June 16, 2008
At the Research Symposium, Dr. Abhay Bang – Director of the Society for Education, Action, and Research in Community Health (SEARCH) based in Gadchiroli, Maharashtra, India – presented on the topic of research on the use of appropriate technology for health care at the community level.
Dr. Bang opened his dynamic presentation with the statement KNOWLEDGE IS THE NEW FORM OF WEALTH, and argued, “there is a fortune at the bottom of the pyramid,” – with the people.
Presentation (PDF): Bang Abhay Appropropriate Technology May 2008
He asked, why appropriate technology? What is appropriate? Answer: the social context, the problem addressed, the human power, and the resources/cost of services must all be appropriate to the community being considered.
Dr. Bang presented on his research on care and management of neonatal sepsis that was published in the Lancet in 1999. This study not only found that sepsis could be managed at home by village health workers under supervision of a physician, but that this method could reduce the neonatal and infant mortality rates by nearly 50%.
The local context of his work: rural villages in India where neonatal care was not available to the overwhelming majority of families and thus where 83% of women gave birth at home, either because hospitals offering neonatal care were too far geographically to access, the cost of care was too expensive, or because of traditional views. Among the obvious challenges, both the prevalence of literacy among adult females and low-birth weight among newborns stood at roughly 40%. In this region, nearly 60% of under-five deaths were due to neonatal causes — the leading neonatal causes being prematurity, birth asphyxia, injury and infections. Earlier research findings that home-based care of pneumonia in neonates could reduce the neonatal mortality rates provided encouragement for this research in the community.
Literate female health workers were trained and tested to manage and care for sepsis in 39 out of 100 villages. Equipped with a kit with low-tech items and medications, including cotrimoxazole and gentimicin for sepsis, the method tested succeeded in drastically reducing neonatal and infant mortality over the three years of the study.
The evaluation of the study included questions such as:
Relevance to community? Study was highly relevant to the community because neonatal care was virtually inaccessible, involved the traditional birth attendants in the community, village health workers were all residents of the community
Effective? Highly effective, reduced neonatal mortality, built capacity of women in communities to become village health workers, provided in-home and free options for care to families.
Cost? Free to families, end result – cost $5.30 per newborn vs. $17.30-44.20 per day of care for newborns in urban hospitals – with stays averaging 8.8 days. Much more cost-effective!
Ethical? Got permission of advisory board and written permission of families to provide care at home. Although the use of simplified diagnostic criteria allowed for over-diagnosis of sepsis, few laboratories and the need for urgent care justified the use of this method. Of the all the newborns during the study, 6.5% were treated with antibiotics, a rate similar to newborns treated in both hospitals in Boston and India. Though the care offered to the newborns in this study was not equivalent to the highest quality of care available at the time in the wealthiest countries, as some prominent ethicists have argued it should be, Dr. Bang emphasized that this care was ethical because it was the best quality available in the villages.
Power shift? females in communities were trained to be village health workers, health education was provided to mothers and grandmothers in year three of the study.
Dr. Bang concluded his presentation by asserting that the most innovative research ideas are found by speaking with the people in the communities, leaving the audience with the words:
“Go to the people, live among them, love them, listen to them, learn from them, begin with what they know, build upon what they have.”
In the discussion that followed the presentation, the following questions were addressed:
- What research questions need to be addressed on appropriate technology?
- The question of how to best address empowerment
- What are the research priorities for appropriate technology?
- Important to concentrate on health systems research in developing countries
- Appropriate technology addressing illiteracy: using oral learning/teaching/cultures as a teaching methodology
- Revisit prevention (health education) – behavioral change communication
- Good fit and good point-of-care technology: take solutions to the problems
- Example in Eastern Nepal: training nurses to take portable ultrasound (“video x-ray”) to rural areas. Two year study being conducted currently.
- What messages need to be conveyed to and by the community about the implementation of research studies pertaining to appropriate technology?
- How is long-term sustainability of activities achieved?
- Research capacity
Questions that remain to be answered include:
Applying results from Dr. Bang’s research on neonatal sepsis to the last question, the potential of sustaining funding for the treatment method was raised by testing such a cost-effective method that was upteen-times cheaper than treatment in hospitals, and upteen-times more effective than what was formerly widely practiced in the villages. The potential to sustain the infrastructure developed was increased because female village health workers had already been trained, care kits had already been developed, interventions were all virtually all low-tech, and only one physician was needed to evaluate the quality of care by the village health workers.
Are there any other answers to the questions proposed here or any other examples of best practices that make use of appropriate technology that could be applied in other developing country contexts?