Dr. Nalini Saligram , Founder and CEO of Arogya World Talks about Improvement of Healthcare in India

The COVID-19 pandemic and resultant restrictions on the movement have caused a lot of stress and anxiety among people, directly affecting their productivity and health negatively. Arogya World, a global health non-profit organization, has launched extensively researched mental health criteria, as part of its Healthy Workplace framework, to help corporates address employee mental wellbeing in a structured manner. This effort, the first-ever of its kind in India, was initiated by the organization in direct response to repeated requests from business and HR leaders during the pandemic.

In an exclusive interaction with The CSR Journal, Dr. Nalini Saligram – Founder and CEO of Arogya World, Ashoka Fellow, elaborates on this along with other initiatives of the non-profit. Following are the excerpts of the interaction.

1. The COVID-19 pandemic highlighted that quality healthcare and capacity building in healthcare is of utmost importance for development of a country. How can CSR contribute to this?

Covid revealed how important it is for all countries to strengthen if not overhaul their entire healthcare system, so we are better prepared as a world for future pandemics.  India learned the hard way in 2020-21, how inadequate the existing healthcare infrastructure was, that we need urgently to increase capacity, including in Tier 2 and 3 cities, and get more and better-trained doctors and nurses.   COVD also highlighted the huge inequities in the health system, which disproportionately affects the underserved.

Thus, we need to urgently strengthen primary health care services and highlight the importance of preventive care. For example, Non-communicable diseases (NCDs), which include heart disease, diabetes, cancer, and chronic lung diseases, are the leading cause of death worldwide. 2 out of 3 deaths are from NCDs.  While human suffering is catastrophic, so is the cost of treatment.  25% of a poor family’s income is spent on one family member with diabetes, pushing the family deeper into the abyss of poverty. Data indicates that the share of out-of-pocket health expenditure (the cost directly borne by the family/patient) in India due to NCDs has doubled (32 percent in 1996 to 64 percent in 2014).

Another thing we all learned in the last couple years is that NCDs and COVID are inextricably linked.   It is increasingly being recognized that the collision of Diabetes and COVID is a public health train wreck.  People with diabetes have much more negative health outcomes from COVID – they are more likely to require hospital stays and intubation and more likely to die. The reverse is also true – COVID leads to type 2 diabetes.  Preventing diabetes now is more urgent and important than ever before.

Everyone – policymakers, company leaders, and the NGO sector – now realizes the strategic importance of health for our country’s future.  Companies can contribute by investing more in health, through their CSR and other efforts including:

– Strengthening primary care: more investment is needed to increase healthcare capacity including for example developing more hospital or ICU beds, and to better utilize the power and reach of ASHA and other frontline workers. CSR can also support better training for healthcare workers, and processes that improve the operational efficiency of health and wellness centers and hospitals

– Supporting the use of technology in many ways including in NGOs and start-ups

– Supporting disease prevention especially NCD prevention through healthy living

– Increasing access to mental health support

– Increasing emphasis on healthcare in communities in and around plants and factories

Our country’s competitiveness depends on this.

2. What role does society need to play to ensure access to quality healthcare to everyone?

Government and CSR can drive tangible advances in health including driving universal health coverage, but civil society has a major role to play in building a healthy living movement.  If all of us as individuals lead healthier lives, we can prevent NCDs, increase productivity and resilience, and become vibrant, healthy, contributing members of society.

We know from the World Health Organization that 80% of heart disease and 80% of diabetes can be prevented by eating right, exercising, and avoiding tobacco.  We can keep people out of the healthcare system, by educating them on prevention, reaching them where they live, learn and work – outside the healthcare system.

Society must change its mindset, reject unhealthy options and demand healthy lifestyles.

Civil society can help in tangible ways.  We can for example send text and voice messages on NCD prevention to villagers all over the country, get urban women to understand what to eat and in what quantities at each meal, ensure that companies help their employees measurably improve their physical and mental health and also educate children about the importance of healthy habits with compelling games and activities.

This is important not only to Build India Back Better from COVID-19 but also critical to build immunity and resilience in people so we can be better prepared for future pandemics.   Healthy living can also help us become a more productive workforce and preserve India’s competitiveness on the global landscape.

