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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 208-214

Barefoot nurse project: A micro-entrepreneurship health model for universal access to the screening of diseases, ensuring self-sustainability in India


Indian Institute of Public Health, State Institute of Health and Family Welfare Premises, Bengaluru, Karnataka, India

Date of Submission12-Apr-2020
Date of Acceptance04-May-2020
Date of Web Publication05-Oct-2020

Correspondence Address:
Dr. Biswamitra Sahu
Indian Institute of Public Health, State Institute of Health and Family Welfare Premises, First Cross, Magadi Road, Bengaluru - 560 023, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_109_20

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  Abstract 

Context: There is still a substantial service gap in India, especially in preventive screening and referral of noncommunicable diseases. There is a growing evidence supporting the role of community health workers (CHWs) in screening diseases and their effectiveness in averting noncommunicable diseases.
Aim: The aim of this article is to describe a model of CHW-barefoot nurse (BFN) (concept, design, recruitment, training, services, products, and evaluation) and share some initial findings.
Setting and Design: This study was implemented in seven locations (Doddaballapura, Nelamangala, Magadi, Bidar, Aland, Hadagali, and Aurad) of Karnataka.
Materials and Methods: The model of BFN, design, intervention development, and implementation is carefully documented and elaborated in this article.
Statistical Analysis Used: The preliminary findings of the intervention were analyzed using descriptive statistics.
Results: The concept of BFN model is a preventive health delivery model where local women from the community get trained with skillsets required for screening several diseases and provide health promotion products at the doorstep of the community. BFNs are young (25–45), from community, completed basic education (10–12 years), digitally literate, and speak local language. Self-sustainability is embedded in the model as it ensures that the BFN earns livelihood from their services by charging a nominal fee with no investment, just using a kit donated by philanthropic organizations. The screened beneficiaries of BFN suggest relatively higher prevalence of hypertension (22.2%) than diabetes (14%). The female beneficiaries and those in the younger age group are relatively more hypertensive.
Conclusion: There is high acceptability of the BFNs reflected from the screened number reflecting the willingness of the community to pay a nominal fee for the BFN services. This study has generated evidence supporting self-sustainable model of funding CHW which is crucial in improving access and strengthening the health system in India.

Keywords: Barefoot nurse, community, India, micro-health entrepreneurship model, noncommunicable disease, preventive health delivery, screening, sustainable finance


How to cite this article:
Sathyanarayana T N, Sahu B, Pai AG, Vivekananda P V, Hazra A. Barefoot nurse project: A micro-entrepreneurship health model for universal access to the screening of diseases, ensuring self-sustainability in India. Indian J Health Sci Biomed Res 2020;13:208-14

How to cite this URL:
Sathyanarayana T N, Sahu B, Pai AG, Vivekananda P V, Hazra A. Barefoot nurse project: A micro-entrepreneurship health model for universal access to the screening of diseases, ensuring self-sustainability in India. Indian J Health Sci Biomed Res [serial online] 2020 [cited 2020 Oct 28];13:208-14. Available from: https://www.ijournalhs.org/text.asp?2020/13/3/208/297182


  Introduction Top


Community-based screening of diseases with skilled frontline community health worker (CHW) is under revival. This is primarily because frontline community-based workers are culturally appropriate, community centric, and they have the potential to catalyze universal health care.[1] There has been a substantial revival of CHWs, especially in low- and middle-income countries.[1],[2] There is a growing evidence supporting the role of community-based trained workers to screen diseases and their effectiveness in preventive services. Their services are often unpaid and voluntary;, however, from program sustainability point of view, there is a necessity to understand paid preventive health-care services.[3],[4] The positive experiences could potentially bring enormous changes in preventive health-care services.[2] To avert the growing health-care expenses, the developed countries are also attempting to explore cost-effective preventive health-care services such as trained health workers. The assumption is to improve access of health-care services, avert health inequities, and strengthen health system performance in a sustainable way.[1] More and more policymakers are examining low-cost, evidence-based sustainable options to develop primary health-care cadre at community level. Thus, the key step is to develop and demonstrate sustainable community-based universal screening of diseases.

