Author: Dr. Karan Rai, General Manager, and Ms. Tavleen Kaur Malik, Senior Executive, Monitoring, Evaluation, and Research (MER) Team, ECHO India
The need for an adequate, skilled, well-trained and motivated workforce to accelerate the progress toward universal health coverage (UHC) and improved health outcomes has been acknowledged by the United Nations General Assembly. (4) Every country, irrespective of its socioeconomic development level, faces the deep-seated challenge of maintaining a balance between the supply and demand of the health workforce. India has taken significant initiatives to upskill the existing healthcare cadre, introduce new cohorts from the population to improve health outcomes and ensure quality health services are easily accessible, available, and affordable for its citizens. In order to meet the goal of Universal Health Coverage (UHC), the concept of upskilling or capacity building of the health workforce is an adjuvant to manage the demand and supply aspect of the health workforce. The concept of UHC is aspirational and an expression of fairness, and (2) focuses on three facets: population, services, and financial protection. UHC also plays a significant role in achieving sustainable development goals (SDGs). While it directly contributes to Goal 3, which is Good Health and well-being, UHC also indirectly impacts the other SDGs.
The management and distribution of the health workforce is a critical bottleneck in India. There are various challenges associated with it, which include shortages of health workers, (1) international migration of the health workforce, the effect of the market forces on the workforce (4), the skewness that is observed in preference to practice in developed settings (tertiary care hospitals). In contrast, rural healthcare facilities observe fewer practicing physicians (1). This imbalance is an obstacle to achieving UHC. Thus, to accelerate the progress toward UHC, building a health workforce that is fit for purpose and practice is imperative. (2) The development of the health workforce is a technical process. It requires holistic planning, education, and management of human resources, expertise, and political commitment to implement and transform the health system. (4) Such pragmatism will, thus, increase the pace of acceleration towards UHC. (2)
The COVID-19 pandemic has given the realization of the unpredictable nature of the diseases that may arise with time, the rising healthcare needs of the population or the newer demands that will be placed on the healthcare workers. Moreover, countries aspiring to achieve UHC need to strengthen their health systems. (4) As the “Health Workforce” forms a significant component of the Health System Framework, it depends on a sufficient, equitably distributed and well-performing health workforce for the progressive realization of UHC. This, in turn, has the potential to improve health outcomes, enhance global health security and impact economic growth by creating a pool of qualified employment opportunities. (3)
Capacity Building of healthcare professionals provides a shift towards education as well as training that prepares the cadre to respond to the labor market demands (1), be efficient in managing the changing burden of diseases, deliver effective primary care (3) and good quality population-wide health and clinical services, create a positive practice environment, enabling the cadres to have a problem-solving attitude and serve as efficient decision makers in times of crisis or emergency, (1) as well as enhance their soft skills such as the ability to communicate, show empathy, be sensitive towards differences in culture and gender and promotes teamwork. (3) Even recent analyses of low-income settings have suggested positive returns on investment from training front-line workers such as nurses, midwives, and community health workers. (1) The ECHO Model is now being utilized to build the capacity of the healthcare cadre, that is – Nurses, Auxiliary Nurse Midwives (ANMs), Accredited Social Health Activists (ASHAs), Medical Officers, Community Health Officers (CHOs), Lab Technicians, General Physicians etc. is being implemented in India even rural and remote areas, as well as globally where the healthcare professionals are trained leveraging the technology.
The ECHO Model, which follows the “hub” and “spoke” model through technology, bridges the gap between existing challenges associated with the health workforce, with the primary goals of increasing the satisfaction of the health workforce, decreasing staff turnover, increasing patient satisfaction and lead to better health outcomes. The adaptability of the ECHO Model is reflected in its acceptance and utility by National Health Missions, Government & Private Colleges and Private Organizations. ECHO India has worked with partners across the country to utilize the Model for health workforce training in areas such as Mental health, Oncology, Non-communicable diseases, Infectious diseases, Tuberculosis, Beta-thalassemia, Maternal and Child Health, Immunization, and many more focus areas is now also being implemented in focus areas such as School Teacher Education, Gender Equity, Agriculture, Livelihood, Water & Climate to train educators at school, NGOs, civil society members, other community members who are working exclusively in these domains.
