Tag Archives: lessons learned

The Art and Science of Diagnosis

A professor from Ohio State e-mailed me the article with the deceivingly understated subject line of all-lower case “fyi.” The Hindu write-up’s headline, though, didn’t mask the shocking contents: “Appalling condition of primary healthcare services” it read. (1) Short and potent, it described the lurid details of a study carried out across the health sector in India, rural and urban, private and public. The details showed a fundamental lack of ability by medical professionals to diagnose even the most common conditions (asthma and dysentery, for example) or ask the most basic questions (whether there was “pain radiation” for an unstable angina). The result was a low rate of diagnosis, whether it was in rural Madhya Pradesh or Delhi.

Overall, healthcare providers provided the correct treatment only 30.4% of the time. (2) Even worse, 41.7% of the time the clinics provided unnecessary or even harmful treatments for “patients” that the research study trained (“from the local community”, the article notes). Many providers, even in public clinics, were unqualified. Medical guidelines and treatment protocols were followed at low rates; providers only asked 33.7% of the recommendations. In Madhya Pradesh, doctors spent 3.6 minutes with patients, while Delhi medical professionals spent a marginally better but still terrible 5.4 minutes. For reference, the Medical Council of India recommends doctors spend at least 10 minutes with each patient. (3)

The article highlighted tough facts that Calcutta Kids has been tackling for years. Through our experiences with the health clinic, we’ve worked to combat the norm of primary health in India: brief, non-comprehensive visits and a disregard for protocols and checklists. We’ve uploaded to the resources section of our website our child health World Health Organization’s IMCI and IMPAC-based Child Health and Pregnancy and Maternal Health protocols and checklists which our doctors are trained and demanded to use. Our two health clinic physicians, Drs. Pal and Sen, work with our management staff to ensure that the protocols we have provided them matches their process for diagnosing patients. See the above-mentioned resources below:

Child Health Protocol (0-2 months)
Child Health Checklist (0-2 months)
Child Health Protocol (2 months to 5 years)
Child Health Checklist (2 months to 5 years)

Pregnancy and Maternal Health Checklist and Protocol

It’s an important process that Calcutta Kids has to do to ensure our beneficiaries get not just quantity but truly quality care. It hasn’t been an easy process to bring in this cultural change into our clinic over the years, but it’s a necessary one. In addition, the creation of standardized protocols ensures a consistent level of care that our beneficiaries can expect, regardless of personnel changes. As Atul Gawande noted in his Harvard Medical School commencement, it’ll require an understanding of a team of healthcare providers- a “pit crew” that includes our health workers- not just the lone cowboy physician:

“The work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.” (4)

Many rightly criticize the low rates of spending on health per GDP in India, ranking 171st out of 175 countries according to a WHO study. (5) But the situation is even grimmer: it is not enough to just increase spending, build more primary health centers or even to write diagnostic protocols at a national level. The groundwork of implementation at a doctor to patient level must be accomplished. At our health clinic, we work on this ground level to make sure that provision of the highest level of primary healthcare is a reality for the mothers and children of Fakir Bagan.–Pranav Reddy

Citations:

  1. Appalling condition of primary healthcare services. The Hindu. R Prasad. December 6, 2012. Retrieved from http://www.thehindu.com/health/medicine-and-research/appalling-condition-of-primary-healthcare-services/article4167677.ece on Jan 1, 2013.
  2. In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps. J Das, A Holla, V Das, M Mohanan, D Tabak, B Chan. Health Affairs. December 2012. 31(12):2774-84
  3. MCI wants docs to spend at least 10 mins with each patient. The Times of India. K Sinha. September 1, 2011. Retrieved from http://articles.timesofindia.indiatimes.com/2011-09-01/india/29953546_1_opd-patients-doctors on Jan 1, 2013.
  4. Cowboys and Pit Crews. The New Yorker. Atul Gawande. May 26, 2011. Retrieved from http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html#ixzz2H02jhJMO on Jan 1, 2013.
  5. World Health Statistics 2011 Report. World Health Organization (WHO). 2011; 127-139. Retrieved from http://www.who.int/whosis/whostat/2011/en/index.html on Jan 1 2013.

SWOT Weakness–>Monthly Meetings

In the spring of 2012, our 2011-2012 AIF Fellow Margy Elliott conducted a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis for Calcutta Kids. Margy carried out long interviews with representatives of all of our stakeholders including all of the staff; beneficiaries; donors; former interns; current interns and volunteers. The management team along with the board of trustees has carefully gone over this detailed document and is implementing changes so as to promote and further reinforce our strengths, fix the weaknesses, take advantage of the opportunities, and close the holes on the potential threats. Over the coming months, we will share ways in which we have used the SWOT analysis to strengthen and protect Calcutta Kids.

