Rose Weeks

Technology to the People! Taking Telemedicine to Scale in Rural India

This post was contributed by the Center for Health Market Innovations (CHMI) as part of NextBillion’s Healthcare With the Base of the Pyramid series.

Long known as an IT capital, India’s health infrastructure for years lagged behind the Tiger-like force of its software industry. No more: In the past decade, thanks to growing support from government, private sector innovation, and a great leap forward in infrastructure development, so-called Information Communication Technology (ICT) is transforming the way people receive health care.

The “next generation” telemedicine model is proliferating rapidly in India, where 70% of people live in rural areas where health infrastructure is still insufficient. Telemedicine uses ICT to “provid[e] accessible, cost-effective, high-quality health care services,” in the words of a recent WHO Global Observatory for eHealth report. Telemedicine models, in which rural patients are connected to trained physicians over telephone or Internet, can become the first point of access for a variety of illnesses and diseases such as eye related issues, intestinal problems, infections and heart disease. Most importantly, patients get into the health system early and do not delay care seeking for fear of transportation and costs.

Today, CHMI profiles more than 55 telemedicine programs globally including 24 in India (program implementers and CHMI’s partners in 16 countries are continually adding new programs to the open database).

World Health Partners is a not-for-profit franchising organization that provides healthcare services to the poor in Uttar Pradesh across Meerut, Muzzafarnagar and Bijnor districts. In less than 18 months, the project established a health service delivery network covering 1,300 rural villages of Uttar Pradesh through 1,300 shops, 120 telemedicine centers, nine diagnostic centers and 16 franchisee clinics. The project’s central medical facility in Delhi conducts 80-160 tele-consultations per day. Next up: an expanded pilot in Bihar, with funding from the Bill & Melinda Gates Foundation. Gates has also initiated a rigorous evaluation of the model’s health impact.

Sehat First, another franchise model utilizing ICT, aims to set up 500 health centers across Pakistan by 2012. Founded in 2008 by d.o.t.z. technologies as a Karachi-based pilot, Sehat First received an equity investment from Acumen Fund. The initiative’s telemedicine consulting service gives patients access through clinic staff to physicians, even specialists like gynecologists and pediatricians, over IP-based video phones.

Amrita Institute of Medical Sciences (AIMS) and Research Centre uses telemedicine to connect general providers to specialists. In addition to the flagship hospital at Kochi, the Institute also has established several smaller satellite hospitals in semi-urban and rural areas to serve the local populace. Students from the health sciences campus in Kochi often are posted to these hospitals, and doctors and other medical staff serve there as well. Satellite hospitals are linked to the 24/7 telemedicine service of AIMS Hospital. The technology allows for the transmission of a patient’s medical records and images, and provides a live two-way audio and video link, which allows a general practitioner at the health center to connect with a specialist at AIMS.

Raja Bollineni, of CHMI partner organization ACCESS Health International, is charged with mapping ICT-related health initiatives in India. Bollineni got interested in the promise of so-called e-health when working in Rwanda. He proposed a system for Partners in Health to allow people in rural Rwanda to consult on eye problems with specialist ophthalmologists located at Central Hospital University Kigali.

Although these models have garnered a lot of excitement in India and abroad, Bollineni is quick to point out a number of challenges impeding the implementation and further growth of these programs, including capital investments, infrastructure limitations, lack of supportive policy, and low awareness levels in the communities. One other important barrier to sustained growth is the difficulty in getting sufficient volume to sustain your business.

“Startups shouldn’t go in for high-end technology,” suggests Bollineni. “You can save your capital for other investments, and the tariffs are also high on imported technology.” Bollineni suggests that implementers look at connectivity, and be realistic-even more basic Internet over phone can be effective, with limitations

Garnering sufficient volumes of revenue is another big challenge for implementers. “For telemedicine programs to go to scale, they have to be able to attract a sufficient volume of business,” says Bollineni. In his view, there are two ways to make them economically viable. The first is to obtain government support for expanding infrastructure. The best way to do this is to create bundled shared services that utilize the same infrastructure. He recommends adding on dental services, dermatology and diagnostics to boost revenues, and points to Punjab-based Healthpoint’s innovative choice to sell clean water cheaply adjacent to a telemedicine-equipped clinic.

How equipped does a clinic have to be to incorporate telemedicine? According to Bollineni, there are many options. Very well connected clinics use broadband with speeds of 512 kb/second, while Integrated Services Digital Network (ISDN) lines are the most preferred connectivity options for practical reasons to connect remote areas which only require a minimum bandwidth of 128 kb/second, costing about 171 Rs/hour (less than $4). VSAT too is a good option although a costlier proposal but provides much faster data transmission than ISDN. Video conferencing requires 256 kb/second ISDN or IP based support.

Among those using high-end technology are Apollo Telemedicine Networking Foundation’s tele medicine centers an initiative of Apollo Hospitals, the Joint Commission-certified hospital chain that has set up more than 100 telemedicine centers in India and 10 overseas to boost their business and make follow up visits more convenient.

For start-ups with less capital, Bollineni points to tech “hot beds” developing ICT used for telemedicine in South and West India. “Neurosynaptic has an interface box set which can transmit images and data at very low band widths-this seems to working very well,” he said. World Health Partners uses the Bangalore-based company’s ReMeDi kit. Mumbai-based Maestros has developed Element 6, a portable medical kit for telemedicine. Bollineni also pointed to technology development and incubation centers at Indian Institute of Technology (IIT) Kanpur, IITM’s Rural Technology and Business Incubator (RTBI), Centre for Development of Advance Computing (CDAC) centers across India and the School of telemedicine at Sanjay Gandhi Postgraduate Institute of Medical Sciences.

Bollineni cautions that the government must continue to play a stewardship role in accelerating this developing sector. More standardization of hardware and software and developing practice guidelines will help program managers implementing telemedicine programs overcome inter-operability, portability and security issues. Bollineni also urges government to implement the ICD 10, an international system of codes that classify symptoms and diseases.

With ACCESS, Bollineni is working to build collaborative and co-operative efforts from and among the network providers and the system developers. This April, as part of its work to forge connections between innovators with the Center for Health Market Innovations, ACCESS will be hosting a tele-health roundtable to bring both groups together for dialogue. Contact Bollineni to learn more.