Transforming Indian health care: Leveraging standard treatment workflows for equitable and effective care

Authors: Kavita Kachroo, Prudhvi Teja, Moinudeen Syed, Sahithya Vanjavakam

1. Kalam Institute of Health Technology- A JBI-Affiliated Group, Andhra Pradesh, India
 

Introduction

World Evidence-Based Healthcare (EBHC) Day 2024 highlights the theme “Beyond Health: From Evidence to Action,” underscoring the power of evidence to create meaningful change in health care systems and beyond. India’s health care system, serving over 1.4 billion people, faces significant challenges in ensuring equitable and efficient care delivery, particularly at the primary care level. Despite efforts to improve health care access, inconsistencies remain, especially in resource-limited settings where physicians are overburdened. In this context, simplified, evidence-based guidelines are crucial for delivering uniform and effective care nationwide.

To tackle these challenges, the Indian Council of Medical Research (ICMR) introduced Standard Treatment Workflows (STWs), which are concise, user-friendly tools that streamline health care by offering practical, evidence-based guidelines for managing common diseases. The STWs are a prime example of how clinical evidence can be transformed into actionable tools that guide health care providers in delivering high-quality, standardized care. This blog will explore how STWs shape health care in India, the obstacles they help overcome, and their broader impact on the health care system.

With these challenges in mind, it is essential to understand the background of India’s health care system and the specific needs that STWs address.

Background

India's health care system is characterized by a wide range of disparities in access to care, particularly in rural and underserved regions. Outdated clinical guidelines, delayed diagnosis, and inconsistent care across facilities often lead to suboptimal patient outcomes. Furthermore, physicians, particularly at the primary care level, face cognitive overload due to an ever-increasing volume of medical knowledge that is difficult to keep up with. A report highlighted the need for simplified clinical guidelines that are easy to follow and implement, especially in resource-constrained settings (Grover et al., 2024).

The JBI Model of Evidence-Based Healthcare offers a pragmatic approach to navigating the complexity of global health systems and improving outcomes (Jordan et al., 2022), much like the STWs, which were specifically designed to overcome several key challenges in India's health care system. These include:

• Simplifying complex guidelines: Traditional guidelines are often too dense for quick reference. STWs distill this information into concise, one-page formats that health care providers can easily access and apply, even in high-pressure situations.
   
• Reducing variability in care: Variations in clinical practice have long been an issue in India, contributing to inconsistent patient outcomes. STWs standardize treatment protocols across different levels of the health care system, ensuring that patients receive consistent, evidence-based care, regardless of location or resources.
   
• Improving resource utilization: In settings where resources are limited, the overuse of unnecessary diagnostics and treatments can deplete valuable health care assets. STWs promote the rational use of resources by providing clear guidance on when to employ specific interventions, ensuring that treatments are both cost-effective and appropriate to the clinical scenario.
   
• Enhancing decision-making efficiency: Time constraints and heavy patient loads can lead to decision fatigue for health care providers. STWs streamline clinical decision-making, enabling faster, more accurate treatment choices without compromising care quality. STWs offer a streamlined solution by providing concise guidance in a simplified format, helping clinicians quickly make informed decisions and standardize care across all levels of the health care system.

Understanding these background challenges sets the stage for a deeper examination of the specific problems facing India’s health care system.

The problem

India’s health care system faces significant disparities, particularly in rural areas. Approximately 70% of the population resides in rural regions, yet they are served by only 30% of the country's health care facilities, highlighting a significant gap in access to quality health care (Sharma, 2024). As of March 2022, there were 31,053 primary health centers (PHCs) across rural and urban areas, with the majority 24,935 (80%) located in rural regions (Arora, 2024; Rural Health Statistics, 2023).  However, the rural health infrastructure is strained, and many PHCs lack adequate staffing and updated treatment guidelines. This results in inconsistencies in clinical practices, thereby affecting treatment outcomes and leading to increased health care costs (Arora, 2024).

These disparities create a pressing need for effective solutions, prompting a search for answers that can unify clinical practices and enhance care delivery.

