Law enforcers

How one Uttar Pradesh district is using technology to prevent sex-selective abortions

But the Hapur authorities are failing to monitor images and alerts that the tracking devices send out.

On January 11, 30-year-old Mamta from a village in Hapur district, Uttar Pradesh had her sixth child. It was a girl. She had wanted a boy and had tried to find an ultrasound centre that would tell her the sex of the baby before it was born.

“These days, the doctors are scared to do this work,” said Mamta, who is also an Accredited Social Health Worker or ASHA and is supposed to help stop the illegal practice of pre-natal sex determination, which in many parts of India sometimes leads to sex-selective abortions. Her name has been changed to protect her identity.

Mamta has five daughters, the oldest of whom is 11. When she was pregnant with her son, who is three years old, she had undergone an illegal sex determination test at an ultrasound centre near her home. When asked why she had wanted a boy through her sixth pregnancy, she said, “Aurat zulm zhelti hai.” Women suffer injustices.

An analysis of sex selective abortions in India published in 2011 shows a rise in the number of such abortions since 1990, especially in families where the firstborn child is a girl.

In Uttar Pradesh the sex ratio at birth, as per civil registration system data, has declined from 883 girls for every 1,000 boys to 881 girls for every 1,000 boys. In Hapur district, the sex ratio at birth was an abysmal 797 girls to 1,000 boys in 2014.

Early in March 2016, about 70 doctors assembled in a Hapur hall for a workshop. District health department officials had called the doctors there to tell them that they would be fitting ultrasound machines with tracking devices. The aim was to prevent sex determination from images from these ultrasound machines.

The tracking device called Active Tracker made by Magnum Opus, a company in Pune, was first used and became popular in Maharashtra’s Kolhapur district in 2009. The Hapur health department and the district magistrate have cleared a proposal to fit an Active Tracker in every health centre that uses an ultrasound machine. The device is supposed to record all images that an ultrasound machine generates in real time and issue alerts to the health department if it is tampered with or dislodged from the machine.

“In Hapur district now, sex determination is zero,” claimed Dr AK Singh, chief medical officer of the district.

However, union government officials and activists working in the area do not approve of the device as a tool to stop the practice of sex determination because they are not convinced of its efficacy.

Still, the district administration is relying on Active Trackers. Hapur officials are so confident that the mere presence of trackers will deter doctors from sex determination that they have not been monitoring the images being recorded by the devices.

Law not implemented

The Pre-Conception and Pre-Natal Diagnostics Testing or PCPNDT Act prohibits doctors from revealing the sex of a foetus examined. Doctors can normally tell whether the child is going to be a boy or a girl through ultrasound imagery around the 12th week of a pregnancy.

The law mandates all doctors to register their ultrasound machines with district authorities. Doctors have to fill a form called Form F with details such as the number of weeks of pregnancy of the patient, the reason for sonography and the number of children the patient already has. Doctors have to fill the Form F each time the machine is used, even if it does not involve a case of pregnancy.

While some districts have ordered that doctors fill the Form F online, most districts such as Hapur still collect the physical copies of Form F from every ultrasound centre every month.

“Officials always know which centres are conducting sex determination,” said Dr Neelam Singh, member of the National Inspection and Monitoring Committee under the PCPNDT Act.

Singh, who is a gynaecologist in Lucknow, said that under the PCPNDT Act, district officials are supposed to audit Form Fs to check for discrepancies. Ultrasound centres sometimes under report the number of patients they examine in order to escape legal action if they have performed sex determination tests.

The PCPNDT Act says that non-maintenance of proper records is a punishable offence. Doctors can be booked for this violation and can be sentenced to three months imprisonment or a fine. There have been very few PCPNDT cases filed in Uttar Pradesh. Since 2002, only 190 cases have been filed in the state under the Act, of which 39 cases have been disposed of while 12 convictions have been secured.

There are no substitutes to constant monitoring and raids on centres. “They act as a strong deterrents against the doctors,” said monitoring committee member Singh. “But the system is such that the officials only try to help the errant doctors. The law is hardly implemented.”

In Hapur, though, authorities have come down on doctors violating the law. On April 26, the Hapur district health administration conducted a sting operation on an unauthorised centre in Pooth village where there were allegations of a doctor conducting sex determination tests at his farm house. Health officials sealed three other ultrasound machines for violations.

“These cases created a terror in Hapur,” claimed district chief medical officer Singh.

Dr AR Anuragi, district health official who oversees implementation of the PCPNDT Act, said that Hapur’s sex ratio continues to dip possibly because women are going outside the district for tests.

“They can go to Meerut, Ghaziabad or Haryana too,” he said. “But in Hapur district nobody is conducting sex determination.”