Context

The Indian government has been undertaking several efforts to strengthen community-based preventive health services. Despite these efforts, there is a substantial service gap, especially in preventive services such as screening and referral of noncommunicable diseases.[1] The Indian government health-care services are still aiming to expand health services in rural areas while the urban population grows exponentially.[5],[6] However, defying our assumption that urban areas are well served by the Indian health system, the service gaps are increasingly observed in urban and peri-urban areas. Further, there is a growing cost incurred in private hospitals making the preventive health services inaccessible to a large number of vulnerable populations.[7] In addition, the remote population, especially the locations where there is limited or complete lack of government services, are more at risk of developing the preventable noncommunicable disease.[6]

Study context

The Health Innovation Unit of the Public Health Foundation of India has developed the barefoot nurse (BFN) model. This model of preventive health delivery trains local women with skill sets required for screening several diseases, specifically noncommunicable diseases (NCDs), and delivering health promotion products at the doorstep of the community. This model empowers neighborhood women and improves the community's access to NCDs in areas where the government lacks the health workforce. Self-sustainability is embedded in the model as it ensures that the BFN earns livelihood from their services by charging a nominal fee with no investment, just using a kit donated by philanthropic organizations. We assert that this model is likely to bridge last-mile connectivity and to complement the government health services in preventive health.

Aims

The aim of this article is to describe the model of BFN (concept, design, recruitment, training, services, products, and evaluation) and share some initial findings.


  Subjects and Methods Top


Study site

Feasibility of this model of micro-health entrepreneurship was tested in seven locations, namely Doddaballapura, Nelmangala, Magadi, Bidar, Aland, Hadagali, and Aurad taluks/blocks of Karnataka state.

Design

The intervention development (concept, criteria for BFN recruitment, development of training module, developing training video, and formative research for product procurement) and implementation is carefully documented and elaborated in this article.

The secondary data used for analyzing preliminary findings are downloaded from the BFN app that is entered by the BFN, which are real-time data from the field. The preliminary findings of the intervention are analyzed using descriptive statistics. This prospective study was approved by the Institutional Ethics Committee (IIPHHB/TRCIEC/166/2019). This article is based on secondary data obtained from the BFN database hence does not require the authors to obtain informed consent from participants.

Empirical design and intervention

The purpose of this project is to pilot a community-based disease screening model delivered at the doorstep by locally trained BFN for improving NCD identification, referral, and also creating a sustainable livelihood for the BFNs. The primary aim of BFN project is to improve access to basic preventive-promotive health-care services at the doorstep of the community which is the first step in the prevention of NCDs. The BFN project is a micro-entrepreneurial endeavor by delivering services at a nominal price. This model of delivering service by charging a nominal cost incentivizes the BFN to reach the unreached. Each BFN after recruitment and training is allotted a site with an area comprising approximate 3000 houses. The working of BFN is managed by the BFN coordinator under the supervision of a local nongovernmental organization. Currently, the BFN project is ongoing in 8 blocks/taluks of Karnataka state spread across 555 villages/urban areas. The BFN project was initiated in 2019, in collaboration with the department of health, Government of Karnataka, India.

The selection process of barefoot nurse

The BFNs are selected with certain set criteria which are as follows:

  • Ideally, a woman aged between 25 and 45 years
  • Willing to work
  • Hailing from an area neighboring the intervention
  • Should have completed 10–12 years of education
  • Possess minimal digital literacy to be able to do data entry into the mobile app
  • Speaks the local language.


Preference is given in recruiting a BFN from the Muslim community in an area inhabited primarily by Muslims and recruiting BFN from the Hindu community in an area inhabited by Hindus.

The recruitment criteria are then circulated at an intervention site with the help of a local Non Governmental Organization (NGO) as a livelihood option for those looking out for employment. The prospective candidates who show interest are given an introduction regarding the project. The short-listed candidates are then asked to submit a formal application form along with identification proof.

