“ECHO aims to help expand India’s medical care reach-out capacity”

In an exclusive joint face to face interaction with Dr Arvind Lal, Founder and Chairman, Dr Lal PathLabs; Dr Sanjeev Arora, Founder and Director, Project ECHO; and Dr Kumud Rai, Head, ECHO India, the BioVoice tried to understand the efforts behind Project ECHO, an initiative to increase and extend the medical care capacity to far off and rural areas. Read on:

(L-R) Dr Arvind Lal, Dr Sanjeev Arora and Dr Kumud Rai.

The Project ECHO (Extension for Community Healthcare Outcomes) is a movement to demonopolize knowledge and amplify the capacity to provide best practice care for underserved people all over the world. While it started as a way to meet local healthcare needs, now it operates more than 130 hubs for more than 65 diseases and conditions in 23 countries. In an exclusive face to face interaction with Dr Arvind Lal, Founder and Chairman, Dr Lal PathLabs;  Dr Sanjeev Arora, Founder and MD, Project ECHO; and Dr Kumud Rai, Head, ECHO India, the BioVoice tried to know more about the new initiative

Please tell us in detail about the idea behind the Project ECHO? Where does it operate in India and how? 

Dr Sanjeev Arora: Project ECHO started as a way to meet local healthcare needs. When I was working as a liver disease doctor in Albuquerque, I found that thousands of New Mexicans with hepatitis C could not get the treatment they needed because there were no specialists where they lived. The clinic where he worked was one of only two in the entire state that treated hepatitis C.

It was then the Project ECHO was created so that primary care clinicians could treat hepatitis C in their own communities. Launched in 2003, the ECHO model makes specialized medical knowledge accessible wherever it is needed to save and improve people’s lives. By putting local clinicians together with specialist teams at academic medical centers in weekly virtual clinics or teleECHO clinics, Project ECHO shares knowledge and expands treatment capacity.

The ECHO model does not directly provide care to patients. It breaks down the walls between specialty and primary care. Together, the primary clinicians and specialists participate in weekly virtual clinics supported by tele-conferencing technology, combined with mentoring and patient case presentations.

Based on the huge success of Project ECHO in New Mexico, USA, ECHO India was started as a not-for-profit Trust in 2008. The idea was to replicate the ECHO model to improve healthcare delivery to rural and underserved areas of India.

ECHO India has come a long way from its first collaboration with National Aids Control Organisation (NACO) and Maulana Azad Medical College (MAMC) on managing HIV Aids patients. Currently teleECHO clinics in India are run by 15 hubs to tackle different disease states like Addiction and Substance Use Disorders, Mental Health, Tuberculosis (MDRTB), Hepatitis C, Liver Diseases, Cancer Screening and Prevention, HIV, Palliative Care, Corneal Ulcers, Hypertension, Maternal & Child Health.

Dr Lal, you mentioned that there is a shortage of doctors and nurses in India. How can India cope up with this human resources scarcity challenge?

Dr Arvind Lal: What is gone from India is gone. There are many who top doctors left. What we have to understand that there is no way we can stop doctors from going out of the country but we can’t allow people to suffer the way they are due to the quality of treatment.

As Dr Sanjeev Arora was pointing out that ECHO India will train the doctors. Here is an MBBS doctor sitting in the rural area which is again not well staffed, can do his bit in tackling not only the killer diseases but non-communicable lifestyle diseases such as cancer, high blood pressure, obesity, cardiac diseases etc. Even for highly skilled gastroenterologists, the doctors are not available. The idea is to disseminate the education downwards.  We have run out of time and we can never have so many doctors and specialists caring about 1.3 billion Indians. The innovation is only going to come from the technology. The country as a whole has to adopt the disruptive ways to tackle the issue. There is no time to re-invent the wheel. We should rather make use of what is available to us. Echo India is trying its bit and the modal adopted by them should be given a try.

Dr Rai, you want to add your experiences during the project so far? 

Dr Kumud Rai: Echo India has made good partnerships. I will give the examples of two such institutions. One is our association with the PGI, Chandigarh and Punjab Government. The Hepatitis C is a big problem in Punjab perhaps due to widespread drug abuse. PGI used to see close to 1,300 patients in a year and there are more than 1 lakh patients going through Hepatitis C. We introduced this programme through PGI doctors’ run clinics at district levels and within one and half years, they have treated 40,000 patients. The difference it has made in terms of scale is enormous.

NIMHANS in Bengaluru started running a survey that 3.5 percent of Indians suffer from some sort of mental issues. They have started mentoring the doctors from Chattisgarh, Bihar and of course Karnataka where they were no psychiatric specialists but they have trained 1,000 doctors in common mental disorders such as substance abuse, women health, anger management and serious psychiatric issues.

These are general practitioners but look at the wonders they can do. They can at least sort out the majority of the problems. Of course, there would be many who will require to be referred to specialized treatment. Similarly the Tata Trust and Tata Memorial are running the cancer clinics at 84 institutions. These are some of few partnerships.

Dr Arora, you mentioned that the concept of Echo India is different from telemedicine? 