3. There is still a lot of stigma against speaking up about mental health. How can we go about defeating it? What role does Arogya World seek to play in this?

One of the ways to reduce stigma is to talk about the issue at length.  We should encourage dialogue on mental health, in neighborhoods and on TV, in policy debates, and at the kitchen table.  And at the workplace.  If more people talk about it, about how mental health is a matter of chemical imbalance and put it in physiological terms so people get it, and that all of us are on a spectrum, sometimes having good days, sometimes anxious and stressed and in poor mental health, then there is greater empathy for those around us who do suffer from mental ill-health.

Arogya World has focused a lot on mental health in recent years.  Our Healthy Workplace program requires companies now to adhere to a comprehensive set of criteria covering both the physical health and mental health of employees.  By keeping mental health criteria, developed by Harvard professors, on par with physical health criteria, we raise the importance of mental health in companies and reduce stigma at the same time.  Health to us is comprehensive  – both physical health and mental health are of equal importance.  We convey that to companies now right from the get-go.    14 companies that were recognized as Healthy Workplaces in 2021 were the first companies to qualify against the comprehensive criteria.

In addition, we have developed case studies of exemplary companies that have robust approaches to destigmatizing mental health at work and have plans to bring these best practices to other companies as well.

We also have text messages developed with NIMHANS that would help working Indians reduce stress.  Companies should feel free to reach out to us (info@arogyaworld.org) to learn more.

4. What are the major areas of focus of Arogya World?

Arogya World, a health NGO, has followed a doorstep health model to take NCD prevention to 6 million women, men and adolescents all over India over the last 10 years.  Our goal is to reach 50 million in the next 5 years through our science-based, well-designed programs — Healthy Schools, Healthy Workplaces, mDiabetes, and MyThali — catering to different age groups and social demographics. We measure the impact of all our programs and believe very much in the power of partnerships to reach scale.  We believe we are becoming the catalytic actor for diabetes prevention and mitigation in India.

Healthy Schools – We use teachers and peer leaders, to educate children aged 11-14 about diabetes and its prevention using our proven two-year school-based program with age-appropriate, compelling games, and activities that teach the basics of healthy living to middle school children before their lifestyle habits are set. Effectiveness is measured through pre-post behaviour change analysis – the program has shown 15% improvement in awareness and health behaviors. The data are being validated for effectiveness and fidelity with Stanford’s Center for Asian Health Research and Education.  So far, Arogya World has reached over 600,000 middle-school children all over India working with many partners and governments (including Goa, Maharashtra (Thane district) and UP (Banda district)).  The program, aligned with India’s Ayushman Bharat National School Health curriculum, was digitized in response to COVID and the eLearning modules are available on Diksha, the government portal for school education.

Healthy Workplaces – Indians get type 2 diabetes some 10-20 years earlier than people in the West.  India is a young country with median age 27 years. Leveraging workplaces which employ so many of these young people, as platforms for change, is smart.   Since 2013, Arogya World has deployed the programme in several companies, in a variety of sectors, and now has about 165 companies in India that are recognised as Healthy Workplaces, covering more than 3.3 million employees.  The program which strives to build a data-driven culture of health in workplaces, has made great strides, in partnership with industry associations such as CII.

mDiabetes – Through this effort, we sent 56 million messages developed with Emory University, on diabetes and its prevention, to more than one million people in 2012-2013 working with Nokia  Since then with support from RIST (Rural India Supporting Trust), we completed the program in 300,000 more consumers from the base of the pyramid in Aravind Eyecare Center communities in Tamilnadu.  Currently, we have a program ongoing in 100,000 villagers in the Hyderabad region in partnership with LV Prasad Eye Institute to test the effectiveness of mDiabetes integrated with community health education – also supported by RIST.  In 2021 we were one of the recipients of the Google AI for Social Good award, through which we are testing the use of Artificial Intelligence to improve our mDiabetes program.

The program has been shown to be effective, demonstrating 20% improvement in multiple health behaviors, in people all over India.  Our mDiabetes program, 6 months long with messages sent twice a week to motivated consumers who opt-in, has content is available in 12 languages in SMS, voice and Whats App.   We believe it is a great add-on to the COVID era grassroots networks and partnerships activated via CSR.

