Smart Doctor : How smartphones Hold The Key To Improving Rural Health In India

Introduction

In India, despite the government's huge spending on schemes like National Rural Health Mission (NRLM) even basic health care facilities are out of the reach of the rural populace.

Around 70 % of India resides in rural areas with limited access to basic medical facilities, dismal healthcare infrastructure and a disproportionate number of doctors when compared to the huge population.

Rural India is home to more than 750 million people and like anywhere else in the world, heart diseases and other chronic conditions are the major causes of death or severe disabilities. Often families in rural India are large joint units relying on a single bread winner and the death or disability of the sole breadwinner pushes families deep into poverty and destitution.

Around 86% of all the medical visits in India are made by those living in the rural areas. Most people in rural areas travel more than 100 km to get to the nearest health care facility and up to 80% of the cost of the healthcare services is borne privately by the rural households, which pushes them deeper into poverty. The impact of the lack of healthcare facilities in rural areas can be seen in poor parameters of child health, maternal health, infant mortality, maternal mortality and diseases like tuberculosis & malaria. .

The healthcare system in India is already overburdened; the doctor-patient ratio is alarmingly unhealthy with just one doctor for every 1800 citizens in urban areas which dips further in rural areas to one doctor per 60,000 patients. The health care infrastructure in rural India is also grossly inadequate at all levels – primary healthcare centers, community healthcare centers and sub-center levels; all are lacking in facilities, medicines and trained manpower. Added to which, the doctor absenteeism in rural areas is around 56 %, further compounding the problem.

In such a dismal scenario, a ray of light is emerging in the form of mobile phone technology. Despite the lack of basic facilities like electricity, drinking water, education or healthcare infrastructure, the mobile phone penetration in India is huge. Although only 3% of households in India have a PC, over 69% of households have a mobile phone. In fact India has the 2nd largest mobile phone subscription base in the world, with over 900 million mobile phone users and has already surpassed China in the high-end smartphone market on the back of falling prices of high-end devices and the growing adoption of 3G services. Mobile devices have good penetration even in rural areas where other sophisticated infrastructure components do not exist.

As of 2014, the rural telephone density in India stands at 48%, while the urban tele density stands at 52%. Mobile services cover 541,939 villages in India out of a total of 597,669, leaving just 55,669 villages without any kind of mobile telephony services. Only 9% of India’s rural population does not get any kind of mobile phone network whereas the rest are already covered with the mobile telephony.

Rural areas are also said to be internet savvy with over 38% of active consumers accessing the internet via mobile phones rather than in cyber cafes or community service centers. Furthermore, the penetration of social media in rural India has seen a 100% increase since 2014 compared to a more conservative 35% year on year growth in urban areas. According to Neil Shah, Research Director at Counterpoint Research

“Our estimation is that roughly 35 million smartphone users come from rural India and this number is growing rapidly, and could cross the 50 million mark in the first half of 2015, with 2016 being an inflection point for smartphone growth in rural India”.

This steady rise of mobile phones is a key element in the viability of mobile technologies for improving the healthcare sector in India. With such a huge penetration in areas where other basic infrastructure is lacking, tapping into mobile networks for the healthcare delivery seems to be a very reasonable proposition. Many companies, as well as the Indian Government, have already started using mobile platforms to successfully improve healthcare parameters in rural areas which are otherwise inaccessible to the traditional healthcare workforce.

M-Health

The innovative practice of using mobile phones for the delivery of healthcare delivery has been termed as m-health. M-health is fast emerging as a sub-segment of eHealth (the use of information and communication technology for healthcare) and with the advancement of technology, m-health as a concept extends to the use of any type of mobile device (e.g. phones, tablet computers, PDAs etc. ) for healthcare delivery.