One of the discovered internal weaknesses was a lack of communication between the field staff and management. Many staff members commented on the need for regular communication and regular staff meetings. So we started such monthly meetings in July and we’ve been having such fun with them.

October 2012 Monthly Meeting. Staff sitting in front of “jack-o-lanterns” they made.

We follow a simple agenda for these meetings:

  1. Ice-Breaker
    1. At the end of the previous meeting, a staff member is nominated to prepare and conduct the ice-breaking session at the beginning of the next meeting.
  2. Introduction
    1. We start off each meeting with a case study from the field—usually in the form of a PowerPoint presentation with photographs and associated text. The case is often meant to inspire the staff; share a lesson learned; or show how a particular counseling technique worked or didn’t work. As our work is divided into three geographical areas, each area has a chance to present once every three months.
  3. Updates/Announcements
    1. Job openings
    2. Program changes
    3. Data Feedback–we discuss the quantitative accomplishments of the past month
    4. Welcoming of new staff members; bidding farewell to departing staff
    5. Status updates on ongoing projects
    6. General explanation of accomplishments over the last month
    7. General plan for the coming month(s)
  4. Questions & Answers
    1. This is an opportunity for anyone in the organization to ask questions and raise concerns which need to be dealt with as an organization.
  5. Birthday Celebration & Welcomes and Goodbyes
    1. At these meetings we celebrate all the employees who have birthdays that month.
    2. While eating snacks and cake, we toast our departing staff members and welcome our newcomers.
The meetings are events which both management and field-level staff look forward to. They are a time for recommitting to our cause and to celebrate the community that is Calcutta Kids.

Ice-breaking activity

At the October monthly meeting, Noah and Evangeline were in charge of the ice-breaker. The day before the meeting, we told every member of the team to come in to work the following day with a cooking knife (they dubiously obliged) and Halloween and pumpkin carving was introduced. The staff broke up into groups of 2 and made beautiful ‘jack-o-lanterns’. The following day, Area-In-Charge, Barnali took all the pumpkins and cooked them into a delicious pumpkin stew and the whole staff ate it for lunch along with home-made luchis. –Noah Levinson

Chandan and his carved pumpkin

Sumana and her carved pumpkin

Walking the Walk

As a fellow with the American India Foundation Clinton Fellowship For Service, I have spent the past nine months working with Calcutta Kids. It has been an incredible experience, and the things I have learned while working here will remain with me throughout my life and career.

One thing that has really impacted me is how this small, but mighty organization is not just one that “talks the talk”. Every day, every employee, every community member is provided with love, compassion, and a sense of humanity that so many organizations may lose as they get caught up in their day-to-day work. “Walking the walk” is what has made Calcutta Kids such a beloved organization in this community. I wish you could see them in action too. Here’s just a sample of the amazing things I’ve seen, which are just a part of Calcutta Kids’ daily work:

– I’ve seen the Community Health Workers in homes, teaching families intimate lessons that will improve their health; teaching mothers how to initiate breastfeeding; and being the first visitor a new mother receives after giving birth.

– I’ve seen technical staff carefully stop programs that turned out to be ineffective in our area.

– I’ve seen the staff embrace a child from the neighborhood, teaching him English, providing him food, and even brushing his teeth when his mother cannot.

– I’ve seen the work in the clinic, where the technical staff knows the names and faces of individual mothers and children.

– I’ve seen mothers come to receive diarrhea treatment, and stay for nap under a fan with her child without any disturbance by the staff.

– I’ve seen severely malnourished children literally being wrapped up in the arms and love of every staff member – from our cleaners to our doctor – as the mother comes daily to learn how to provide proper nutrition for her child.

– I’ve seen management put aside social norms to prove Calcutta Kids values girl children as much as boy children.

– I’ve celebrated with the staff when babies are born with a good birth weight, when our support group started coming to meetings without being called, and when 86 people came to the clinic the day a new immunization was offered (more than 50% increase from an average week of immunizations).

– I’ve joined in concern when unhealthy children come to the clinic, and have seen the staff go to great lengths, sometimes even on the weekends, to ensure the child’s health improves.

