As a scientist at the New Delhi-based Institute of Genomics and Integrative Biology (IGIB), Dr. Anurag Agrawal often ponders the links between genes and lung disease. Could there be a connection between height, weight and a propensity to develop asthma? How might diet affect chronic obstructive pulmonary disease?
In the winter of 2013, he started thinking: What if there was a way to use shipping containers to collect and mine people’s health records, thereby gaining insights into disease to provide treatment?
One such container eventually made its way to a village in Uttar Pradesh. Here, villagers could gain access to a paramedic, deposit blood samples and have a qualified doctor advise them by monitor. They could submit a cardiogram, have a doctor look at it within days and, if necessary, sound an alert.
The IGIB is one of 39 state-funded Council for Scientific and Industrial Research laboratories. As a government establishment, it had limited scope to expand. But five years ago, IGIB partnered with Narayana Health (NH), a renowned Indian multi-specialty hospital chain, and the American IT giant Hewlett-Packard, to install more than 40 such ‘eHealth’ centres in various parts of the country.
The NH network now uses these shipping containers as part of its rural health outreach, which includes electronic medical records (EMR), biometric patient identification and integrated diagnostic devices. The HP cloud-enabled technology allows for the monitoring of clinical and administrative data.
With one doctor for every 11,000 people, India falls far below the World Health Organisation standards, which specifies one doctor per 1,000 patients. The problem is particularly stark in villages, where access to primary healthcare centres is a major challenge, and where it is difficult to attract qualified doctors. In theory, the spread of mobile phones, falling internet data rates and inexpensive healthcare lodging facilities (such as shipping containers) can lead to significant penetration of eHealth into villages.
In the field of radiology, for instance, telemedicine has been a game changer. It’s possible for remote eHealth centres to beam MRIs or cardiograms into well-equipped hospitals in cities to be studied by experts. But Agrawal, who now heads the IGIB, says that success is still limited. “The time of qualified doctors is still a huge cost,” he noted, “and while telemedicine has certainly made access to second opinions and to international consultation easier in urban areas, I’m not sure whether rural India has benefited as much.”
Ajoy Khanderia, CEO of Gramin Health Care (GHC), an Indian startup that provides health services in underserved areas, believes rural India is where the potential of providing affordable health care can be maximised. His team has set up more than 100 clinics across six states and conducted over 4,800 health camps. The startup says it earned 10 million Indian rupees (USD 138,461) in 2017 and expects a five-fold increase in 2018.
Unlike NH’s shipping containers, GHC has established its health centres in bazaar shops provided by the Indian Farmers Fertilizers Cooperative Limited (IFFCO), which holds a 26 percent stake in the company. These centres are staffed and digitised healthcare clinics where, according to the company, “anyone can walk in, get a proper diagnosis, a subsidised doctor consultation and gain access to branded high-quality reliable medicines through its advanced assisted medicine technology platform.”
In the kiosks, a nurse conducts physical examinations and contacts a doctor using a live audio or video feed. Patients can submit their vital signs via a tele-diagnostics kit. The whole process doesn’t take more than 15 minutes, according to GHC. But difficulties remain. “The hardest is to change patient behaviour and get them to come to institutional healthcare instead of the traditional village quack and building,” Khanderia said. “The other important aspect is that we are not an NGO and we have to be affordable yet cost effective.”
In villages where GHC has a presence, penetration is less than 20 percent of the population. It’s higher in the states of Uttar Pradesh and Haryana, where the company reaches up to 15 villages per operational centre and about 20,000 patients in total each year. To access their services, patients buy a health card that costs 120 rupees, or less than two dollars, per year.
GHC focuses mainly on pathology services, since surgery requires centralised facilities. Analysts from the George Institute for Global Health, while optimistic about the potential of eHealth to provide health care delivery, say there’s a long way to go.
In 2017, the institute’s eHealth review pointed out that regulation is needed: “Most of the apps have been developed by independent developers rather than by healthcare organizations. The clinical value and health benefits of these apps are inadequately documented, leaving uncertainty about their effectiveness and efficacy.”
In the same way that Agrawal saw the potential for gathering health data, via rural healthcare, to uncover clues to diseases, GHC hopes to benefit from this information too. The team has collected more than 150,000 patients’ health records across the country, and plans to open 4,000 more kiosks and 1,000 health centres (polyclinics) in the next five years.
A state-funded insurance programme that aims to allocate 500,000 rupees worth of coverage a year to every poor family—about 40 percent of India’s population—could be helpful to eHealth initiatives. “Given that cost of access is a major hurdle, I would expect insurance schemes to play their role,” said Agrawal.