M-health can be broadly used in the following three ways to help the end consumer –

1. Information Services - the lowest tier of m-health offers one-way communication between healthcare providers and patients. Patients can read basic information about diseases, healthcare myths, treatments of common ailments etc. and can send questions to a panel of medical experts.
2. Enabling Services - This kind of m-health service allows for a two-way information-flow between the patient and healthcare providers. This type of service can act as a substitute for traditional methods of health delivery and can help extend health services to a much larger market. These include services such as teleconsultation, video consultation over 3G, appointment scheduling, triaging, SMS prescription services etc.
3. Transformative Services - This is the most transformative arm of m-health, where real time health data can be collected by the m-health network. Currently these kinds of services in the field are limited to health monitoring for chronic conditions such as cancer and diabetes. The platform can also include vital sign monitoring during healthcare transportation of a patient, transmission of real time radiology images during live surgeries etc.

The advancement of technology is slowly pushing m-health more towards transformative services; the availability of faster networks, higher coverage of 3G/4G network and lower cost of hand held devices are just some of the reasons for this change. In many global markets, transformative services of m-health are already being implemented successfully and in a cost effective manner and this has inspired many firms in India to tap m-health innovatively so as to improve healthcare delivery in rural India.

The case below discusses four such innovative models which are transforming lives in rural India.

Operation ASHA

India has 2.8 million Tuberculosis (TB) cases and accounts for 31% of the total disease burden of TB in the world. TB kills over 750 people per day in India and over 300,000 children drop out of the school every year because they, or someone else in their family, is suffering from TB. Operation ASHA (OpASHA), a non-profit organisation founded in 2005, is an initiative to bring TB treatment to disadvantaged communities, mostly in rural areas.

The organisation works on providing a cure for TB especially for Multi-drug-resistant tuberculosis (MDR-TB) in India and Cambodia. OpASHA is currently active in over 2000 slums and many villages across nine states of India. The treatment of TB is a very long process and noncompliance to the treatment during that long phase, is said to be the major cause for the spread of the disease and proliferation of MDR-TB.

To improve treatment compliance, OpASHA delivers their services at the doorsteps of affected households and to reach a larger section of the community, OpASHA launched its innovative app ‘e-Detection’ in 2013. E-Detection is a contact tracing and active case finding software. The main function of this app is to identify and diagnose a new patient early. The app asks a series of questions to the suspected patient and then uses a decision based algorithm depending on the user responses, to identify newly suspected TB cases. The app is connected to a central server through the internet or SMS messaging and updates the server every 20 minutes, allowing data to be easily accessed from a central server.

The app is easily downloadable on a mobile phone, uses local languages and is very user friendly, even for an illiterate person. TB is a highly infectious disease and new cases often go unidentified for a long period of time. Using the data gathered from this app, OpASHA then puts all the active cases on a geo-map using GPS and can even track their drug compliance on another app called ‘e-Compliance’.

E-Compliance has been developed by OpASHA in collaboration with Microsoft Research and is an innovative solution for tracking patient compliance with TB treatment. E-Compliance has a biometric terminal, which is easily downloadable on a tablet with SIM card. The tablet is provided to the healthcare worker based in a village who then goes to each house, scans the fingerprint of the patient (who is already registered in the server with fingerprint) and the patient is prescribed the appropriate medication under supervision of the health care worker. E-Compliance has significantly reduced the non-adherence to TB treatment among the rural populace. If the patient misses the dose, e-Compliance issues an alert to the patient, health worker and to the doctor concerned, following which another healthcare worker from OpASHA meets the patient within 48 hours for counselling and ensures treatment compliance. Biometric technology reduces false responding or manipulation of the software helping OpASHA to achieve a very high adherence and treatment success rate for MDR-TB. OpASHA has already registered over 400,000 transactions using their innovative apps.

SMART Health India

SMART Health India is collaboration between the George Institute for Global Health and the Oxford Institute of Biomedical Engineering (IBME), University of Oxford and is a unique low-cost, high-quality healthcare delivery app. The app was originally developed with a focus on cardiovascular diseases. However it has inbuilt capabilities to address a much wider range of health issues, including diabetes, kidney disease, respiratory disease and TB.