The search for answers

In response to these challenges, ICMR, the National Health Authority, and the World Health Organization India developed STWs to create a unified approach to clinical decision-making. These workflows were designed to be simple, adaptable, and accessible, providing health care providers with the tools needed to deliver high-quality care efficiently.

The development process involved extensive consultation with domain-specific experts, who identified priority diseases and conditions based on their prevalence and impact on public health. STWs are continuously validated and refined to meet the specific needs of health care providers in diverse environments, from rural health centers to tertiary hospitals in urban areas (Grover et al., 2023).  By consistently applying these workflows, health care professionals can make decisions based on the latest evidence, ensuring a higher standard of care and reducing variations in treatment outcomes (Ghosh, 2024). By consolidating complex medical guidelines into easy-to-follow workflows, STWs help reduce the cognitive burden on health care professionals, enabling them to focus on patient care (Grover et al., 2024). The Union Health Ministry has called for the implementation of 157 STWs across 28 specialties, highlighting the importance of integrating these workflows into everyday clinical practice to improve patient outcomes (ETHealthworld, 2024). Pilot programs are underway in two Indian states to test the effectiveness of STWs in managing both acute and chronic conditions, with an emphasis on gathering feedback from health care providers to ensure these workflows are practical and adaptable. 

The potential of STWs extends beyond local implementation; their success could influence global health care practices.

Potential global impact

STWs, if effectively implemented in India, could indeed serve as a model for other low- and middle-income countries facing similar health care challenges. By leveraging evidence-based workflows, India can significantly improve health outcomes and bridge the health care gap between urban and rural areas. STWs align with global health goals, such as achieving universal health coverage, which is a key target under Sustainable Development Goal (SDG) 3, "Good Health and Well-being” (Lahariya et al., 2023).

STWs also contribute directly to other SDG 3 targets, such as reducing maternal mortality, ending preventable deaths of newborns, and ensuring consistent and high-quality health care for all, thus helping achieve the universal health coverage target (United Nations Sustainable Development). The ripple effect of implementing STWs not only enhances health care delivery but also fosters economic stability and sustainable development, leading to better public health outcomes. The consistency in translating evidence into practice creates a sustainable model for ongoing improvements in patient care (Grover et al., 2024).

However, as with any initiative, the path to successful implementation is not without its challenges.

Challenges

The pilot implementation of 157 STWs across two regions in India has revealed several challenges and provided valuable insights:

• Adapting to local contexts: Many health care facilities faced limited resources, making it difficult to fully implement some workflows. In resource-constrained areas, certain workflows requiring advanced diagnostic tools were modified to focus on essential treatments that could be effectively managed with available resources. This adaptation allowed health care providers to utilize STWs successfully while considering local constraints.
   
• Provider engagement: Health care providers often struggled to shift from established practices to following STWs. To address this, local health authorities conducted interactive workshops that included practical demonstrations and role-playing scenarios. These hands-on training sessions facilitated smoother integration of STWs into daily routines, enhancing provider confidence and understanding.
   
• Feedback integration: Establishing structured feedback mechanisms was crucial in gathering insights from health care providers. Regular forums were organized where providers could share their experiences and suggest improvements to the workflows. This feedback was instrumental in refining the STWs, ensuring they remained relevant and user-friendly in diverse clinical settings.
   
• Lessons learned: The pilot implementation underscored the importance of flexibility in STW design, the necessity of continuous training tailored to local contexts, and the value of actively engaging health care providers in the feedback process. By adapting to regional needs and maintaining open communication, STWs can be effectively integrated into various health care environments (Grover et al., 2023).

“Sustainable change requires energy and persistent effort”. With these challenges identified, the next steps are crucial to ensuring that STWs reach their full potential.

Next steps

For STWs to reach their full potential, several key steps must be taken:

• Broader disease coverage: Expanding STWs to cover a wider range of diseases and conditions will help health care providers manage a greater variety of cases effectively (Grover et al., 2023).
   
• Regular updates: Continuous updating of STWs based on the latest clinical evidence is essential to ensure they remain relevant and effective (Grover et al., 2024).
   
