Novartis India’s Arogya Parivar Reaches 42 Million

Travelling by moped, Sunita Bhalerao is a familiar and welcome sight to the impoverished villagers who live near Nashik in Maharashtra. For the men, women, and children she sees along her daily routes, spreading the vital messages of health awareness and prevention and dispensing medicines and words of concern, Sunita is the face of Novartis India's Arogya Parivar rural healthcare initiative.

Launched just three years ago, the project, whose 270 health educators today offer improved health care access to 42 million people in 11 states, is already rising to the next challenge facing India, the world's second most populous country: chronic or non- communicable diseases.

"Arogya Parivar has implemented a very effective field operation that allows important messages to be conveyed about awareness and prevention of diseases. The program is making laudable efforts to increase the detection of otherwise undiagnosed diseases and is helpful by making relevant medicines and other health products available as close as possible to the villagers. It seems to us that Novartis is taking the right path of creating such a social business."

Sean Mayberry, Managing Director, Population Services International (PSI) India  (Source: Novartis India)

"India is undergoing rapid epidemiological transition as a consequence of economic and social change," reported the International Journal of Epidemiology in 2006, adding, "Hundreds of mil- lions of individuals living in rural India are probably now at much greater risk of death from chronic or non communicable conditions than from communicable diseases."

Indeed, chronic diseases, including coronary heart disease, stroke, cancer, and diabetes are the leading causes of death in India, as well as most other l o w- and middle-income countries (LMIC). In 2005 chronic diseases ac- counted for 53% of all deaths in India, as well as 44% of all disability- adjusted life-years (DALYs)—by 2020, the Global Burden of Disease Study projected, 66.7 % of all deaths in India will be attributable to chronic diseases.

Among all diseases, chronic or communicable, cardiovascular disease (CVD) is the leading cause of death in India; like other chronic diseases, it also strikes at a much younger age than in developed countries. The burden of CVD also falls disproportionately on India and other LMIC. In 2003, the DALYs lost because of coronary heart disease were 20 per 1,000 population in India, compared with 5 and 8 in Australia and the United States, respectively.

Stroke in India too is "very much on the rise," the journal Circulation reported in 2006.Diabetes is as well. India already leads the world in number of people with diabetes. By 2030 the number is projected to climb to 79 million, up from just 32 million in 2000.

A New Model For Increasing Healthcare Access

The main ingredients of Novartis's rural health initiative, which has doubled in size and scope in just a few short years, are prevention, partnership, and innovation. They're the defining characteristics of this very successful program that combines social business practices with humanitarian ideals, as well as the human touch of people like Sunita Bhalerao.

Arogya Parivar, which means "healthy family" in Hindi, is organized into cells, currently numbering 280. Each cell, which covers a 25-30 kilometer radius, includes 100 or so villages and has between 180,000 and 200,000 inhabitants. As of 2009, the280 cells covered205 districts across 11 states, including Maharashtra, Gujarat, Tamil Nadu, Karnataka, Rajasthan, Madhya Pradesh, Uttar Pradesh, Chhatisgarh, Haryana, Bihar, and Uttarakhand.

Each region, and the villages within them, has its own epidemiological and cultural particularities, so the program is adapted as it expands into new territory. But the emphasis is consistently on prevention, as well as ensuring treatment in the event of illness.

A team of eight health educators and a supervisor are deployed in each cell and works closely with village leaders and local NGOs. Overseeing the health educators, all non-physicians who are recruited from among villagers themselves, is a team of dedicated Novartis managers. They in turn work with a third-party organization of 25 managers who are in direct day-to-day con- tact with the several hundred field- workers. In addition to being responsible for the strategy and content of the program, the Arogya core team selects and trains all the people who staff the cells. "Each health advisor completes a training program for three to four diseases and we also train them in public speaking,” said Oliver Jarry, Project Head (2006-08).

“It is heartening and very exciting to see such enthusiasm from our healthcare people.  They show total dedication to the job,” added current Project Head Anuj Pasrija.

This innovative use of non-physicians allows the program to reach many more people than a physician-based system with information about prevention and health awareness and to overcome cultural barriers that prevent many people from seeking treatment or even listening to health messages.

