Perhaps now more than any other time in our history, we are realising the importance of technology in social service delivery, and its role in enhancing the general quality of life. Growing up in India, where the majority has minimal access to basic public amenities like healthcare, one develops an appreciation for the value of enabling such technologies that assist and scale service delivery in the context of developing countries.
Technology can be transformative in delivering healthcare services, where the density of doctors is one per 1,000. A strong imbalance exists where urban areas have four times as many medical practitioners compared to rural areas, making rural India grossly underserved. The quality of education of providers (allopathic, ayurvedic, unani and homeopathic) is not comparable between rural and urban centers. When 58 percent of the doctors in urban areas had a medical degree, only 19 percent of those in rural areas had that qualification. Hence, the rural healthcare infrastructure story is significantly different.
A FirstPost article published last year states that “India compares unfavorably with China and the US in the number of hospital beds and nurses. The country is 81 percent short of specialists at rural Community Health Centers (CHCs), and the private sector accounts for 63 percent of hospital beds, according to government health and family welfare statistics.”
The healthcare sector represents a huge opportunity to leverage technology to improve critical processes that today pose a big challenge in the delivery of quality healthcare. These include reaching millions who are geographically spread across the country, providing better and more accurate diagnosis, managing operations and facilitating effective collaboration and dialogue between doctors and healthcare workers.
The question remains, how do we use technology to improve healthcare delivery for everyone in India. Individuals, especially people living in rural areas, face challenges in gaining access to healthcare. The diversity and vastness of the country can pose some of the hardest problems to tackle, but can technology be part of the response to these challenges?
The convergence of technological solutions with data analytics, cloud computing, telecommunications, and wireless technologies will improve accessibility and manage labour shortages more efficiently in the healthcare industry. Benefits derived include easy accessibility irrespective of geographical location, fewer errors, fast response for emergencies, and improved patient experience. The cost of providing medical services has also been rising steadily. As technological innovation better integrates with healthcare delivery, it will enable scale and lower costs, driving up adoption. And adoption will be further driven by the automation of critical processes at hospitals in administration, finance, billing, patient records and pharmacies.
Telemedicine and remote advice
Even though telemedicine has been receiving a lot of interest lately and feels like a recent phenomenon, it has been around for over three decades. According to an NIH report from 2008, NASA played an important role in the early development of telemedicine to provide healthcare to astronauts when they were in space. Today, it serves a similar purpose – providing healthcare to those who lack access.
Telemedicine is a powerful tool that allows medical expertise to be received beyond the boundaries of a medical facility. It saves millions of dollars in patient travel costs and missed appointments. However, telehealth is not new to India, and has been around for over a decade now. Health systems across the country have the opportunity to create meaningful impact by adopting scalable telemedicine technologies.
This can be done by entering into public private partnerships so as to provide the project more sustainable financial support. We are already seeing such models emerge that can be gold standards for implementation of telehealth in India. One such model is the recent PPP entered into by Apollo Tele-Health Center. A Hindustan Times article describes in detail the telehealth centers set up by this partnership in Kelong and Kaza in Himachal Pradesh that have facilitated more than 3,000 consults and provided emergency care for over 200 people in the region.
Adoption of technology also comes with its share of challenges. Ratan Jalan, the Founder and Principal Consultant at Medium Healthcare Consulting, a boutique consulting firm, and the CEO of Apollo Health and Lifestyle Limited between 2000 and 2008, understood the challenges first hand having tested such models.
He states that:
Most of the tele-consultation providers haven’t really taken off because they haven’t adequately addressed the challenges at the ‘receiving’ end – where the patient resides. A patient is less likely to take up complete control of the patient-physician dynamics with a ‘remote’ physician and would like to involve the ‘local’ physician whom he trusts. And unless that physician is adequately compensated and integrated in this solution, I don’t see it taking off. In fact, that was the challenge we faced, even when I was looking at telemedicine project at Apollo almost a decade ago.”
Jalan’s concerns are valid. Firms in the space must consider physicians in the community and find ways for them to adopt such technologies.
Lybrate, a Delhi-based healthcare startup, was started with the vision to bridge access to healthcare. The direct-to-patient mobile app is a healthcare delivery platform providing health tips customised to a user and access to an online database of physicians. Its closest competition is Practo, backed by the likes of Tencent, one of China’s biggest internet investors, and Google. Practo is designed to be a platform company connecting you to multiple healthcare services such as booking appointments, diagnostic tests, and obtaining medication to name a few. This is a promising start to what could be a high impact, widespread use of technology to improve healthcare delivery.
Home and elderly health
The idea of nuclear families has been rising in India. Younger couples move to cities away from home to be closer to work, leaving parents to live on their own. Culturally, India has not yet bought into the idea of nursing homes, and hence the emergence of home care services is more popular. Some interesting models have already been making their way into this space – Life Circle Health Services is one such company that provides trained, professional caregivers to seniors. This model, like many other service-oriented models in India, can be logistically challenging, operationally expensive, and very dependent on the availability of the right type of talent in the area.