Calcutta Kids is not fancy, and we like it that way. Our interventions are simple and heartfelt. The staff prides itself on feeling like family, and the community members are treated like an extension of that family. The facilities are clean and the women are respected. I’m grateful I was able to spend my Fellowship with an organization as sincere and hard working as Calcutta Kids. – Margy Elliott

A Message for the Community

I was recently asked, “If the population Calcutta Kids serves were to remember only one of the messages you give, what would it be?” Without any hesitation, I replied with a wonderful message I had just learned: “A child gaining weight cannot be very sick. A child not gaining weight cannot be very well.”

This is a message that Charles Janeway, Professor of Pediatrics at Harvard Medical School told his students.

This simple, yet profound statement embodies the work of Calcutta Kids; it provides convincing verbal ammunition against many of the daily battles we fight against long-held superstitions, misinformation, and a general lack of understanding regarding the importance of good nutrition during the first 1000 days.

Explaining the science behind the cognitive and physical developments that occur in the first 1000 days of life depending on nutritional status is nearly impossible for an uneducated mother to understand. Counseling, behavioral change communication, growth monitoring and promotion, and access to healthcare — indeed everything we do at Calcutta Kids — does lead to reaching the objective of good nutrition within the window of opportunity. But the programs and the activities are not enough. In our efforts to get people to care about nutrition, I believe we are underutilizing our greatest resource — the women themselves with whom we work — the true movers and shakers. If these women truly grasp what we are trying to achieve for their children and why they will figure out ways to help others understand the problem; they will take the challenge personally and seriously; and they will ensure that they themselves are well looked-after during pregnancy and will ensure that their children get the nourishment they need at the right time.

There is simply no question that every mother wants what is best for her child. But in order to assure that she provides what is best to her children, she needs to understand and really believe that proper nutrition will make a difference.

We have translated Janeway’s message into Hindi and are promoting it as a sort of mantra for Calcutta Kids. Before long I hope that every pregnant woman and mother we work with will know the mantra — but more importantly will grasp its meaning.

Jab bache ka ho sahi vikas…

To hain ye sehat ka agaaz…

Jo bacha na ho mota Zindagi bhar hain woh rota…

(A child gaining weight cannot be very sick. A child not gaining weight cannot be very well.)

– Noah Levinson

Low Cost Health Insurance – Too High a Cost

Originally posted in the Fall 2011 Newsletter

One of the basic tenets of Calcutta Kids is that we are willing to be innovative and take responsible risks, making sure to carefully monitor and evaluate everything that we do. When these innovations work, we scale them up, but when a program or project doesn’t prove cost-effective or in the best interest of the families we serve, we have a responsibility to discontinue it. One such case is our micro health insurance program, which we are ending after many months of careful consideration.

Although the initiative proved inadequately effective, we were able to assist hundreds of families in managing the fees associated with healthcare; and we also worked with some wonderful colleagues who have since turned into friends at the International Labour Organization (ILO), the United India Insurance Company (UIIC) and the Center for Insurance and Risk Management (CIRM).

While many of our Calcutta Kids beneficiaries purchased and benefited from the insurance program, many more did not. We discovered, sadly, that most of the families who purchased the insurance were economically better off than most of the desperately poor slum dwellers; they would have purchased health insurance anyway, and simply found Calcutta Kids’ product less expensive than what’s available on the market.

Another unfortunate discovery was that the micro health insurance program threatened to compromise the trust which the community has had    for Calcutta Kids and which we cherish. The reasons for this are twofold: first, that the door-to-door sales by Calcutta Kids health workers led some beneficiaries to think that Calcutta Kids was now trying to make money from the community; and second, because what had originally been a cashless product had, without our permission, become a reimbursement product with claims often taking more than 3 months to settle. Ultimately, it became clear that Calcutta Kids is neither an insurance company nor an insurance agent and is simply not in a position to run such an operation single handedly.

We had hoped that we could use our comparative advantage as a trusted presence in the slum to educate about, promote, and sell inexpensive health insurance to slum dwellers and then rely on partners – expert organizations in the field of insurance – to manage the office work, including claims. However, those partners were unable to change their systems (created as part of a for-profit industry) to address adequately the needs of the poor. The difficulties we faced with regard to claims management, oversight, and partner cooperation – with the costs heavily outweighing the benefits – simply made it impossible for us to continue running this program.

Calcutta Kids is committed to the proposition that every experience of an organization like ours, positive or negative, needs to be shared with the larger development community. Accordingly, we are most pleased that CIRM, a research group in Chennai, is carrying out an in-­‐depth study of our program and the challenges that made it inadvisable for us to continue its operation. The publication and dissemination of this work will certainly enable other groups to learn from our experience, and, in turn, move forward this important area of international public health.