Role of Technology and Innovation in Rural Healthcare in India 5Anshul PachouriSenior ResearcherInstitute for Competitiveness, IndiaE-Mail: email@example.com
Rural India: A SnapshotDefinition of Rural India s Monthly Per Capita Consumer Expenditure - 2009- Series1, Rural ( US $) 10, 21.18The most standard and widely accepted definition is given byCensus of India in 2001 which define an area as rural area if itfulfills the following conditions;(1) Population density of less than 400 sq km Series1, 2004-(2) Atleast 75% of the male population engaged in agriculture Series1, 1999- 05, 12.87(3) No presence of Municipal Corporation or Board. 00, 10.80Quick Facts Series1, 1993- 94, 6.36Rural India – 70 % of the total Indian populationTotal Rural Population :- 833 Million IndividualsContribution to the National Savings – 33 % Source: Data Extracted from Key Indicators of Household Consumer Expenditure in India 2009-10, Ministry of Statistics, Government of IndiaContribution to Total Consumption – 57%Contribution to Total GDP – 45% • The monthly household per capita consumer expenditure (MPCE) in rural areas has increased by more than thrice from 1993-(Source: IBEF, NCAER and Census of India) 2010. • Rural areas are going high on spending. • But in the actual terms, they are spending half in comparison to their urban counterparts.
Rural Healthcare : Opportunities• India BoP healthcare market is estimated to be 26.5 Shortage of Series1, Radiogr Community Health Centers Manpower atbillion 2005 International dollars at purchasing power aphers, 2724parity dollars. In 2008 Series1, Genera l Medical• The average rural population meant to be served by each Officers, Total Series1, 9933health sub-center and primary health center is more than Specialist6000 and 36000 respectively. Doctors, 11361 Series1, Paediat ricians, 2991• It is estimated that nearly 1.75 millions of beds will berequired to achieve the status of 2 beds per 1000 people, Series1, Physici700,000 doctors to reach one doctor per 1000 population by Series1,ans, 2949 Obstetr2025. (PWC) icians & Gynaecologists,•The total capital investment to reach the above targets is 2271 Series1, Surgeoestimated to be US $ 80 billion approx. ns, 2583• 8% of the total expenditure of rural people on health. Series1, With Facilities at Primary Healthcare Centers Telephone, 54. Series1, With 3% Computer, 47. Series1, Reach 0% able in all weather Series1, Witho conditions, 92. ut Water 5% Series1, Witho supply, 12.4% ut electric supply, 14.2% Series1, With 4-6 Series1, Opera beds, 59.3% tion Theatre, 36.0% Series1, Labou r Room, 64.9%
Rural Healthcare: Challenges Rural People Challenges Organizational Challenges Distribution and Reach Affordability Recruiting skilled manpower Accessibility Tackling social issues and local beliefs ( Self medication) Awareness Creating awareness among the rural consumers Quality of Healthcare Services Changing the mindset of the rural people
Emerging Business Models Changing Times in Rural Healthcare Tele-Medicine With the advent of time, there has been significant change Healthcare in the business models practiced in Primary Information rural healthcare and each type of healthcare is served by a Healthcare Systems particular type of business – model and format. Emerging Hospitals on Traditional brick and mortar model can’t serve the Trends Wheels healthcare needs of rural people. There is a need of sustainable and scalable business Secondary models which can cater to this potential customer base. Tele-Medicine Healthcare Healthcare Information Management Systems:Telemedicine and BPO Model: This model also uses the ICT technologies to guide its usersA new model which is emerging today is delivering healthcare about various good health practices.with the help of information technology tools. It teaches its subscribers about the different steps they shouldCompanies have discovered a notion to provide doctor’s advice on take which depend on the type of disease or health problem theyphone by using latest tele and video conferencing technologies. encounter.