Anant Kumar, the Founder and CEO Of Life Circle, has been able to overcome some of these challenges by adopting technological solutions. He says, “With services provided in hundreds of homes across multiple cities, technology plays an essential role in the maintenance and tracking of service quality. Some of the areas where Life Circle has deployed technology are:
- An algorithm to help match most suitable caregiver or nurse with patient requirement – language, stature, skills, budget, duration, and distance.
- Life Circle’s digital “Patient Care Plan” module helps nurse manager prepare a customised plan for every patient, which is shared electronically with the family members.
- The caregiver’s background is verified with the national court case registry, and identification data matched with national identification database.
- Caregivers work can be tracked using any feature phone. All attendance validated with the patients in real time.
- Senior’s health condition remotely tracked and validated by a team of senior nursing staff.
- The caregiver can accept work, review care plan, check their payment.
Anant’s vision for the future of home healthcare in India is exciting, as he see’s technology being a critical part of the puzzle. He says “Today, 15 percent of seniors in India are staying alone, and this number would rise in the future. With the rise in nuclear families and with the absence of traditional family caregivers, Life Circle is actively working towards “Ambient Assistive Living” where sensors would play an active part in care provisioning by being less intrusive. The sensors would help with emergency calls, falls detection, environment sensing (light, humidity, temperature).”
Shifting gears to a focus on policy and how we can learn lessons from Japan, which has the highest proportion of people aged 65+ years. Japan has a universal mandatory long-term insurance care system, partly paid by payroll taxes and partly by the general tax revenue. The primary caregivers remain the family, but they are offered subsidised services of daily home care, visiting nurses, etc.
Policies have always been the biggest influencers to enforce behavioural change, but technology can be as impactful when it comes to changing the way services are delivered. Some technology-enabled services that may complement elderly care are – emergency caregivers, medication delivery services with trackable reminders, and ride access facilities. Technology can play a big role in providing doctors with frequent updates of their elderly patients, allowing them to manage their care plans better without visiting the patients at home or having them come to the clinic premises.
Some models that are operating well in the US are HomeTeam, Capsule, Honor. HomeTeam, a New York-based health technology startup providing home care to the elderly and chronically ill, focuses on giving the health aide technology enabled tablets to track their schedules and home visits. Capsule is an upcoming healthcare company that calls itself the new kind of pharmacy with medication delivery. Honor, also a San Francisco-based startup, focuses on specialised training for its caregivers and provides the patient and their family a care platform, giving them more control over managing their own care plan.
Today, we are living healthier and longer lives. Building a healthcare system that effectively manages care for the elderly is inevitable. Even though we’re among the youngest country in the world, this is a certain state and is only a matter of time before it becomes a priority.
Data and analytics
As the healthcare sector in India becomes more prominent in terms of its revenue generation and its need for a strong labour force, innovation in the sector is not far behind. According to a paper by the International Advanced Research Journal in Science, Engineering and Technology (IARJSET), the Indian healthcare sector is expected to witness a growth of $220 billion by 2020, and a workforce of $7.4 million by 2022. Building infrastructure so as to leverage data to make healthcare decisions can be a powerful endeavor. Starting small, this article talks about two such opportunities – personal wearables and electronic health record systems that are widely used across developed nations.
A paper focused on the Indian wearable market titled – ‘Wearables, The Next Big Thing in Smart Healthcare’ by the IARJSET states that 2016 witnessed $2.5 million units of wearables shipped across the country, $.675 million of these alone in Q4 of 2016. The wearable market in India today is immensely popular with not only younger audience, but also those paying more deliberate attention to their health.
Wearables provide easy access to data, ability to self-monitor health, and track progress over time. Community level data analysed correctly could help predict the level of incidence of disease and offer opportunities for preventative healthcare in the medium to long term.
For healthcare providers, this means lower error rates in diagnosis and other medical errors, fewer visits to the doctor saving time and money, and better overall care for the patient population.
Though more challenging to implement, electronic medical record systems is another big opportunity for India to leverage. This makes healthcare more efficient, safer, and cost effective over time. Having everyone’s medical records electronically saved has far-reaching impact that outweighs the heavy cost of this transition. India, today, is not far behind to adopt electronic record keeping in medical facilities and is further along the pathway of digitising healthcare records.
The Aadhaar card system can be the catalyst to a strong electronic health record system in India. Even though Aadhaar today focuses much on linking income taxes, passports, bank accounts etc., this will only serve as a foundation for a stronger medical record system.
Doxper is trying to simplify the way healthcare data is recognised and digitised. It has a few different offerings catered towards health systems, physicians, and patients. The marketplace for electronic medical records is ripe in India and companies such as Practo and DocEngage are vying for space.