• Training and education: Comprehensive training programs for health care providers on using STWs should be implemented, particularly for those in rural or underserved areas. Without proper training, even the best-designed workflows can fail to achieve their desired impact (Grover et al., 2023).
   
• Research and evaluation: Ongoing operational research is needed to evaluate the real-world impact of STWs on health care delivery, patient outcomes, and system efficiency (Grover et al., 2024).

References

Arora M. (2024). Reduced burden on urban hospitals by strengthening rural health facilities: Perspective from India. Journal of Family Medicine and Primary Care, 13(4), 1178–1182. https://doi.org/10.4103/jfmpc.jfmpc_1561_23

ETHealthworld.com. Health ministry asks states to implement 157 standard treatment workflows in 28 specialities - ET HealthWorld. https://health.economictimes.indiatimes.com/news/policy/health-ministry-asks-states-to-implement-157-standard-treatment-workflows-in-28-specialities/112181223

Ghosh S. (2024). ICMR releases 32 new treatment standards for treating common and serious diseases under five specialities. https://www.livemint.com/science/health/icmr-releases-32-new-treatment-standards-for-five-specialties-11721893125536.html

Grover, A., Bhargava, B., Srivastava, S., Sharma, L. K., Cherian, J. J., Tandon, N., Chandershekhar, S., Ofrin, R. H., Bekedam, H., Pandhi, D., Mukherjee, A., Dhaliwal, R. S., Singh, M., Rajshekhar, K., Roy, S., Rasaily, R., Saraf, D., Kumar, D., Parmar, N., Kabra, S. K., … Chatterjee, A. (2023). Developing Standard Treatment Workflows-way to universal healthcare in India. Frontiers in Public Health, 11, 1178160. https://doi.org/10.3389/fpubh.2023.1178160

Grover, A., Cherian, J. J., Aggarwal, S. S., Pandhi, D., Suranagi, U. D., & Bajaj, A. (2024). Optimising Indian health care delivery with standard treatment workflows. Clinical Epidemiology and Global Health, 29, 1017322024.

Jordan, Z., Lockwood, C., Aromataris, E., Pilla, B., Porritt, K., Klugar, M., Riddle, D., Wang, N., & Munn, Z. (2022). JBI series paper 1: Introducing JBI and the JBI Model of EHBC. Journal of Clinical Epidemiology, 150, 191–195. https://doi.org/10.1016/j.jclinepi.2022.04.008

Jordan, Z., Pilla, B., Porritt, K., Munn, Z., Aromataris, E., & Lockwood, C. (2023). Turning the flywheel: mobilizing the JBI model of evidence-based healthcare. JBI Evidence Implementation, 21(1), 96–100. https://doi.org/10.1097/XEB.0000000000000342

Lahariya, C., Sahoo, K. C., Sundararaman, T., Prinja, S., Rajsekhar, K., & Pati, S. (2023). Universal health coverage in India and health technology assessment: current status and the way forward. Frontiers in Public Health, 11, 1187567. https://doi.org/10.3389/fpubh.2023.1187567

Rural India Online. (2023). Rural Health Statistics, 2021-22. https://ruralindiaonline.org/en/library/resource/rural-health-statistics-2021-22/

Sharma K. (2024). Bridging the urban-rural divide. Express Healthcare. https://www.expresshealth care.in/hospital-infra/bridging-the-urban-rural-divide/445455/

United Nations Sustainable Development. Health. https://www.un.org/sustainabledevelopment/health/
 

To link to this article - DOI: https://doi.org/10.70253/KAPV7491

Links to additional resources 

https://main.icmr.nic.in/content/standard-treatment-workflows-stws

https://main.icmr.nic.in/sites/default/files/Books/STW_Manual_v1.pdf

https://main.icmr.nic.in/content/books

Disclaimer
The views expressed in this World EBHC Day Blog, as well as any errors or omissions, are the sole responsibility of the author and do not represent the views of the World EBHC Day Steering Committee, Official Partners or Sponsors; nor does it imply endorsement by the aforementioned parties.