Case 1.1: Apollo Tele-Medicine Challenges Apollo Telemedicine is largest and oldest telemedicine network in India founded by Apollo Hospitals in 1999. •Changing the mindset of the people towards telemedicine. •Winning the trust of the patients of rural areas. Apollo Hospitals has two concurrent businesses in rural •Standardize the protocol of interaction between doctors and healthcare and telemedicine, one is under the banner of Apollo tele-medicine center. Telemedicine Network Foundation and other is Apollo Reach Hospitals. Healthcare Delivery Model The company was started way back in 1983 by visionary doctor The patients were advised from doctors from the distance Dr. Prathap Reddy when private healthcare was not so popular in varying from 200 to 2800 Kms. India. The technology had enabled the telemedicine centers to scan and mail the X-Ray’s and other medical Apollo Telemedicine Networking Foundation The details of the patients were transferred to be multi-specialty hospital by using desktop software. First project of Telemedicine was implemented in the village of Aragonda in state of Andhra Pradesh by building 50 beds hospital connected to Apollo multi-specialty hospital of Chennai. Video conferencing tools supplied by the Indian Space Research Organization (ISRO) were used to make tele-medicine possible to reach the villages of India. One tele-consultation with the super specialized doctor is done at price of US $ 11.2-16.7 and 50 US $ if overseas consultation is being done.
Case 1.1: Apollo TelemedicineISRO Offering Primary and Affordable & Quality Managing customer Poor Patients Secondary Healthcare health-care services in data online (Subsidized)State services Tier-2 cities and ruralGovernments Tele-Medicine areas Rich PatientsMedicalEquipmentSuppliers Doctors Video-conferencing through tele-medicine Para-Medical staff centers Diagnostic Setup MedicinesInfrastructure (Hospital, Equipment, Staff) Fees for specialist tele consultationResources (Doctors, Paramedical staff) Fees for Primary and SecondaryTraining, ICT Setup, Software Healthcare Services Medicines
Case 1.1: Apollo Tele-Medicine Social Benefits Social Costs Access to quality and affordable healthcare to all, expert Tacking the cultural differences and creating opinion to the patients awareness Metrics Organization Structure & Leadership Number of specialists tele-consultations, Centralized, Technology driven, multi-skilled Average doctors and staff time taken per patient, system downtime, Cost per patient, quality of service, number of tests Results Today, ATNF has more than 150 tertiary hospitals which are connected to 35 specialty hospitals across the globe. Today, Apollo had done 69000 tele-consultations done by more than 100 tele-consultation centers setup across the globe. The Aragonda hospital has done more than 2000 consultations had been provided in the last 10 years from direct video interaction with specialist doctors.
Case 1.2: Apollo Reach Hospitals Apollo Reach Hospitals In 2008, Apollo started its initiative Apollo reach hospitals to deliver low cost quality healthcare in Tier- 2 cities, sub-urban and rural areas. Apollo reach hospitals also extend the telemedicine network of the group which helped the people of the villages to get the best advice at their reach. Challenges The Apollo reach hospitals faced the critical challenge of availability of the doctors as people don’t want to work in smaller cities. Innovation in Business Model The Apollo reach hospitals targets both rich and poor patients in equable manner. The revenue comes from the high income people and affordable healthcare was provided to the low income people on the other side. The health insurance covers RSBY hospital expenses up to Rs. 30,000 ($667) for a family of five people. The transportation costs were also covered up to a maximum of Rs. 1000 ($23) including Rs. 100 ($2.23) per visit to the hospital or doctor. Apollo had also signed a loan of 50 million dollars from International Finance Corporation to open up more reach hospitals and telemedicine center in 2010.
