ECHO of Good Health

Dr. Sanjeev Arora, a liver disease specialist from Albuquerque, New Mexico, started Project ECHO in 2003. Photograph courtesy SARA MOTA

If you live in a big city, qualified doctors of nearly every specialty are often easy to find. But what if you live in a rural community? The specialists you need could be thousands of kilometers away.

This is precisely the sort of problem that Project ECHO (Extension for Community Healthcare Outcomes) was created to address. It is an innovative and multifaceted model that increases health care access for underserved communities.

Project ECHO began in 2003 when Dr. Sanjeev Arora, a liver disease specialist from Albuquerque, New Mexico, decided to confront a disturbing reality: Thousands of patients in his home state were unable to get treatment for hepatitis C simply because specialists were hardly accessible from where they lived.

To combat the problem, Dr. Arora created a free educational model to mentor local health care providers to treat the disease themselves, anywhere in New Mexico, guided and supported by specialists like himself. Dr. Arora’s goals were bigger, though. “We knew if we could treat something complicated like hepatitis C…in rural areas, we would have a model that could treat all kinds of complex diseases in developing countries,” he said in a 2013 TEDx Talk.

To begin with, Project ECHO set up 21 “centers of excellence” across New Mexico, each run by a local health care provider, and all tasked with the mission of treating hepatitis C everywhere in the state.

Treating a disease, however, is far more complicated than following a list of instructions. Dr. Arora had to find a way to train local health care providers so they could quickly gain the specialized knowledge that he had attained through years of study and practice. The answer? Case-based learning.

Project ECHO began enabling hands-on mentorship through technology. Local health care providers in even the most remote areas are connected via weekly web-based calls and virtual meetings with specialist teams. The teams advise their local partners on how to best treat individual patients.

The Project ECHO model is not traditional telemedicine, in which a specialist assumes care of a patient, but is telementoring, a guided practice model where the participating clinician retains the responsibility of managing the patients.

In India, the first ECHO clinic began in 2010, as a collaboration between the National AIDS Control Organization and Maulana Azad Medical College on managing HIV/AIDS patients. Since then, the programs have worked on addiction and substance use disorders, mental health, tuberculosis, hepatitis C, liver diseases, cancer screening and prevention, and more. All ECHO programs in the country fall under ECHO India, a nonprofit trust registered in 2008, which works toward replicating the ECHO model in the areas of health care, education and environmental security.

Today, ECHO India has grown to include hubs in 10 states and has signed a Memorandum of Understanding with the Government of India’s Ministry of Health and Family Welfare.

In 2018, ECHO India entered a partnership with the National Health Systems Resource Centre, as a Capacity Building Implementor under the Ayushman Bharat Yojana. The goal is to set up 153,000 Health and Wellness Centres across the country, and ECHO India would support capacity building of staff at these centres. With King George’s Medical University, Lucknow, and National Health Mission, Maharashtra, already operating as ECHO hubs, a pilot program to train accredited social health activist (ASHA) workers is currently being run in collaboration with Community Empowerment Lab and National Health Mission, Uttar Pradesh. The aim is to replicate such hubs in all states.

One of the components of the Ayushman Bharat Yojana is to provide comprehensive primary health care, with an expanded range of 12 services available at the Health and Wellness Centres. To implement these, a mid-level health care provider will be placed at each center located at the sub-center level. The National Health Systems Resource Centre has partnered with ECHO India for joint training and capacity building of these health care providers.

A cascade model of knowledge sharing will be built for continuous capacity building of health care providers at all levels, including specialists, doctors, paramedical professionals, mid-level health care providers and frontline workers. Government of India’s Ministry of Health and Family Welfare has released a mandate to conduct ECHO programs by all states for training and capacity building.

Speaking at an orientation program for doctors and health care professionals in 2017, Dr. Colonel (Retd.) Kumud Rai, chairman of ECHO India, said, “The Indian health care environment provides a one-of-a-kind opportunity for the adoption of the ECHO model. The need for specialty care in India, especially in rural settings, is substantial and growing. System-wide integration of Project ECHO offers a solution that can benefit the entire population.”

Many prominent health care institutes in India have partnered with ECHO India. There are 26 active hubs, including the Mumbai-based Tata Memorial Centre, which has launched programs to connect hospitals from the nation-wide National Cancer Grid using the Project ECHO platform. At the National Institute of Mental Health and Neuro Sciences (NIMHANS), the Virtual Knowledge Network NIMHANS ECHO program has completed 22 programs and is currently running eight more for participants across the country and abroad. This program has trained over 4,000 health care professionals, and works with the state governments of Bihar, Chhattisgarh and Karnataka.

The ECHO model has also been adopted in the field of education, by Ambience Public School in New Delhi. The ECHO Teacher Mentorship Program works on improving the skill-sets of teachers and ensuring that they are constantly mentored. After successfully completing seven ECHO programs, with focus on English, mathematics, early literacy, science and mindfulness, among others, the second hub was launched at Ambience Public School, Gurugram. The Ambience Preventive Health and Wellness ECHO is a unique program that focuses on helping teachers, parents and counselors identify early signs of various health issues in children. The participants are mentored by doctors from institutes like the All India Institute of Medical Sciences, Max Super Specialty and NIMHANS.

Regardless of the community served or disease treated, Project ECHO’s goals remain the same: To make quality, comprehensive health care available for even the most rural and underserved communities in India, the United States and beyond. “We want to demonopolize knowledge,” said Dr. Arora in his TEDx Talk.

“Typically, knowledge is trapped in the head of super-specialists like me. We want to share it freely with our primary care colleagues. We want to improve access to quality health care and reduce disparities.”

Michael Gallant is the founder and chief executive officer of Gallant Music. He lives in New York City.

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