Arogya Parivar has four main operational elements:

  • The health educators reach out into the community and provide health information and encourage healthy behaviours. They also refer the sick to local doctors and partner with local NGOs to achieve wider dissemination of health information. The educators use vernacular and multi-lingual collaterals and audio-visual communication tools.
  • Supervisors share health information with local pharmacies and partner with local doctors, hospitals and NGOs to organize health camps where villagers can receive treatment and preventative care. They also have at their disposal micro-vans capable of showing audio-visuals.
  • Medicine packs, with their own special packaging, are developed that are affordable and specifically designed to address rural diseases – for example, Novartis in India has developed a WHO-approved ORS+Zinc anti-diarrheal formulation in affordable sachets, and an anise flavour. To enhance affordability, Novartis may modify standard package sizes of products, such as calcium tablets for pregnant women. “We revived an old design of a tube holding 15 pills, half the number and half the price of our smallest standard pack,” Mr. Jarry said. “It’s been a phenomenal success.”
  • Educators build strong linkages with local pharmacies to ensure that medicines are available and that patients are taking them. These linkages go well beyond traditional pharma practices, which focus on doctor detailing. In many cases, this has meant setting up new distribution networks capable of supplying even the most distant locations. If all else fails, the distinctive Arogya Parivar vans are used to make deliveries.

When originally conceived and created, Arogya Parivar’s primary focus was on combating tuberculosis, other respiratory infections, coughs, colds, allergies, skin and genital infections, malnutrition in mothers and children, intestinal worms, and digestive problems.  Today, the program is increasing its focus on such chronic diseases as diabetes and epilepsy.

India’s Prevention Imperative

Innovative partnerships like Arogya Parivar are desperately needed to prevent India’s chronic disease epidemic from reaching its full potential.  The economic and human tolls of chronic conditions are too great to ignore – this is especially so in India, where deaths from chronic diseases occur disproportionately among main income earners in households.

$237 billion -- how much India will forgo in national income from 2005 to 2015 as a result of premature deaths caused by heart disease, stroke and diabetes

Source:  World Health Organization

“The socio-economic impact of premature death due to chronic disease is enormous,” Rohina Joshi et al. reported in 2006.  “The death of the main income earner in a rural household, at a relatively young age, has direct consequences on the welfare of the family, drawing them into a downward spiral of poverty.

Consider the impact of CVD alone in families.  Half of all CVD deaths in India occur in the working-age population (as compared to one-quarter in developed nations), and the CVD death rate in the working population is twice that in the U.S.

At the macroeconomic level, the picture is equally bleak.  According to the World Health Organization, the projected foregone national income due to heart disease, stroke and diabetes was $9 billion in 2005, as compared to $1.6 billion and $0.5 billion for the UK and Canada respectively.  The projected cumulative loss of national income over the ten-year period ending in 2015 is $237 billion, more than seven times that of the UK.

India’s Prevention Gaps

Research reveals just how massive the holes are in India’s prevention efforts.  To begin with, two-thirds of the population have limited access to basic healthcare, which right out of the gate means that most are getting little preventative care and health education.

Consider public awareness of the risks of stroke.  “About one-fourth of the unaffected urban respondents had no knowledge of any warning symptoms compared with one-third of the unaffected rural population,” reported the journal Circulation in 2008.  “Only 55% of the urban population were aware of 1 warning symptom of stroke.

With respect to people who have been diagnosed (or had an episode such as a non-fatal stroke or heart attack), even secondary prevention is a serious problem.  “In a recent study in rural Andhra Pradesh, India, fewer than one-sixth of those with a previous cardiovascular event (mostly myocardial infarction) were receiving anti-platelet therapy,” the Journal of the American College of Cardiology reported.  “50% of people with diabetes were aware of their condition, and of these, only two-thirds were receiving glucose-lowering therapy.”

Innovative programs like Arogya Parivar are an essential public health tool in a country like India, where the rural population is large and poor and has little access to preventative care and health awareness programs, let alone treatment.  Its reliance on non-physicians such as Sunita Bhalerao is noteworthy, in as much as several public health experts have cited the benefits of using non-physicians to deliver preventative care, health education, and medicines.