Dr Sanjeev Arora: What makes it different from the telemedicine is that the former gives an idea to fish and ours is to teach how to fishing. The basic idea at Echo India is that the issues that are dynamically complex as the situation is constantly changing. The current model of training involves the lectures to the doctors and then expecting them to implement, which is very difficult. In comparison to that, we sit next to them do what we call guided practice. We create a community of doctors for practice and mentor them practically, leading them to become trained practitioners over the period of time. The capacity to treat that one disease goes up 10 folds and later to 50 folds over the period of time. The example of PGI Chandigarh which adopted our model has a cure rate of 91 percent. In a district far away from PGI, they are getting the treatment done and that too at such a good success rate.

Dr Lal, there is a dearth of funding for healthcare startups in India. In the absence of enough funds, how can we innovate in India?

Dr Lal: What I mentioned in my talk was that while the e-commerce startups such as Flipkart and other online businesses in India can manage to get fundings, the healthcare startups don’t get the same attention. The only money that comes is minuscule for startups and the reasons might also include not being disruptive enough.

The startups that are coming up with ideas such as comparisons apps for charges of the doctors. They are at that level which has to change from something basic to more medical. This is not a doctors’ job to get the appointments done or do price comparisons.

ECHO India is coming in to enhance the capabilities of doctors to check the patients. We are not talking about the basic medical issues but Hepatitis C where even the gastroenterologists too sometimes are foxed what to do. Bringing that level up from basics to the trainer’s level is what ECHO is doing. That is not the only solution but yes a major one in the present scenario.

Could you share some experience while pitching for ECHO in the various countries? 

Dr Arora: Last week I was in Vietnam. I spent five days there and met with every leading institution there. 3,000 bedded hospital in Hanoi and 2,500 bedded hospital in Ho Chi Minh city and 30 other institutions including the medical universities. Every single one of them decided to adopt the ECHO.

And I was surprised at such a heavy intake and I asked myself why is that Indian institutions are not quick to adapt it in the same way. I realized the answer is that there is a responsibility problem.

The biggest hospital in Hanoi was given the job of improving the care given to patients of the 20 Northern provinces of Vietnam. And they were responsible for all the tertiary care and development of that area. When I went to another hospital in Ho Chi Minh City, they were given the responsibility of not only the tertiary care and training of medical students but also the responsibility of entire 32 Southern provinces of Vietnam.

Every day 6000 patients were lining up at the hospital. They realized that moving knowledge to other places only cannot only beat their problem but improving their knowledge and then spread it in a systematic way would work best for them.

How can we replicate these models followed in Vietnam within India?

Dr Arora: When I come to India and when I go to All India Institute of Medical Sciences (AIIMS), I see that their rule is to provide tertiary care but they don’t have regional responsibility. In my view, every state medical institution, every central medical institution like PGI, Chandigarh and  NIMHANS, Bengaluru has to be given a mission. Not the mission to see the difficult patients or train the doctors but a mission to create a triage system for the whole region. An AIIMS should be able to look after the people from 6 states. It should be responsible for the ultimate care of 100-200 milion people. Then a system like ECHO can be brought in for the support. But we don’t prescribe responsibility to the big institutions. And everybody seems to be doing their own thing and there is a little chaos in the system.

Let me tell you a sad story. I was in National Institute of Mental Health & Neuro Sciences (NIMHANS) and I met the director. He told me there are 30 poor patients who are to be examined by him on the same day. All of them, he said, belonged to West Bengal. Since there is no epilepsy doctor in their vicinity, they came all the way to Bengaluru.

Comparatively, the things are better in Vietnam.

I would like to meet the health minister to present my ideas and design for consideration. First time I flew to Vietnam in my life and I met the health minister there. He told me that he is going to bring ECHO to Vietnam wholescale. I met him because he could see that it was a system intervention based on the idea that you must have the right care. For that, you have to have right knowledge at the right place at the right time. Any amount of money and resources cannot change this equation. The knowledge has to come and you need a way to mentoring and democratising the knowledge. That is the theory we are proposing.

Dr Rai: To be fair, we have met a couple of health secretaries and they were optimistic. It is good that they have appreciated the ideas. The problem is so humungous that nothing materialised at the table so far but I am sure positive things will happen.

HIV, Hepatitis C space have witnessed good efforts by the ECHO and those will be the achievements to showcase for execution of other ideas.

Why is the healthcare funding often neglected in the government’s budgetary allocations?

Dr Lal: The Government of India has said that we are going to increase the allocations from 1.5 to 2.5% of GDP by 2025.  They are doing whatever they can do. Then you need the political will, you need the management will and expertise which all have to flow in one direction. It is not just one health minister thinking in one direction, one health secretary thinking in one way, one CMO or one CGHS. Everybody has to come on the same platform.

It was good to see the joint efforts towards eliminating the Tuberculosis. From WHO top executives to the top ministers of the government including the prime minister himself. The same approach was used for containing polio and other diseases.

Let me give you an example. 2.8 million patients are there and every minute, a patient dies due to TB. The problem has been there for a long time but finally, the Government has woken up.

Similarly, there has to be thrust on the other diseases like the TB has been taken up. A lot of time has already passed. We welcome the change.

Dr Arora: It is heartening to see that the Prime Minister has himself taken up the task. Something is happening now.

Dr Rai: The healthcare budgets are expected to increase with the passing time. The increased attention to healthcare means that it will surely receive its due.