Case 1.1: Apollo Tele-MedicineISRO Diagnostic Tests Affordable & Quality Primary & Secondary Poor Patients health-care services in Healthcare (Subsidized)State Governments Tele-Medicine Tier-2 cities and Consultation rural areas Insurance Offer Rich PatientsMedical Equipments (RSBY)Suppliers Primary and Secondary Healthcare Doctors Face2Face Consultation Para-Medical staff Video-Conferencing Diagnostic Setup Infrastructure (Hospital Setup, Equipment etc) Primary and Secondary Healthcare Resources (Doctors, Paramedical staff) Money from Insurance Training, ICT Setup, Software Medicines
Case 1.2: Apollo Reach Social Costs Social Benefits Publishing Papers to create the awareness Access to quality and affordable healthcare Inclusion of poor people (paramedical staff) Metrics Organization Structure & Leadership Poor-Rich Patients Mix, Average time taken per Centralized, Technology driven, multi-skilled patient, system downtime, Cost per patient, quality doctors and staff of service Results The inclusive business model of Apollo Hospitals had helped to reach sustainable revenues ranging from Rs 6000 ($132) to Rs. 7000 ($154) per bed. It is estimated that more than 1, 00,000 patients who earn less than 2$ per day had been served from Apollo reach hospitals. The group aims to open 15 more hospitals and serve more than 400,000 patients by 2015. The group also aims at opening 1000 telemedicine centers by the end of 2012.
Case 2: E-Health point ServicesE-Health Point services is owned by HealthPoint Services India (HIS) Healthcare Delivery Modelstarted its operations in 2009 in partnership in Ashoka Foundation andNaandi Foundation in the state of Punjab. Tele-medicine consultation was done by HIS urban health center where doctors give their advice and diagnose byThree projects were started simultaneously at different places by video-conferencing tools.providing the services of tele-medicine, diagnostic services,pharmacy and clean drinking water supply to around 10000 people. Doctors were recruitment from local areas so that there are no linguistic disadvantages and they are especiallyIn 2011, E-Health Points (EPHs) are operational with more than 80 trained to for providing tele-consultations.EPH centers spreading over seven districts of Punjab. EPH also has the facility of performing near 70 tests andInnovation in Business Model equipped with devices like digital stethoscope, blood pressure monitoring machine and ECG.The services were offered with a nominal fees of less than 1$ mostly tomake it affordable for rural households. The average cost of each medical test was just $1.The subscription was given at a very nominal fees of 1.5$ per month andgives 20 liters of clean drinking water daily which has helped indecreasing the water-borne diseases in rural areas.The medicines were given to patients by licensed pharmacy available atEPH and are sold at a discount of up to 50% on the listed prices anddirectly procured from channel partners of the companies to get the costadvantage.
Case 2: E-Health point ServicesAshoka Pharmacy Affordable & Quality Primary Healthcare Poor PatientsFoundation health-care services in Tele-Medicine rural areas Clean Water Rich PatientsNaandi ConsultationFoundation Providing Clean WaterGovernmentof Punjab Doctors Video-Conferencing EPH Centers Video-conferencing Setup Center Staff Infrastructure (Tele-medicine center, Equipment etc) Resources (Doctors, Staff) Tele-medicine Fees, Medicine revenues and Clean Training, ICT Setup, Software water subscription
Case 2: E-Health point Services Social Costs Social Benefits Organizing awareness and information sessions Access to quality and affordable healthcare to the poor Metrics Organization Structure & Leadership Number of Patients, Average time taken per patient, system downtime, Medicine sales and Collaborative, Inclusive, Technology driven water subscription, service quality Results EHP has done about 29000 tele consultations, 15000 diagnoses and 35000 prescriptions have been given since its inception to September, 2011. T he impact and wider reach of EHP at bottom of the pyramid can be understood by the way that it has around 3,50,000 daily users of clean water in rural areas.