“Systems based on non-physician health care providers may be of great value,” Rohnia Joshi et al., wrote in Circulation.  “Not only are non-physician healthcare providers more numerous and widely distributed than physicians, but their services are affordable to a much larger proportion of the population.”

Writing about priorities for expanding access to cardiovascular healthcare, Joshi, along with other researchers, again endorsed the value of deploying non-physicians in rural areas—via a model similar in many respects to Arogya Parivar:

A critical first step in the resolution of disparities in access to care in LMIC settings is to establish locally relevant templates for acceptable and affordable primary healthcare oriented toward evidence-based, cost-effective strategies.  Such strategies would promote awareness and improve access to prevention, early diagnosis, and early treatment.

All in a Day’s Work

Sunita Bhalerao is part-teacher, part-healer, and part-angel.  She visits weekly open-air markets, fairs, and festivals, where she speaks to villagers and distributes pamphlets on health awareness.  She helps organize health camps, interacts with Anganwadi workers to reach out to women and children, works with local pharmacists to ensure stocks of medicines are always in supply and liases closely both with doctors and patients to ensure patient compliance.

On a given day, Sunita, or any one of her colleagues across India, could travel 35 kilometers, all by moped.  In one village, she might meet with a local paediatrician and gynaecologist to brief them on health issues affecting women and children, and then in another talk to 50 mothers about the risk of diabetes.  She might then travel to a third village to talk to a group of husbands about why it’s so important to their families that they stay healthy.

In just three years, Arogya Parivar has proven to be a winning concept.  It empowers villagers, provides employment, and improves rural healthcare.  Ultimately, it will dramatically enhance the well being of families, as main income earners benefits from chronic disease prevention and treatment.  Even better, it’s a model that can be replicated in India and throughout the developing world.  Clearly, it inspiration is the belief that the way to a healthy India is to create one health family – Arogya Parivar – at a time.

Arogya Parivar:  In brief

  • Established in 2007.
  • Its 270 health educators cover 280 cells in 205 districts (28,000) villages in 11 states.
  • About 4 million people receive health education every year.
  • 286 supervisors work with over 22,000 doctors and 18,000 pharmacies.
  • Initially, 11 therapeutic applications were offered for rural conditions.
  • Today, such chronic diseases as diabetes and epilepsy are treated.
  • In total, 42 million people reached, their access to healthcare improved.

References:

  • Rohina Joshi et al., "Chronic diseases now a leading cause of death in rural India—mortality data from the Andhra
  • Pradesh Rural Health Initiative," International Journal of Epidemiology, 2006; 35: pp. 1522, 1528.
  • K. Srinath Reddy et al., "Responding to the threat of chronic diseases in India," The Lancet, 2005; 366; 9498: p. 1744.
  • Rohina Joshi et al., "Fatal and Nonfatal Cardiovascular Disease and the Use of Therapies for Secondary Prevention in a Rural Region of India," Circulation: Journal of the American Heart Association, 2009; 119: p. 1950; Rohina Joshi et al., "Global Inequalities in Access to Cardiovascular Health Care," Journal of the American College of Cardiology, 2008; 52; 23: p. 1818; K. Srinath Reddy, "India Wakes Up to the Threat of Cardiovascular Diseases," J. Am. Coll. Cardiol., 2007:50: p. 1370.
  • Shyamal Kumar Das and Tapas Kumar Banerjee, "Stroke: Indian Scenario," Circulation, 2008; 118: pp. 2723.
  • "Responding to the threat," p. 1744.
  • "Global Inequalities in Access," p. 1818.
  • "Chronic diseases now a leading cause of death," p. 1528.
  • "Global Inequalities in Access," p. 1818.
  • World Health Organization, "Preventing Chronic Diseases: A Vital Investment," 2005, p. 78.
  • Das and Banerjee, p. 2722.
  • "Global Inequalities in Access," pp. 1819-20. Another study of the same population showed that just 14 percent of individuals with a history of vascular disease were taking aspirin, 41 percent were on blood-pressure lowering medication, and 5% were taking a cholesterol-lowering medication. ("Fatal and Nonfatal Cardiovascular Disease," p. 1955)
  • "Fatal and Nonfatal Cardiovascular Disease," p. 1953.
  • "Global Inequalities in Access," p. 1824.