Skill-based training

The training of the BFNs takes place at two levels, namely face-to-face training followed by audio–visual training. The selected candidates first receive an intensive 2 day long face-to-face training by medical professionals regarding protocol of screening five disease conditions, communication, handling of devices; recognizing values/signs for referral, counseling, mobile app data entry process, logistics management, data review, and health promotion. As part of the training, BFN trainees work in a group of 3–4 for 2 days, and the next day, the review is done. The training continues to refine and hone the skill set of the trainees. Hands-on training continues with a group activity to improve screening technique in selected BFN areas for 2 weeks. At the end of the training session, skills are assessed to determine the ability of the BFN to perform screening and data entry effectively. After the BFNs are selected, the BFN coordinator reviews and re-trains for a day each month to assess the progress in improving already acquired skillset and also introduces new learning topics and product/services. Second, another level of fine tuning of the skill set of the BFN happens through sharing of short audio–video clips of 2–5 min covering topics such as device usage methods, device setting techniques, data entry tips, and waste management tips. These videos were developed in the local language (Kannada) explaining the screening procedures.

Services

The BFNs are required to make door-to-door visit in their designated area and counsel people about NCDs. Those who are counseled may choose to undergo one or more screenings from the list below.

After the screening, the BFNs are trained to refer the high-risk cases to the nearest clinic for further diagnosis and treatment. The BFNs are also trained in health education about NCDs prevention and health promotion information.

The kit and mobile application

The BFN project has received one-time support by philanthropic organizations in the form of a kit that contains the screening instruments and few health products. The kit is used by the BFN who carries it on their daily round to screen blood pressure, blood sugar, hemoglobin, urine protein, refractive errors, weight and height, and supply few health promotional products. After rigorous training, each of the selected BFN receives a kit and mobile application. The mobile application is installed in BFNs smartphone, and BFNs are trained to use the mobile app to enter the beneficiary data as well as orders for new stock.

In-built sustainability of barefoot nurse

The BFNs project is designed in such a way that the BFNs after obtaining the training and have the kit can earn livelihood without any additional financial assistance. The sustainability of the project is conceptualized through the money that the BFN earns by delivering health services such [Table 1] lists the disease conditions being screened and the markers, namely, blood pressure, blood sugar, hemoglobin, urine protein, refractive errors, weight and height. They also supply some health promotional products.
Table 1: List of items in the barefoot nurse kit

Click here to view


Health promotion products

In addition to basic disease screening services, the BFNs also carry certain health promotion products such as sanitary pads, multivitamins, anti-helminthic tablets, pain balms, oral rehydration salts, and others. The pricing of these health promotion products is highly subsidized as a strategy to benefit the community and as a source of livelihood for the BFN. This enables the BFNs to earn some extra income in addition to the income that she generates from delivering screening services. Thus, selling these health promotion products is a motivating factor for the BFN to continue with her services. The retail price of the products is determined by the product review committee and prices on health promotion products are less than the market price of the products. The BFNs purchase these products from BFN project office coordinator at wholesale prices which are significantly less than market price. However, health promotion of the community is the primary motive behind subsidizing the health promotion products, and revenue generation for the BFN is only a secondary objective behind this strategy.

Evaluation

The evaluation of BFN project is done at different levels,

  1. Process evaluation
  2. Outcome evaluation.


Process evaluation

During intervention development the efficacy of audio–video training (AVT) was assessed by testing performance of BFN in the pre-AVT phase compared to post-AVT phase. Similarly, the health promotion products that are included in the kit are a result of the formative research where the community members were asked regarding the products that they will find useful to be supplied by the BFN at their doorstep.

Outcome evaluation

The outcome of the intervention is an ongoing process where the live data that are entered by the BFN into the mobile app and that data are being analyzed to assess the performance of BFN in terms of screening. A rigorous evaluation of the BFN project is being conducted through randomized controlled trials. The primary outcome indicators include (a) proportion of population screened for NCDs (diabetes, hypertension, anemia, vision problems, and kidney ailment), (b) proportion of population, who are diagnosed with NCDs repeated the screening, and (c) proportion of first-time detection and referral of NCDs. The secondary outcome measures include an average amount of money earned per week/month, per BFN, timeliness, and completeness of data filled in data entry app.