Case 3: Piramal E-SwasthyaPiramal E-Swasthya was started in 2008 as a social healthcare Healthcare Delivery Modelinitiative of well established pharmaceutical company PiramalHealthcare in collaboration with Dean Nitin Nohria of Harvard BusinessSchool. • Patient comes to the Piramal SwasthyaInnovation in the Business Model Sahayaka (Health Worker) for treatmentE-Swasthya doesn’t charge any consultation fee from the patients, theyjust charge the expense of the medicines. • Health Worker tell the symptom to the callThe medicines were made available to the health workers for selling to center executivethe patients to generate instant revenues.The marketing was done in a very effective manner to engage therural people and BoP households through regular messages, drug • Call center executive feeds the symptomsremainders and publication of articles on telemedicine. as input into clinical decision support systemChallengesThe patients are not ready to buy all medicines as prescribed or • Clinical Decision Support displays thejust don’t complete the full course of medicine. recommended prescription based on various algorithmsRecruit the motivated health workers which can take the model to thenext level. • Doctor validates the prescription and ifTo address this challenge, E-Swasthya has launched pilot project with required talk to the patientGovernment of Rajasthan to recruit ASHA (Female Government Healthworkers).
Case 3: Piramal E-SwasthyaGovernment of Pharmacy Affordable & Quality Primary Healthcare Poor PatientsRajasthan health-care services Tele-Medicine in rural areas Health worker Rich PatientsTata ConsultancyServices Selling Water purification tabletsVision Spring and reading glassesAquatabs Doctors Video-Conferencing Health workers Call center Health worker Clinical Support Systems Infrastructure (Call center) Medicine revenues Resources (Doctors, Call center Staff, Health worker) Training, ICT Setup, Clinical Support System
Case 3: Piramal E-Swasthya Social Costs Social Benefits Awareness through publishing newspaper articles Access to quality and affordable healthcare to the poor Metrics Organization Structure & Leadership Number of Patients, Average time taken per patient, system downtime, Medicine sales and, Innovative Technology driven service quality Results E-Swasthya has treated 40,000 patients through several pilot projects which were deployed . E-Swasthya gets on an average 1.2 patients per health worker per day in 50 operational villages. To cover all the costs including the operational, technological and personnel and make the model financial sustainable in the long run, it is required to achieve 1.7 patients per health worker per day on an average for 1000 villages. The figure is quite achievable as already many villages have witnessed more than 3 patients per health worker per day.
ConclusionTele-medicine has emerged as a sustainable business which can cater the healthcare needs of the ruralpeople and bottom of pyramid.Tele-medicine is extremely helpful in primary and secondary healthcare, however more advancementsare required to replicate the model for tertiary healthcare in rural areas.The use of information & communication has removed the distribution and geographical challenges indelivering the primary and secondary healthcare in rural areas.ICT has significantly reduced both the infrastructure and operating cost for delivering the qualityhealthcare services to rural areas.Tele-medicine has been used as market development tool by the companies to create a new market forgetting an expert doctor advice without meeting him in personal.The emerging business models looks very promising but it’s very early to comment on their long termscalability and sustainability. The next 2-3 years will actually show clearer picture of the future of tele-medicine in India.The treatment of the poor segment at cheap and affordable price is a huge social capital created by thesebusiness models.By giving treatment to the poor segment and people in rural areas, these business models are contributing inthe inclusive growth of India full filling the dream of “healthcare to all”.
RecommendationsGovernment hospitals should be converted into public private partnership models to make them more profitable and effective indelivering the healthcare.Companies need to make tele-medicine as their core activity rather than a side activity. They need to offer full basket of healthcareservices in order to make their business models more sustainable and scalable.There is also a need of more advanced healthcare information management system like Nokia health tools. Healthcare informationsystems can play a crucial role in preventive healthcare and creating the awareness about healthcare with the increasing penetration ofmobile phones in rural India.The government need to give adequate subsidies and tax benefits to the companies operating in rural healthcare to make theirbusiness models more scalable which can enhance the reach of tele medicine to different parts of the country.It is very important that bigger companies should enter the market the tele-medicine and rural healthcare industry to develop themarket and make it more scalable and sustainable.