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Is the application / software still being built or are their existing educational or telemedicine platforms that could be used? If you are already leveraging LHWs, can the sensitization services be delivered through them? Or is there a reason that a higher tech solution to connect to other professionals is needed?

Unfortunately, the clinical and technical capacity of existing network of LHWs to deliver sexual and reproductive health is limited in Pakistan. We realized that to overcome the gap of sexual and reproductive health service provision and uptake, we needed to plug in specialists to deliver high quality care. We wanted to capitalize on developing a network of existing human health resource and infrastructure at community level by providing them capacity building and technical training to effectively utilize a digital solution to deliver SRH services and advocacy.

Based on this need, we developed an in-house real time digital solution that is currently functional across 14 telemedicine centers in Pakistan. The use of our solution to provide sexual and reproductive health services can help bring needed care to women who do not have physical access to services or health centers. As women in underserved communities are often home bound and are not allowed traveling to health centers, our solution will decreasing the need for clinic visits through approaches that allow telephone follow-up or self-assessment. The unique feature of the portal is that it offers a real-time screen sharing option that enables health care professionals to educate girls and women regarding their sexual and reproductive health conditions and its consequences. In addition our innovative approach with text messaging can help support adolescents to access sexual and reproductive health services by providing information and reminders about medications and appointments.

Our digital innovation aims to build young people’s individual capacity to make safe choices; to make Sexual and Reproductive Health services better adapted to young people’s individual needs; and to strengthen the linkages between information and service provision.

This is a creative idea that addresses multiple challenges within the community, what considerations are given to the local environment, is it safe to engage in a hub and spoke model? 2) What are the rates of use of mobile technologies? Most importantly, what are the rates of women's access to technology? How are girls privacy taken into account?

As per 2016 statistics, Pakistan has a total population of 192,826,502 out of which 34,342,400 are internet users. This equates to a 17% penetration of internet uptake in Pakistani population. In addition, three fourths of the population in Pakistan has access to mobile technologies. Women in low- and middle-income countries are reported to have limited access to cell phones, with South Asian women being 37% less likely to have cell phones than men. For women in Pakistan, unfortunately several factors, such as literacy and cultural barriers, act as inhibitors that lead to the ICT gender divide.

Our hub and spoke model is a unique and first of its kind effort to digitally make reproductive health truly accessible to every low-income marginalized Pakistani. To improve acceptability and uptake at the community level, we leverage existing clinical infrastructure of community health nurses and convert them as our e-spokes by plugging in technological facilities. Adolescents feel safe to avail services via our model as the health workers deployed by us, as these frontline health workers already have been active in the community and has continued to deliver health services in the past.

Policies and procedures are in place to protect the privacy and confidentiality of young people. All user information is stored on cloud and is password protected to ensure privacy. Beneficiaries availing the virtual consultations are instructed to use headphones for their privacy. At Hubs, a separate room in dedicated for the adolescents to connect with the virtual doctor for consultation and information to ensure visual and auditory privacy. The doctor or nurse attending the adolescent is instructed to speak in a lowered voice when asking them personal or private questions. Sehat Kahani team has also developed training programme which includes policies and procedures for protecting the privacy and confidentiality of our beneficiaries. We conduct trainings and online modules for master trainers to reinforce privacy and confidentiality. The performance and practices of service providers and staff in relation to privacy and confidentiality are regularly monitored and appropriate actions taken. We also induct our beneficiaries in feedback loop whereby we request them to report whether or not their privacy and confidentiality was protected while availing the consultation.

Dear Open IDEO team,

Thankyou for your feedback. Below are the responses to some of the questions raised.

How would this be financed long term? How will workforce be compensated? Long term tech support?

To ensure sustainability, we have deployed a revenue sharing business model. For E- Hub a general and specialist virtual consultation cost 0.50$- $3 to the beneficiary respectively. For At home service [E-spokes] the beneficiary has to pay $1 - $5 to avail a virtual primary and specialist consultation respectively. Out of that revenue, 30 % is provided to the nurse/ Community health provider [frontline health worker], whereas the remaining 70% is the revenue to Sehat Kahani.

Sehat kahani is also responsible to provide a monthly retainer of $150- $200 to the at-home female doctor/specialist who is supervising the consultation. For Value added services - lab collection point, ultra sound services, pharmacy sales, secondary and tertiary referral services via E-Hub or Spokes, a beneficiary pays somewhere between $2-$5. This earned revenue is split with the third party on a variable basis. Usually, it accounts for 60% of the revenue earned.

For the proposed solution we can achieve self- sustainability is if we reach to 450 patients per month per hub or spoke for a period of 12 months. The long-term sustainable partnership allows the communities with a means of accessing tests, awareness material and other facilities which are otherwise missing. In addition, Sehat Kahani will continue to provide long term technical and clinical support and continue to develop their capacity by inducting frontline female health provider and doctors in online continuing medical and nursing education network.

