Can Telemedicine Alleviate India's Health Care Problems?

Chakrajmal village, in the Bijnor district in the North Indian state of Uttar Pradesh, got its first doctor in 2008. He was not based in the village, though. The villagers had access to the doctor via a telemedicine project launched by World Health Partners (WHP) to provide health care services to 1,000 villages in Uttar Pradesh's Bijnor, Meerut and Muzaffarnagar districts.

Set up in 2008, WHP, a U.S.-headquartered international nonprofit, provides basic health care and reproductive health services by harnessing local market forces to work for the poor. According to Gopi Gopalakrishnan, founder-president of WHP, the organization's model is to draw on private sector capacity through social franchising, innovations in labor management, and low-cost technologies to develop a scalable and sustainable health care service delivery model.

WHP's Uttar Pradesh telemedicine network now comprises around 1,200 local individuals called Sky Care Providers and 120 entrepreneur-run centers branded as Sky Health Centers. The Sky Care Providers are given training and low-cost mobile solutions by WHP to perform diagnostics, symptom based treatments, tele-consultations and, wherever needed, referrals to the Sky Health Centers.

These centers use remote diagnostic devices for measurement of basic parameters such as blood pressure, heart rate, electrical activity of the heart and pulse rate. The patients are connected to doctors at WHP's central medical facility in New Delhi via computers and webcams. The entrepreneurs have the option of leasing the equipment from WHP. For the patients, consultation charges vary from 20 U.S. cents for below poverty line households to US$1 (at the exchange rate of Rs. 50 to a U.S. dollar).

Patients who require surgery, inpatient care or specialized procedures that cannot be delivered via telemedicine are referred to the nearest WHP franchised health care clinic. Currently WHP has 16 such clinics in Uttar Pradesh. Since 2008, WHP has provided villagers in Uttar Pradesh with around 35,000 tele-consultations for common ailments such as fever, indigestion and gynecological problems.

Gopalakrishnan is now replicating this model in Bihar. Currently there are 104 telemedicine centers up and running in 13 districts of the state. He hopes to expand to 400 centers across 25 districts (covering a population of 70 million) by end of 2012 and 1,250 centers over the next three years. Apart from treating basic ailments, Gopalakrishnan now also wants to focus on detection and treatment of tuberculosis, visceral leishmaniasis, childhood pneumonia and diarrhea.

"There's a huge, unmet health care need in our rural hinterlands. The challenge is to make health care affordable for the masses and attractive to the providers at the same time," says Gopalakrishnan. "Telemedicine is a good strategy to strengthen the existing human resources available in health care. The scale, however, will come only through effective government intervention."

According to Rana Mehta, executive director and leader of health care practiceat PricewaterhouseCoopers (PwC), access to health care in India "gets limited by the affordability factor and hence telemedicine -- or the remote diagnosis, monitoring and treatment of patients via videoconferencing or the Internet -- has a very important role to play. It is at a fairly nascent stage right now having started only about a decade back, but it is undoubtedly a fast-emerging trend, led by growth in the country's information and communications technology sector."

K. Ganapathy, president of the Apollo Telemedicine Networking Foundation, past president of the Telemedicine Society of India and adjunct professor at the Indian Institute of Technology, Chennai, is categorical that telemedicine is the way ahead. "We can't go far with conventional brick-and-mortal hospitals,' he says.

Vijay Govindarajan, professor of international business at the Tuck School of Business at Dartmouth College, not only sees India as one of the early adopters of telemedicine, he also notes that the country has the potential to develop innovations that can be adopted in other parts of the world, including developed nations like the U.S. "In the United States, we are thinking of IT [information technology] as just electronic medical records," Govindarajan says. "This shortchanges IT's full potential. Driven by extreme need, India is inventing new ways to use information technology to improve health care."

Govindarajan lists the reasons why telemedicine will take off first in India: A severe shortage of doctors, especially in rural areas; very high patient volumes; widespread availability of mobile networks; rapid growth in the availability of low-power, hand-held medical monitoring devices, and the shift away from the proprietary, local area network-based medical image archiving and communications systems to a networked tele-enabled system. "Innovations in telemedicine will accelerate in India, where access and cost are critical issues. These telemedicine innovations will be adopted in the U.S., where cost and access are becoming increasingly talked about. This is a classic reverse innovation story," he adds.

Potential for Growth

A January 2012 report titled, "Global Telemedicine Market Analysis," by RNCOS Industry Research Solutions, an India-based market research and information analysis company, projects that the global telemedicine market will grow at a compound annual growth rate (CAGR) of around 19% from 2010 to 2015. An earlier report in 2009, titled "Global Telemedicine Market: 2008-2012" published by Infiniti Research, a London-based market intelligence firm, pegged the size of the global telemedicine market in 2008 at US$9 billion. According to this report, Asia is the fastest growing region for the telemedicine market with India and China leading the growth.