In addition to the implementation of the ECHO® programs, Monitoring Outcomes forms one of the core principles of the ECHO Model to assess the impact of the programs. Various evaluation studies at Project ECHO® have depicted that training using the ECHO model results in an increase in the knowledge level and confidence of the healthcare professional in focus areas such as COVID-19. (6) These findings were similar to other studies using Project ECHO for capacity building in sessions focused on Hypertension, Mental Health (10), Addiction, Dementia, Breast, Cervical and Oral Cancer Screening programs, and Chronic pain and pain management. The other findings reflected on improvement in the professionals' clinical practice, which further benefited the patient (6) and how tele-ECHO training offers a unique platform to upskill the trained human resource in a limited resource setting. (9). As of date, there are more than 560 publications related to the ECHO Model globally, including more than 50 from programs based in India.
The success of telementoring via the ECHO Model is due to pragmatic reasons such as reduced travel costs for trainers and trainees, reaching a wider population swiftly, and training can be deployed quickly; and instructional reasons that make the ECHO Model more effective that is, the option of ongoing mentorship, real-time interaction between learners and instructor and the social presence of the collaboration among participants. (8). All ECHO program activities are enabled by iECHO, an innovative digital platform designed to support the ECHO model at scale.
The pedagogy used makes the ECHO model stand out; it follows four core principles: amplification of technology, sharing of best practices, case-based learning, and monitoring of outcomes. Using telementoring by establishing virtual communities of practice for long-term capacity building has an impact on the education and competence of the healthcare profession, which is of immense importance now, for it impacts not only exponential growth in human knowledge and information as well as on health outcomes, which includes improvement in patient triaging, appropriate referrals, better usage of specialists time and expertise and patient-level outcomes such as increased satisfaction, reduced travel cost and waiting time, increased adherence to the treatment and improved patient experience. This impact is, however, not unidirectional; instead, it creates a system that has a skilled and empowered health workforce that is empathetic, satisfied, efficient, effective and responsive; this contributes to the overall growth and improved health outcomes of the healthcare facility and strengthening of the health system of the country which ultimately facilitates Universal Health Coverage. (5)
References
[1] Timothy Grant Evans et al. Transforming Health Workers' Education for Universal Health Coverage: Global Challenges and Recommendations. WORLD HEALTH & POPULATION. 2017; 17(3): 70-80.
[2] Ties Boerma et al. Health workforce indicators: let’s get real. Bull World Health Organ. 2013 November;: 886-887.
[3] Giorgio Cometto et al. Developing the health workforce for universal health coverage. Bull World Health Organ. 2019 December;: 109-116.
[4] Mozart Sales et al. Human resources for universal health coverage: from evidence to policy and action. Bull World Health Organ. 2013;: 798–798A.
[5] Lorainne Tudor et al. eLearning for health system leadership and management capacity building: a protocol for a systematic review. BMJ Open. 2017 June;: 1-7.
[6] Rajmohan Panda et al. Evaluation of COVID-19 ECHO training program for healthcare workers in India - A Mixed-Method Study. BMC Health Services Research. 2022 July;: 1-10.
[7] United Nations, Progress towards the Sustainable Development Goals. ; 2024.
[8] M. I Singh Sethi et al. Hybrid Training: e-learning model in Promotion of Mental Health. Journal of Mental Health Education. 2017 December.
[9] Prabhat Chand et al. Technology Enhanced Learning in Addiction Mental Health Developing a Virtual Knowledge Network: NIMHANS ECHO. 2014 IEEE Sixth International Conference on Technology for Education. 2014 December;: 229-232.
[10] Bhavya K Bairy et al. Capacity Building in Mental Health for Bihar: Overview of the 1-Year Blended Training Program for Nonspecialist Medical Officers. Journal of Neurosciences in Rural Practice. 2021 April;: 329–334.
Bibliography
Project ECHO Research Archive: https://digitalrepository.unm.edu/hsc_echo_bibliography/