The research team based at the George Institute of Global Health spent a considerable amount of time in field in rural India to integrate local factors, clinical protocols and expert opinions in the development of the app and it has successfully converted the knowledge gathered locally into a programmable algorithm. .SMART Health utilises advanced mobile health technologies that provides the healthcare worker with a personalised clinical decision support system to guide the Systematic Medical Appraisal Referral and Treatment (SMART) for individual members of the rural community.

Each village in India has an Accredited Social Health Activist or ASHA, usually a mature woman recruited to work within her own community. The ASHA is a familiar and trusted figure, who has usually achieved a modest education, at most a high school diploma. ASHAs are the backbone behind the Smart Health initiative and each ASHA has been issued with a tablet which is connected to cloud based software. The patient information (i.e. data such as medical history, risk factors, medication status, vital signs (weight, blood pressure, glucose, etc.) is entered in the device by the ASHA who is trained to handle the app and the tablet then transmits the patient information to a secure server, from where it is accessed by local doctors and hospitals who in turn identify the high risk patients and provide medical advice to the patients. The app also helps ASHAs to develop referrals and treatment plans in discussion with the doctors.

The algorithm behind the app is a clinical decision-making support system (CDSS) which does a real-time analysis of the personal medical information provided by ASHA. IBME has also developed a range of low-cost smart biosensors designed to measure key biological parameters, such as blood pressure, heart rate and respiratory rate, which are also provided along with the tablet to ASHA, with adequate training and which are used together with this app.

SMART Health India has been expanded to more than 50 villages and is now accessed by a population of over 200,000 in rural India.

Arogya Sakhi

The Arogya Sakhi project has been launched by Swayam Shikshan Prayog (SSP), a development organisation which aims to promote empowerment of women as leaders and entrepreneurs in the rural areas. SSP works in 4 major states of India (Maharashtra, Gujarat, Tamil Nadu and Bihar) and covers over 200 villages with its various schemes.

Arogya Sakhi was launched following a survey which alerted the SSP to the fact that over 80% of rural women in its catchment were anemic. This was compounded by the fact that women often cannot travel alone for health checkups due to cultural norms and have to be chaperoned even when visiting a public health care facility. Added to which, in many rural areas, women are the sole breadwinners of the family and are often unable to take time out to visit health care facilities. Often, even during pregnancy, women miss out on important routine investigations such as hemoglobin level count, blood pressure monitoring, weight measurement and urine testing for proteins etc. which are typically carried out on a monthly basis.

Understanding this gap and need, Arogya Sakhi was launched to empower rural women and the SSP trained many rural women to become healthcare workers, who would then provide the routine health checkups of other affected women in the community. These trained women called community health friends or Sakhi and are trained to conduct basic tests like monitoring blood pressure using BP machines, using glucometers, and are provided with a medical kit including all necessary equipment needed to provide home based diagnostic tests. Sakhi undergoes a training module comprising of 10 days of onsite training by trained doctors on the use of diagnostic kits and necessary medical equipment issued to them. The Arogya Sakhi acts as the maternal and child health advocate of the village, assists the ASHA worker and act as a liaison between the community, ASHA worker and government health system.

The major differentiator for Sakhi is a tablet issued to them by the SSP. The tablet has an app developed in collaboration with Armman India, on which Sakhi uploads all the medical information collected from of the rural women patients, which is uploaded to the cloud and accessed by a team of doctors in Pune (an urban city). Based on the individual health parameters, doctors then advise medication or further visits to the nearest health care facility.

Arogya Sakhi programs have spread to over 53 villages, and over 1,800 women have benefitted so far. SSP plans to set up a health & nutrition hub and over the next two years aims to empower 100 Arogya Sakhis to provide awareness and health services to over 300,000 community members, across 300 rural villages and 60,000 rural households. For their services a Sakhi can earn up to Rs. 150 (approx. $3) per patient which adds to their household income and empowers these women in an extremely patriarchal environment in rural India.

