-Kandhamal came to existence on 1st April, 1993 as a result of reorganization of the district of Orissa. The district is a land of scenic beauties, water falls, and natural springs, hill tracts, perched with history antiquities. The District is otherwise peaceful but on 25th December 2007, it attracted attention due to Christians and Hindus and Kandha tribe and Pana caste people. This is the land where Kandha tribes are the principal inhabitants. The district headquarter is Phulbani located in the central part of the district. Administratively it constitute with 2 sub-divisions, 12 CDB, 2 ULB, 153 GPs and 2515 villages. Physiographical the entire district lies with high altitude zone with inter spreading inaccessible terrain of hilly ranges and narrow valley tracts which guides the socio-economic conditions of people and development of the district. More than 50% of population constitutes ST community of aboriginal tribal races. Overall, the district is rank as a backward district in the state of Orissa (India).
The population of the district is 6,90,000 (projected count on the basis of 2001 census) out of which 50,000 is urban population and 6, 40,000comes under rural sector. The literacy rate is 43% and the male to female ratio is 60% to 40% respectively.
There is one district headquarters hospital in phulbani, and four government hospitals in different tehsil place. The state is divided into two sub divisions namely Kandhamal and Baliguda and 12 C D blocks and 153 Gram Panchayats.
Map of kandhamal district Tehsil in kandhamal
Planning of Diabetes Health care
The ever increasing numbers of diabetics alarmingly stretch the disease burden beyond the limits of health care provisions. A primary care clinician with certain with certain expertise in diabetes can barely look after some 30 persons a day by appending 10 min with each and provide minimal care to 1000 diabetics in a month.
To meet diabetic’s requirement and ensure and ensure easy approach to the health center, it has to be set in the center of the chosen place to reach the patients from the periphery and to allow for transportation of patients by ambulance in emergency to the regional diabetes health care center, which can be located at the four tehsil zones.
Hence the risk of development or progression of long term complications could be avoided by improving the quality of diabetes care for patients by establishment of a community health care system.
The healthcare for diabetes provides an excellent example of a chronic disease where primary health care must play a key role. The personnel involved at local and referral levels are physicians, nurses and midwives, community workers, who should ideally work as a team. After a period of training, community health workers have a valuable part to play in the health care team.
The training should enable them to detect new cases.
To test urine or blood for glucose, to identify specific problems.
To give advice, and to know when and where to seek advice themselves.
They should also be able to prescribe follow up care and to provide accurate information to the patient and his family relevant to patient needs.
The primary health center should be staffed with a physician, a nurse and some health auxiliaries. In addition to its health functions, it serves as an educational institution for both the staff and patients, as a center for dissemination of printed information such as diet sheets and as a place where patient’s records are kept. It aims to offer continuous comprehensive and coordinated care. The diabetic care health care centre in different zones will be equipped with OPD, inpatient ward and a care unit with a small administrative wing.
Diabetes Home Care Team
This is a group of expertise which will be located in four different zones of Kandhamal district and will take care of the rural and urban diabetics come under the zone.
The set up of the home care model will consist of a diabetic physician, health workers @ 30 diabetics/ week. Small administrative wing to keep the records and check the digital records coming from various sub units located in the zone and process that data to the respective heath practitioner in the field.
The team will be associated with general health consultants like dietitian, Endocrinologist, physiotherapist, ophthalmologist, dentist, podiatrist etc. so as to direct the patients to the respective consultants for the treatment as per schedule.
Health care worker
Diabetes health care worker play an important role in the community health care systems. They work as assistant to the physician to give patient more detailed information and instructions about diabetes. The diabetic has to deal with special problems every day, including how to plan their meals with various foods, do different kinds of exercises, deal with hypoglycemic events, and seek doctor’s help and so on. A visit to general physician will not cover all information mentioned above, while a health worker in the field can make general information more and more in detailed and personalized to fit the patient’s daily life. The diabetes health worker can also work as diabetes educator to provide information and aware them with new symptoms.
There is a need of comprehensive plan for diabetic education; a person once diagnosed with diabetes has to live with the disease. All the more, this disease affects several aspects of the victim’s life, such as diet, lifestyle, physical well being, mental state, economic conditions, sexual and marital life, etc. so in any discussion regarding diabetes not only patient but also his family should take active participation.
The education plan should go through three phases, are
Primary or initial education.
Secondary or in depth education
Tertiary or continuing education.
Diabetes education and treatment camps:
The camps will be conducted in periphery of different zones, once or twice a month. It can be worked out in collaboration with social organization or NGO’s to screen the diabetics in each zone. Advertisement or posters should be displayed for urban people while for villages village heads, schools, postal department should be involved. It would be very convenient to organize these camps in to school campus or any public open space. Local newspaper, television advertisement, radio announcement will be good way of publicity.
The diabetics in the camp should receive comprehensive treatment including education regarding the basic education regarding diabetes, diet modification, exercise, medications. Name and addresses should be recorded at same time and registration can also be happen the same time. Those who are not registered at the same time can be followed up with health care workers and convince them the importance of their involvement in the service.
Our aim is to approach the problem of diabetes with a view to prevent and control it, with the help of appropriate diabetes health care system. While designing the system following aspects should essentially be considered.
A web based service which will be more helpful and convenient for the diabetics residing in urban sector. This service will be a user pay service and the user will have free access to the basic informative web support, but has to subscribe for full service by paying yearly subscription. This will provide consultant support in respect to the diagnosis and necessary product support. Once the service is subscribed then the diabetic will get all the required product support and online feedback account. This will provide him the required day to day feed back in respect to diet, exercise and everyday tips for BGL management. They will get additional facilities like chat rooms and blog room where they can learn and share there views. This will help them to come out of their depression and form a community and make friends. They can chat directly to doctors and write directly through blog to get feedback from various expertises from all over the world.
The rural sector will be mostly managed by the health workers, each zone will be having a central health care unit, which will take care of the online data of the zone and provide health worker support for the zone.
The zone will be divided in sub zones and a particular area will be given to the health workers where he/she can take care of 30 diabetics, at the rate of 5 diabetics per day. So if we consider 3% is the diabetic population in the state then the number comes around 21,000 approx. out of these 2000 will be residing in developed cities, which can have direct access to internet. Where as rest of the 19, 000 people has to be taken care by the health workers.
The diabetics can visit to doctors every month and the regular day to day management can be governed online. Those who don’t have access to web as in rural and remote areas can be managed by health workers on mobile healthcare.
Heath care worker needs to carry a carer’s kit which will have enough space to carry necessary space to keep products and medicines for demonstrations, a small display screen for data review, internet connection device if required, small handouts and manuals for diet and exercise guide.
The benefit of subscribing the service can be explained to the user by showing the long term returns and the use services in critical conditions in longer run.
The design project will have a physical design outcome with the potential of it being web enabled. A well thought and practically designed health care service. The end deliverable will be a range of multiple operating systems for diabetics that will keep the updated records and directly communicated to concern doctors. Essential product design, development and support for the community.
National Institute Of Design. India
RMIT University. Australia
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