There are no clear numbers, though, on the current size of the telemedicine market in India. Murali Rao, associate vice president for health care at the New Delhi–based research and consultancy firm Technopak Advisors, estimates the current size of the Indian telemedicine market to be around US$7.5 million. "This is expected to grow at a [compound annual growth rate] of 20% over the next five years," he says. That would take it to around US$18.7 million by 2017. Mehta of PwC on the other hand notes: "Studies indicate that the size of India's telemedicine market is expected to be US$500 million by 2015." (This is a nascent area and estimates vary widely.)

Ganapathy of Apollo points out that 80% of India's population has no direct, physical access to specialist health care and gives some back-of-the-envelope calculations: "Estimates suggest that the telemedicine market is at least for 800 million Indians. Even if half of these 800 million need to consult a specialist once a year, [that still amounts to] 400 million specialist consultations per year. Even if 10% of these are enabled through telemedicine we are talking about 40 million consultations per year from rural India alone…. The market potential for telemedicine is obviously enormous."

While the numbers may vary, what is undisputed is the potential that telemedicine holds. A major driver of telemedicine in India is the dismal state of health care in the country. India's government spending on health as a proportion of the GDP – currently at around 1% of the GDP - is among the lowest in the world. Even in other Asian countries, it is higher. The corresponding amount is 1.8% in Sri Lanka, 2.3% in China and 3.3% in Thailand. Despite the launch of the National Rural Health Mission in 2005, India continues to grapple with a 33% shortage of rural hospitals, which are called Community Health Centers (CHCs). Even in the ones present, there is an acute shortage of staff. According to the Ministry of Health and Family Welfare, there is a shortage of 50-70% of physicians, specialists, lab technicians and radiographers at the CHCs. And around 10-15% of them lack even basic amenities such as water supply and electricity.

Experts have time and again suggested that if the vision of "Health for All" is to be achieved by 2020, India will have to pump in 6% of its GDP in the health care sector. At the same time, technology-enabled health care networks can play a huge role by bridging the distance between doctors and patients through Internet and other telecommunication technologies.

Ground Realities

Some of the major players in telemedicine in India at present include Narayana Hrudayalaya, Apollo Telemedicine Enterprises, Asia Heart Foundation, Escorts Heart Institute and Aravind Eye Care. Devi Prasad Shetty, a leading cardiac surgeon based in Bangalore and founder of Narayana Hrudayalaya Hospitals, predicts that it is only a matter of time before we see a huge spurt in the use of telemedicine. "In the early days, satellite was the only means of managing the telemedicine program and keeping satellite connectivity was not very easy," he notes."However, now with Skype and other ways of videoconferencing there are many options available. With the stabilizing of technology platforms, technical problems are extremely rare."

Shetty is at the helm of one of India's earliest and largest telemedicine programs. Launched around 10 years ago, the initiative is managed through satellite connectivity provided free of cost by the Indian Space Research Organization (ISRO). Presently, the Narayana Hrudayalaya telemedicine network is connected with about 100 telemedicine centers across India. Outside India, as part of the PAN African satellite network, it is connected to 55 cities in Africa. The connectivity also extends to some other places like Iraq, Malaysia and Mauritius. Since its launch, it has conducted around 53,000 tele-consultations in the areas of cardiology, neurology, urology and cancer. Narayana Hrudayalaya also has an electrocardiogram (ECG) network wherein general practitioners in remote locations are given a trans-telephonic ECG machine that helps transmit ECGs. Narayana Hrudayalaya gets about 200-300 ECGs daily. These are interpreted by its doctors and then communicated to the local doctors at the remote locations.

Shetty points out that telemedicine is not just about connecting remote locations. Six years ago, when Narayana Hrudayalaya started performing liver transplants on babies, its cardiac anesthetists did not have adequate experience for this procedure. So Shetty turned to telemedicine. Narayana Hrudayalaya's operating room in Bangalore was connected to the Children's Hospital of Philadelphia and the anesthetists there. "After hand-holding for about five to seven liver transplants, our anesthetists acquired the knowledge," says Shetty. He goes on to add: "In the coming years, most of the medical treatment will be through telemedicine either in the same city or in other countries. There will be enough gadgets available at home to check blood pressure, blood sugar, ECG, oxygen saturation, even ultrasound. Patients will consult the doctors through mobile phones or videoconference through cellphones."