Can Active Tracker help?

An Active Tracker is supposed to allow health officials to remotely monitor ultrasound centres. It generates primary evidence of every ultrasound performed. Authorities can also compare images from the Active Tracker with Form Fs from the clinic in which it is placed, to check if doctors are under reporting the patients they see.

The device is being used in Madhya Pradesh, Rajasthan, Gujarat, Jammu and Kashmir, Haryana, Maharashtra, Punjab, Chhattisgarh and Uttar Pradesh’s Jhansi and Hapur districts.

Active Tracker device attached to an ultrasound machine. (Photo: Menaka Rao)
Active Tracker device attached to an ultrasound machine. (Photo: Menaka Rao)

In Jhansi, health officials have a control room where they can monitor relays from Active Trackers installed across the district. In Hapur, there is no control room but health officials say they can check on Active Trackers from their laptops at any time.

“If the machine starts at an odd time, say 3 am or 6 am in the morning, then we are alerted,” said Singh, Hapur’s chief medical officer. “It could be a case of sex determination.” Singh overlooked the fact that needing an ultrasound machine in a medical emergency not involving a pregnancy at an odd hour of the night or early morning is not implausible or uncommon.

Officials checked some of these cases where an ultrasound machines was switched on during a clinic’s non-working hours. “The doctors are very scared now,” said Singh. “We have told them their machines can be checked any time. If we find out they have conducted sex determination, their registration will be cancelled.”

Even though Singh and his colleagues in Hapur are betting on Active Trackers, health activists have little faith that the device can actually help prevent sex determination.

“It is a completely useless device,” said Sabu George, an activist who has been working for better implementation of the PCPNDT Act. “Some governments feel it will threaten doctors. But doctors are not foolish. You can carry out sex determination with the device on.” A doctor can verbally convey the sex of a foetus to the parents-to-be, a fact that cannot be determined by looking at what images were taken on an ultrasound.

In August 2016, the Ministry of Health and Family Welfare met with an expert committee, including members of the Maharashtra and Haryana health authorities and a professor from the Indian institute of Technology, Kharagpur, to discuss the efficacy of the Active Tracker in the implementation of the PCPNDT Act.

The conclusion from the meeting was that there was not enough evidence to show that Active Trackers have resulted in improvements of sex ratio at birth or helped identify violators under the PCPNDT Act. The lack of results showed that investing in Active Trackers was not paying off and that data generated by the devices was burdening authorities with more work.

Lack of monitoring

Active Tracker images alone cannot be used to catch a doctor violating sex determination laws. Authorities need to supplement evidence from the tracking devices with proof that the doctor is not keeping proper records or catch him red-handed using a decoy pregnant woman.

According to Singh, a doctor can be hauled up for sex determination if ultrasound images show that he is looking at the genitals of a child when there is no anomaly.

“That is nonsense,” said Dr Virendra Vats, who runs a nursing home with his wife on Railway Road in Hapur. “When we check for femur length to see if the foetus is growing optimally, we will focus on the area near the genitals whether you like it or not.”

Dr Virendra Vats who runs an ultrasound centre thinks the Active Tracker will not help improve the sex ratio
Dr Virendra Vats who runs an ultrasound centre thinks the Active Tracker will not help improve the sex ratio

The Hapur district administration remains convinced that the Active Tracker is their solution to the pre-natal sex determination problem. Singh did not clarify who in the district administration was monitoring Active Tracker images to raise the alarm on possible violations.

“We did not have to spend a penny,” said Anuragi. Ultrasound centres themselves paid the Rs 31,500 for the device and will have to pay a maintenance charge of Rs 5,500 every year. Three ultrasound centres said they complied with the government order to install Active Trackers at their own cost because they did not want to get into trouble.

But a handful of centres have resisted installing the tracker. Sahdev Singh Ranawat, Uttar Pradesh state coordinator for Magnum Opus, said that the company had been given an order for 45 Active Trackers, whereas the district administration said there were 49 registered ultrasound machines.

“Four machines were not installed with this device,” said Singh. “The company did not install them.”

A few months ago, the company withdrew its engineer from Hapur after the district administration decided to hold back nine cheques from doctors to be given to the company. Singh claimed that the cheques were withheld because the company did not provide the necessary service of retrieving data from hard drives of installed Active Trackers.

What started as a promising project has now deteriorated into a tussle between the government and company. “If they are not interested in monitoring their centres, we cannot force them,” said Ranawat.

Meanwhile, Singh wants to downplay the rift between the administration and Magnum Opus. “I did not tell you earlier, because I wanted to maintain the terror of the district administration in the state,” he said.

This reporting project has been made possible partly by funding from New Venture Fund for Communications.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.