Alex Boyle and Aashna Shah, both MPH ’24, helped a nonprofit in India improve its patient feedback process while learning valuable lessons for their own public health careers
May 30, 2024 – At Jaipur Foot, if someone comes in before 2 p.m. asking for a below-the-knee prosthetic, they get fitted with one before the end of the day. Without an appointment. For free.
Aashna Shah and Alex Boyle—recent master of public health graduates at Harvard T.H. Chan School of Public Health—spent their winter break working at Jaipur Foot, a nonprofit headquartered in Jaipur, India. They were amazed at how efficiently the organization operated. “In the United States, we’re used to bureaucracy. For the simplest healthcare service, it can take weeks to make an appointment, get seen by a physician, and receive treatment,” said Shah. “It’s unique to see a healthcare model in which a patient receives treatment in a matter of hours—especially one as complex as the custom prosthetics provided by Jaipur Foot.”
During their time in India, Shah and Boyle analyzed patient feedback data to identify trends and to suggest opportunities for how Jaipur Foot can better serve their patients. They also synthesized the organization’s current patient feedback process and provided recommendations on how the process can be optimized to improve data collection and analysis.
Pooling their talents
Jaipur Foot—whose parent organization is an NGO called Bhagwan Mahaveer Viklang Sahayata Samiti (BMVSS)—is the largest nonprofit in the world providing free prosthetics. It has served more than two million people since its founding in 1975. The organization has 30 clinics in India and has also provided services at temporary medical camps in 42 countries in the Middle East, Latin America, Africa, and Asia. Jaipur Foot’s prosthetics look and feel natural and allow the wearer to squat or go barefoot.
Prior to their trip, Boyle and Shah didn’t know each other, but both were planning on working with the organization for different reasons.
Boyle, who studied health management at Harvard, is an orthopedic and trauma surgery resident physician from New Zealand. He wanted to see how Jaipur Foot was able to successfully provide prosthetics in a low-resource setting for free, quickly, and at high volume.
Shah, who is from New York City and whose MPH field of study was health and social behavior, was interested in learning about the organization’s unique, lean nonprofit model—it is funded by donations, including support from the government of India, and spends just 4% of its budget on operating costs, while the average for nonprofits worldwide is roughly 15-20%. She also wanted to see an example of public health implementation in India and get direct experience with patients, which hadn’t been part of her previous work at the intersection of health, social impact, and tech.
Once Boyle and Shah discovered that they were both going to be working at Jaipur Foot—Boyle on a Rose Service Learning Fellowship, and Shah for a practicum—they realized it made sense to pool their talents. “I think the combination of our different backgrounds—my clinical experience and Aashna’s operational experience—worked well,” said Boyle.
“It’s rare when two students are at the same organization and we really love when it happens,” said Stacey King, director of field education and practice in the Office of Education.
High volume, low feedback
Jaipur Foot asked Boyle and Shah to investigate and provide recommendations on their follow-up and feedback processes in Jaipur, the capital city of Rajasthan state in northwestern India. Though Jaipur Foot provides prosthetics, their team is motivated by the larger goal of giving amputees back their dignity, mobility, and livelihoods so that they can contribute to their families and communities—which can be a challenging goal to measure and track.
Through their analysis and interviews with the Jaipur Foot team, Shah and Boyle discovered that serving a large number of patients while operating on a lean nonprofit model had made it challenging for Jaipur Foot to stay on top of patient feedback and follow-up. They learned that the clinic had a large backlog in collecting patient feedback data and that patient volume was seasonal—busier in the summer, slower in the winter. “That means there can be some downtime, depending on which season you’re in,” said Shah. “One of our recommendations was to train other team members to collect feedback instead of just one person, which would allow the clinic to scale data collection up and down as needed. It would give them more flexibility to leverage the existing team in a different way.”
Another opportunity for improvement was determining the best way to record feedback and follow-up. “Western patient-reported outcome measures—the standardized scores used to compare the results of orthopedic treatments—were often not applicable in this setting due to the unique sociocultural requirements of our patients and the fact the majority of patients were young victims of trauma, rather than the older individuals suffering from vascular disease we typically see in the developed world,” said Boyle. To overcome this, Shah and Boyle worked with doctors at Jaipur Foot to develop a feedback system that would identify any recurrent issues with any of the many types of prostheses provided and identify patients with problems requiring reassessment.
One unique cultural challenge they discovered was that many patients were reluctant to give feedback even if they could be reached. “We tried to talk to some patients while they were on site, and I was surprised by how little feedback we received,” said Shah. “Because the prosthetics were given for free, I think a lot of the patients just felt immense gratitude, and they didn’t feel comfortable providing criticism.”
To address patients’ hesitance to share feedback, Shah and Boyle, alongside the team at Jaipur Foot, recommended that team members adopt a consistent practice of using patients’ first names—something that wasn’t always happening—to establish a connection, gain trust, and set the tone for open and honest conversations about the patients’ concerns. They also recommended that clinic staff educate patients about the feedback process and how it benefits both the patient and the organization.
Looking ahead
Boyle hopes to use lessons learned at Jaipur Foot in his work in New Zealand and to provide care in resource-limited and socioeconomically deprived settings in the future.
Back in New York, Shah plans to focus on what brought her to Harvard Chan School in the first place: working to improve mental health care for communities of low socioeconomic status, where there’s less access to financial, educational, social, and health resources. She said, “Being in India and working with the patient population there reinforced for me the need for that kind of work.”
Feature photo: AP/Channi Anand
Other photos courtesy Alex Boyle and Aashna Shah