MyThali – Inspired by the US MyPlate approach, Arogya World translated the National Institute of Nutrition (NIN) guidelines into an easy-to-follow picture that shows people what to eat, and in what quantities at every meal.  MyThali teaches people about the importance of “poshan” (good nutrition) and portion. It has been aggressively promoted to millions, especially women, using social media and traditional media, and has been adapted for rural adolescent girls in partnership with PATH.  Effectiveness evaluation is currently ongoing.  We have high hopes for this program as it tackles a fundamental problem – people are confused about what to eat and often even unaware.  With MyThali, we are on a journey to change the eating habits of the entire country.

5. How can ICT improve the effectiveness in healthcare scenarios in India?

In a country known for many tech advances, technology is a great tool we must leverage to make advances in population-level public health.

– Mobile technology is especially attractive as almost everyone in India has a cell phone – there are more than a billion mobile connections in India. Mobile technology was put to good use in the COVID era to drive vaccination. Simple text and voice messages  in multiple languages are being used for diabetes prevention by Arogya World which is also leveraging Artificial Intelligence to make the content more compelling.

– Mobile apps, graphics and videos are being leveraged to advance people on their health journeys, and digital games and e-Learning tools are being used to teach children the basics of healthy living.

– Technology and the internet are being exploited cleverly to improve training for frontline workers and healthcare providers all over the country.

– NGOs are also using social media not just for promotion, but for educating consumers on eating right.

– Healthcare start-ups are using thermal imaging to detect diabetes years in advance of clinical manifestation and other advances in medical devices, continuous glucose monitoring, insulin delivery, telehealth etc. are tangibly improving heart disease and diabetes detection and treatment. And measurably improving outcomes for patients.

– We are so pleased that the area of mental health has gotten a boost from the use of mobile apps, telehealth and broad listening circles.

– Webinars have simply revolutionized healthcare conferences and the sharing of best practices in health.

– My personal wish list has one more item – figuring a way to use technology and persuade government / big donors to subsidize fruits and vegetables so more people at the base of the pyramid can eat healthy foods everyday and prevent NCDs.

It is exciting to be able to put cutting edge tech advances to improve the health of people everywhere.

6. How did you get involved in Philanthropy? What are the factors that drive you to work towards the betterment of society?

I have a background in science, with a Ph.D. in biochemistry from the Indian Institute of Science, Bangalore.  Some 10 years ago, I was working in public affairs at a US pharmaceutical company and inspired by people I met there as well as public health leaders at Emory University, I decided to dedicate the rest of my life to preventing disease.  I have diabetes and it runs in my father’s family, and learning that India is particularly hard hit by this and other noncommunicable diseases, NCDs, I chose to work in NCD prevention in India. This was my way of giving back.

I wanted to work with like-minded people and like-minded organizations and make a meaningful contribution to global health. That is why Arogya World was formed, and that is what drives me to this day.

7. How can citizens participate in improving the healthcare services in India?

Individuals must take responsibility for their own health, reject unhealthy options, and demand healthy lifestyles.    If we as individuals eat right, exercise and avoid tobacco, we would stay away from doctors and hospitals, prevent secondary complications and spare the precious healthcare capacity we do have in India to care for those who are sick.

A healthy living movement can be powerful – we invite you to join us and build that together in India.  Let’s say no to junk food and sugary drinks, to excess salt, to too many sweets, and fried food.  Let’s say yes to eating 2-3 fruits and 2-3 vegetables and to walking for 30 min every day.  Let’s remember sitting is the new smoking!

8. What message would you like to give to the youth of India who are filled with motivation and energy to work for the welfare of people, but lack direction?

There is a lot we can learn from the younger generation.  They listen to their hearts, follow their dreams and live a life of purpose, saying no often to the trappings of power, big brands and corporate salaries, drawn to our sector to truly help people, lift communities and make an impact. Hats off to them for their strong sense of conviction.

My advice would be for young people to channel their energy, and can-do spirit and work in collaboration with others, young and old, to make sure their impact is enduring and truly helps India move forward.