  Results Top


The BFN project is implemented in seven blocks/taluks, and the details of the project are described in [Table 2]. The BFN project has been operational in the range of 6–10 months. The highest number of BFNs are working in Doddaballapura (25), followed by Aland (15), Nelamangala (10), Magadi (7), Bidar (5), Hadagali (5), and Aurad (3). Consequently, proportionate to the size of BFN team, the highest number of beneficiaries of the BFN project is registered in Doddabalapur (22750), followed by Aland (14599), Nelamangala (8200), and Magadi (7002). However, three BFNs in Aurad (6987) have registered higher beneficiaries compared to five BFNs each in Bidar (6790) and Hadagali (5821).
Table 2: Profile of barefoot nurse project

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[Table 3] cross-classifies in all seven locations the screening done by BFN across six health parameters, namely blood pressure, diabetes, hemoglobin, refractive error, and weight and height. Screening for weight happens to be very popular across all locations. Screening for blood pressure figures is highest in Doddaballapurs, Aland, Bidar, and Hadagali. The screening of diabetes is also high in Nelamangala, Magadi, and Hadagali. Screening of height is highest in Doddabalapur; however, in other locations, weight figures as the least screened parameters along with hemoglobin and refractive error.
Table 3: Number of persons screened for various conditions in different blocks/taluks

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[Table 4] reveals that of the screened BFN beneficiaries, a total of 14% have been diagnosed with diabetes, with 7.4% being old cases, and 7% being new cases. The females screened are relatively more diabetic (7.6%) compared to men (6.9%). Those in the 50–59 age group are more prone to diabetes (7.2%) compared to those in 30–49 (3.8%) and 60+ (3.5%) years of age.
Table 4: Prevalence of hypertension across screened barefoot nurse beneficiaries across sex and age

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[Table 5] delineates screened beneficiaries of BFN suggesting a relatively higher prevalence of hypertension (22.2%) than diabetes (14%). The new cases of hypertension (13.3%) are higher than old cases (8.6%). The females (13.5%) are more hypertensive than their male (8.9%) counterpart. Those in relatively younger (30–49 years) age group are more hypertensive (9.6%) followed by those in middle (50–59 years) and the oldest (60 years and above) are least (5.6%) susceptible.
Table 5: Prevalence of diabetes across screened barefoot nurse beneficiaries across sex and age

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  Discussion and Conclusion Top


This article elaborates the concept of BFN, their recruitment, training, services, products, and evaluation of the project. As a concept, BFN is geared to provide the last-mile connectivity to the community with screening of NCDs and other conditions. The model provides livelihood to the BFNs through the services and products that BFN carries to the doorstep of their community. The BFN undergoes rigors training to screen, supply products, and enter data. It is based on a sustainability model that ensures that the BFN can earn livelihood with a minimum investment with the aid of a kit donated by philanthropic organizations. The preliminary findings highlight the potential of the BFN in screening conditions and promote preventive health in community. There is high acceptability of the BFNs as they are from the community and the screened number reflects the willingness of the community to pay a nominal price for the services of BFN. The study findings show the profile of BFN project and screening key indicators. The services of BFN were designed to complement the government services, especially in locations where the government public health services/workforce is limited. For example, in the urban areas, the number of government health workers is either limited or does not exist. Furthermore, in several rural areas, there is a vacancy of health workers or the area is not covered for screening services. The BFN project shows promise in filling such service gap for screening NCD and other ailments. This article provides evidence that supports the potential of BFN pilot project that needs to be scaled up to fill the larger service gap in this area.

Comparison of barefoot nurse vis-a-vis evidence of community health worker in government setup

In developing countries, especially in India, BFN project is a unique self-sustainable project in preventive health care. In contrast to BFN project, the government-supported CHWs are not embedded in a sustainability model.[8],[9] The incentives received by CHW are often dependent on funding from external sources; thus, we do not know what will happen when the source of funding gets unplugged. However, the Indian government-recruited CHW- accredited social health activist often has expressed dissatisfaction over remuneration;[10] nevertheless, the BFN model seems to be promising because the funding is not from any external source, and the remuneration earned by BFN is based on their performance. The Indian government-funded CHWs projects are riddled with inadequacies due to supervision by rigid hierarchical beauracracy.[11] In contrast, the BFN project receives minimal supervision from a coordinator and does not have to manoeuvre across the bureaucratic system, eventually, enhancing performance. Further, intense supervision and micro management are often may not be sustainable. The key driver for BFNs is financial incentives on dispensing services. Rigorous studies in different settings show that preventive and promotive care services at community level can potentially improve health of population with proper incentivisation.[8]