What is considered a successful telemedicine visit? For example, if an adolescent wants to proceed with family planning alternatives, what are her next options?

At Sehat Kahani we aim to provide comprehensive one stop solution for our beneficiaries to access sexual and reproductive health services. Rather than standalone youth-friendly services or separate spaces within services for adolescents, our initiative is focusing on mainstreaming adolescent-friendly contraceptive services with existing family planning services.

For instance if an adolescent wants to proceed with family planning alternatives, the first step is to schedule a virtual call with a health specialist to avail remote consultation. The consultation will enable the adolescent to make informed choice about her choice of family planning method. Our trained intermediary i.e. frontline health provider would then provide our beneficiaries access to contraceptive materials/ procedures within their communities. Our next step is that we utilize mobile solutions to send sexual and reproductive health information, education as well as notification for the next follow-up visit schedule to our beneficiaries. The follow up visit may be a one-off checkup or it may be ongoing depending upon the needs of our beneficiaries.

Our beneficiaries that are availing the telemedicine visits are also enrolled in preventive health network to ensure continuity of care. These beneficiaries are continuously engaged in health promotion and education campaigns at the community level to induce behavior change. By increasing access to care through more frequent and patient-centered communication with qualified providers, our telemedicine model can yield great results in improving the quality, safety and efficiency of our health care system.

Dear Eliziane Dorneles Siqueira  ,
Thankyou for your extended support and feedback!

1- On Data Storage and Delivery: Sehat Kahani delivers a highly scalable software-based conferencing and communications platform that makes technology transparent for healthcare environments by integrating with clinician workflow tools and patient portals. We achieve an exchange of information that can be live and simultaneous, or pre-recorded, and can be exchanged using text, audio, video, or still images. This unprecedented ease of access and use comes with Sehat Kahani adaptive technology that enables it to deliver consistent high quality video, audio, and content across any IP network and user device. It allows physicians, administrators, and patients to easily take advantage of point-to-point and multipoint video conferencing from virtually anywhere, radically changing the dynamics of Sexual and reproductive healthcare delivery in socio-culturally sensitive communities based in Pakistan.

For the ease of our frontline health care providers and doctors, our solution offers cloud based electronic health system that comprises of current and past diagnoses, current and past medications, allergies, past consultations, lab results etc., of the beneficiaries who have availed services at Sehat Kahani telehealth centers. Our solution is also integrated with pre-defined indicators that are generated based on the data base of the beneficiaries stored. The app then uses this data to help people manage their condition and predict triggers.

Our innovative edge is that our solution offers a real-time dashboard that provides our health workers a quick snapshot of several indicators that includes but is not limited to the number of consultation provided, the number of SRH problems identified, the number of adolescents reached and number of referrals and follow-ups generated in their respective target communities. This kind of technology can have a huge social impact, rapidly improving access to healthcare with relatively little investment.

2- On utilization of interface: Sehat Kahani has developed a digital interface that is currently deployed in 14 rural districts of Pakistan through our hub and spoke model. A hub is a health center located in the community that is equipped with technical tools such as laptop for online consultation, digital peripheral diagnostic tools and a trained community health nurse to deliver sexual and reproductive health services and value added services under the supervision of an online at-home female specialist. Every Sehat Kahani telehealth hub [clinic] is linked to one Sehat Kahani spoke. A spoke is a tabled enabled health provider who will travel door to door to reach beneficiaries at their homes and provide them sexual and reproductive health services and education.

Through this interface we were successful to provide primary health telehealth consultations to 45,000 beneficiaries [majorly women and children] and reached to 500,000 beneficiaries via health education and promotion activities till date. While we were delivering primary health care services we realized a massive need to make SRH services accessible for young adolescents. For this purpose, Sehat Kahani partnered with Spring Accelerator in early 2017 to initially reach out to 6000 young adolescents with early marriages, provided them health services and engaged them in health promotion activities over a period of 6 months. We deployed our digital solution as a prototype to deliver SRH services in 5 target communities and created 5 e-Hubs and 10 e-spokes. In addition we also trained and created a network of 100 front line health workers and specialists to deliver SRH services to our target beneficiaries.

Our prototype stressed on the key importance of addressing gendered inequities, to improve the health and promote the rights of all adolescents and young people. Adolescents must be reached earlier in their lives with sexual and reproductive health programmes and services – particularly the most vulnerable and marginalized adolescents, such as adolescent girls and young women. It was worthy to note that door to door health education campaign could tackle harmful gender norms, power imbalances, traditions and practices, are more likely to reduce misconceptions regarding menstruation, unwanted pregnancies and rates of early child marriages. Gender inequities, in terms of beliefs, attitudes and norms, must be addressed, and equal power relationships must be promoted, as an integral part of all sexual and reproductive health programmes.

For the continuation of this initiative, we will integrate extensive SRH modules, assessment forms, and risk assessment chart and health education videos in our existing interface to deliver comprehensive services for our target beneficiaries.