Some of the biggest benefits of having access to electronic health data through an EMR is being able to mine the data at a larger community level and understand the incidence of chronic diseases.
For example, understanding the prevalence of diabetes and the need to set up dialysis centers in otherwise out of reach communities in India is invaluable. Similarly, malnutrition cases among children who live below the poverty line can be analysed based on location and specific measures can be taken to help those in need.
Given the vastness of the country, we have gotten good at managing otherwise complex distribution networks, but to make these more effective, community healthcare workers can be equipped with better data on where they should spend their time. In an ideal world, we would have more real-time data on incidence of community level disease prevalence and would be able to do so much to improve the quality of life for these communities, but the opportunity to do so still stands before us.
Mental and behavioural healthcare
According to the World Health Organisation, the incidence of depression in India is extremely high, putting it at the top of the list of the most depressed countries in the world – 36 percent of citizens are likely to suffer from depression at some time or the other. The same Forbes article that quotes the WHO stats above, also states that a new study by The Lancet found that despite the rising mental health disorders in India, only about one in ten people receive evidence-based treatment. This may be due to access to services based on location and or stigma attached to behavioural and mental health in India.
Technology enabled service models in the US have come a long way in tackling mental health problems. Some of them give the provider access to better tools and resources to manage mental health for their patients – one such model is Quartet Health, a New York-based startup that just raised a series C of $40 million. The company focuses on the primary care provider or family physician having access to tools that allow them to identify mental health needs, have access to qualified mental health providers and methods to monitor patient progress.
It is fascinating how much your family doctor or primary care physician can control your overall health, even though they end up being in a low-cost setting. Additionally, there is a sudden surge of apps that allow people to manage their own mental and behavioural health issues. Two apps that are popular are Calm and Headspace – both of which use mindfulness and relaxation to bring you to your best each day. They help manage stress – such technologies are easier to market to the millennials in India, they may also be the ones who need it the most. Unfortunately, the problem is not acknowledged in India, as there is a lack of recognition for mental health issues, and depression more specifically.
A news article in the US from 2016 provided a table showing countries with the highest burden of disease for mental disorders, in terms of most years of life lost due to disability or death adjusted for population size, according to WHO.
All said and done, the road to greater technology adoption is not going to be without its share of challenges. Currently, the IT budget for Indian hospitals does not exceed 10 percent of their revenues, substantially lower than allocation to technological investment in hospitals in the west.
Adoption of technology has a long-term impact on cost, and hence there needs to be more intended effort to invest in technology and adopt this high up-front. It means investing in training and hiring manpower, paying for servers, adoption and implementation costs at the healthcare facilities, which will pay for themselves in the long term.
Additionally, clinical transformation, which involves assessing and continually improving the way patient care is delivered at all levels in a care delivery organisation, can also be a challenge to implement. Given how busy clinicians are, there is a natural tendency to resist change and often, incentives to adopt technology at an individual level are limited. For those who see the longer-term benefits will also be early adopter of these technologies, improving the overall business environment and patient care.
As we dig deeper into the potential technology has to disrupt age-old practices in healthcare, it brings up important legal and ethical issues to the mix. With global conversations around data privacy, patient and related healthcare data could peak that data hierarchy debate. Recently, a Business Standard article stated that India’s Health Ministry has proposed a law to govern data security in the healthcare sector, giving individuals full ownership of their data. It said individuals would have the right to refuse or allow data to be generated, collected, accessed, transmitted, or used.
Hospitals would not be able to refuse patients any treatment or care if they did not wish to share such data. Laws will always favour individual privacy over benefits to the establishment, and in this case the decision then lies in the hands of the individual. There is also always a risk in electronic communication of healthcare diagnosis, plans, prescription etc., which could magnify if not properly conducted.
There is no dearth of research studies, relevant data, and true humanitarian stories that prove to us the impact technology can make to healthcare delivery. It requires sustainable funding sources, a deep understanding of the complexities of service delivery in India and a will to see it through. We have favourable government policies that are sure to enhance and encourage such partnerships, and entrepreneurs who understand these challenges first hand and want to bring sustainable solutions to real problems.
Such transformational forces all happening together can take decades to produce real and meaningful change in a country’s economy. India does not need to start from scratch.
We’re well positioned in terms of being one of the youngest countries globally – ‘India has more than 50 percent of its population below the age of 25, and more than 65 percent below the age of 35. It is expected that by 2020, the average age of an Indian will be 29 years, compared to 37 for China and 48 for Japan; and by 2030, India’s dependency ratio should be just over 0.4.’
The last two years have seen record numbers of venture capital and private equity funding in the country. According to E&Y’s report last year, the country received $26.5 billion in 2017, 35 percent higher than the previous high in 2015, and 63 percent higher than the previous year.
If planned and implemented well, technological progress can make a significant contribution to India’s healthcare needs. Such an investment would impact generations to come with lower healthcare costs and put India on the world map as a country to be reckoned as a thought leader in adopting digital health.