Some of this is already happening. Recently, leading telecom player Airtel tied-up with Healthfore (a division of Religare Technologies) and Fortis Healthcare (a Religare group company) as the knowledge partner to offer Mediphone services to its customers. This service allows subscribers to access basic medical guidance on non-emergency health problems over the phone. The service is available around-the-clock at less than US$1 for each consultation.

Other telecom players like Aircel and Idea have launched similar services in collaboration with HealthNet Global, a Hyderabad-based emergency and health care management services firm. The subscribers who call to seek health advice are visited by paramedics who come with a laptop and medical diagnostic equipment and conduct consultations via video conferencing. This is also gaining traction among insurance companies. "We have already conducted 1,000 sessions since our launch in September 2011. We are currently present in Chennai, Mumbai, Delhi and Hyderabad. We plan to expand our services to all the metros," notes Rahul Thapan, global head of marketing & sales for HealthNet Global.

In December of last year, microfinance firm Equitas also launched tele-health care delivery centers in association with HealthNet Global. The project is funded by Fem Sustainable Social Solutions (FemS3), a nonprofit company operating in the social business space. Equitas' Consult 4 Health and Call 4 Health products, developed exclusively for the firm by the Centre for Insurance and Risk Management at the Chennai-based Institute for Financial Management and Research, allow its members to consult physicians from Apollo Hospital over video for a charge of US$1 a consultation. The patient's data is also stored for any further diagnosis and treatment in the future. 

"It is our endeavor to improve the quality of lives of our members and their families," says P.N. Vasudevan, managing director of Equitas. "Health care is a source of significant financial stress for this segment. The initiative with HealthNet Global using physicians from Apollo Hospital will bring a revolution by providing health care to the doorstep of our members and the best medical care anytime, anywhere. We will roll out our services from Chennai and gradually go pan-India." Currently, Equitas has three tele-health care centers operational in Chennai.

Other new models are also emerging. Take Mumbai-based MeraDoctor (My Doctor) founded in 2010 by Gautam Ivatury, who was earlier working in the area of mobile phone-based services, and Ajay Nair, a medical doctor with a master's degree in public health management from Harvard. A phone-based medical advice service, MeraDoctor works on a membership model. The company offers family membership plans for three months and six months; during this period, members are entitled to unlimited phone consultations with MeraDoctor's team of doctors. Members can also avail of discounts at select diagnostic centers that MeraDoctor has tied up with.

There are new products, too. Dartmouth's Govindarajan points to General Electric's innovative low-cost ECG machines, which were developed in India and can take digital images that can be emailed to cardiologists in the U.S. "[This gives] poor patients in remote rural areas access to world-class care," he says.

Another example is 3nethra from Bangalore-based Forus Health. Developed with the aim of enabling mass pre-screening outside the hospital environment, 3nethra is a portable, non-invasive device that helps in early detection of eye diseases like cataract, diabetic retina, glaucoma and cornea related issues. The digital information taken by 3nethra can be easily transmitted electronically. The device won the Samsung Innovation Quotient award in 2011. "At 3nethra, we wanted to work with the system and its limitations," notes K. Chandrasekhar, founder and CEO of Forus Health. "Even a minimally trained technician can operate it. The idea was to develop a solution that was cost effective. The device that we have developed is available for one-sixth the cost of present diagnostic devices. Also, it uses only 10 watts of power. It can run for four hours on a UPS, making it ideal for rural areas [which face enormous shortage of power]."

Challenges Remain

But even as the telemedicine scenario in India is seeing significant developments, challenges still remain. According to Narayana Hrudayalaya's Shetty: "The greatest challenge is getting enough medical specialists to see patients in remote locations and also to get the patients to trust the opinion by the doctors, virtually."

Healthnet Global's Thapan points out that India will soon have a billion phone connections and the network will not be a problem. "It's now about finding the right linkages," he says. Thapan notes that ASHA (Accredited Social Health Activists) workers, for instance, can be trained to aid the doctors. "It will help spread the network," he adds.

Apollo's Ganapathy suggests that the potential of telemedicine in India is still under-realized because of lack of awareness among the masses and lack of a business model that caters to all the stakeholders. "Telemedicine will never reach the critical mass for take-off until doctors are excited about it and unless people clamor for it as a cost-effective method. We need public-private-partnerships to drive telemedicine [in India]."

Mehta of PwC says the entire ecosystem needs to be strengthened. "Ten years ago, there was the technological barrier," he notes. "That has gone away. However, the economic barrier stays. The ecosystem, in terms of incentives for the hospitals, the broadband service providers and the patients, needs to be defined. That is the tipping point of the telemedicine market in India."