This study also adds to health system research literature on the potential benefits of community contribution and its effect in engaging pro-community health services at door steps. A majority of the studies related to incentivisation and its benefits are being studied in education sector and examined performance of teachers.[12] One of the randomized controlled trials also noted improvement in anemia and benefit of incentives to school head to deliver health services among school-going children in rural China.[8] Similarly, in Indonesia, one of the studies examined social entitlements/benefits distribution and its linkage with health service delivery performance.[13] Another study in Zambia through a randomized trial found that the combination of unconditional grants and small incentives helped in minimizing anemia level.[8] These studies reflect that both financial incentives as well as value-driven communication could potentially play a significant role in improving pro-health services among BFNs.

The BFN can also be trained in nonpharmacological interventions, such as yoga, meditation, exercises, and dietary counseling to guide the community members in preventive health. This could help in promoting healthy behavior. This study contributes to the literature of health system research by assessing the nature of health micro-entrepreneurship approach to improve preventive health-care delivery in improving health of population and, more specifically to preempt NCDs.


  Conclusion Top


The findings from this study can potentially be replicable in low-resource settings elsewhere in the developing world, especially in urban India (tier-1, 2 and 3 cities) where there is a limited government-supported health workforce. Scaling up of BFN project can be converted into a program for strengthening preventive health care. The learning from the BFN can aid in making an informed decision through the engagement of relevant stakeholders to improve preventive health care. The self-sustainable nature of the BFN could be re-designed and implemented in a possible program mode. Further, this can adjust the course of the program based on experience, monitoring, and evaluation and synthesize evidence from implementation research. The future progress of BFN project depends on re-adjusting with area-specific minor modifications and initial funding opportunities. The BFN project can play a vital role in strengthening the health system. The value addition of BFN lies in offering a community-oriented, comprehensive preventive care which is financially feasible, culturally appropriate, and equitable to all in a sustainable manner.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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WHO. The World Health Report 2008. Primary Health Care – Now More than Ever. Vol. 26. Geneva: World Health Organization; 2008.  Back to cited text no. 1
    
2.
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Black RE, Taylor CE, Arole S, Bang A, Bhutta ZA, Chowdhury AM, et al. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 8. Summary and recommendations of the expert panel. J Glob Health 2017;7:010908.  Back to cited text no. 3
    
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Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle-, and high-income countries: An overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health 2014;35:399-421.  Back to cited text no. 4
    
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Bhaumik S. India outlines plans for National Urban Health Mission the Indian Government is planning to launch a new urban health-care programme in its latest. Lancet 2012;380:550.  Back to cited text no. 5
    
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Ergler CR, Sakdapolrak P, Bohle HG, Kearns RA. Entitlements to health care: Why is there a preference for private facilities among poorer residents of Chennai, India? Soc Sci Med 2011;72:327-37.  Back to cited text no. 7
    
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Bhutta Z, Lassi ZS, Pariyo GH. Global Experience of Community Health Workers for Delivery of Health Related Millennium Developmental Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems; 2010.  Back to cited text no. 8
    
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Singh P. One Million Community Health Workers: Global Technical Taskforce Report. New York: The Earth Institute, Columbia University; 2013.  Back to cited text no. 9
    
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Mishra A. Trust and teamwork matter: Community health workers' experiences in integrated service delivery in India. Glob Public Health 2014;9:960-74.  Back to cited text no. 11
    
12.
Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk BE, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev 2010;3:CD004015.  Back to cited text no. 12
    
13.
Olken BA, Onishi J, Wong S. Should aid reward performance?: Evidence from a field experiment on health and education in Indonesia. Am Econ J Appl Econ 2014;6:1-34.  Back to cited text no. 13
    
14.
Poulter NR, Prabhakaran D, Caulfield M. Hypertension. Lancet [Internet]. 2015;386:801–12. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0140673614614689  Back to cited text no. 14
    
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Thomas T, Prabhata S, Valsangkar S. Diabetes screening and the distribution of blood glucose levels in rural areas of North India. J Family Community Med. 2015;22:140-4. doi:10.4103/2230-8229.163026.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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