This innovative Sakhi app has already won Vodafone Foundation’s Mobile for Good Award 2014 and the 6th mBillionth South Asia Award 2015 and may change the face of women in healthcare in rural India.

Evolko

Evolko is San Francisco based firm that has designed an app called Evolko Healthradar that provides the communication backbone to the community outreach program of All India Institute of Medical Sciences, Patna (AIIMS).

Evolko Healthradar uses a cloud-based service to facilitate the exchange between doctors and chronic disease patients in rural areas across India. It is an innovative online-offline model where AIIMS Patna has stationed 120 telemedicine officers at various village councils and patients can visit any of the nearest telemedicine officers to routinely record and relay their vital parameters to a panel of specialist doctors through Healthradar. Patients also have an option to speak with the doctors and discuss some additional health problems at a nominal cost of Rs. 50 (< $1).

Doctors can proactively monitor and chat with their chronic disease patients who normally undergo several months or years of treatment. Doctors can access the entire patient history using this mobile app and even access multimedia Electronic Medical Records and advise their patients accordingly.

Amit Khare, CEO of Evolko says-

"From personal experience, I know the requirements of patients with chronic conditions are very different. They are constantly in touch with their doctors and get anxious if they can't immediately report symptoms"

Normally patients of chronic diseases like cancer have to spend hours in transit just to show the routine medical investigation reports to their doctors or to get routine checkups done. The app means that patients need not spend that much time obtaining advice and can now benefit from peace of mind that their doctor is just a tap away.

Six months after its launch in 2013, around 1,700 specialist doctors were monitoring more than 150,000 chronic patients through Healthradar and more than 1000 patients were connecting everyday with AIIMS using the app.

Evloko has already expanded to 28 cities in India and plans to spread its network across 200 cities. The company has already received $3 million funding from angel investors like Arjun Malhotra, cofounder of HCL Technologies and C P Gurnani, CEO of Tech Mahindra and Prof Thomas Kailath, Stanford University, just to name a few.

Evolko has also tied up with Sashastra Seema Bal, one of India's central armed police forces, to set up the tele-medicine outposts at 1,500 places on the India-Nepal border at high altitudes, where even basic health facilities are non-existent. Evolko Healthradar is a major initiative for the health of chronic disease patients in rural areas and already its impact is being noticed favorably both by AIIMS and the rural populace.

Conclusion

Despite the central and state government’s initiative in India to improve the healthcare infrastructure, the capacity of the healthcare system to meet the growing demand of urban and rural populace will always be lacking.

In rural India where more than 80 % of people spend out of their pocket for their healthcare facilities, the use of technology will enable greater access and penetration of the healthcare facilities, which is vital for the growth of the country.

The use of healthcare apps has the potential to transform the healthcare infrastructure in rural India and this paper explores four such innovative examples for healthcare delivery. In future, healthcare apps will play a major role in bringing innovation in successful healthcare delivery in rural India.

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About the authors

Dr. Pathak is a research fellow at ACI. He finished his PhD at Nanyang Technological University in 2015 with his research expertise spans the areas of sound symbolism and perceptions of Luxury versus basic brands.

Gemma Calvert is the Director for Research & Development at ACI and a Professor of Marketing Practice in the Nanyang Business School at NTU. Professor Calvert is an internationally renowned cognitive neuroscientist and the foremost pioneer of the field of Neuromarketing. She has a BSc in Social Psychology from the London School of Economics, a PhD in Neuroscience from the University of Oxford and is an accredited Chartered Psychologist. Her research interests include consumer neuroscience, multisensory integration and sensory branding and cross-cultural influences on behaviour. She has published extensively in the field of human brain imaging, including in Science and Nature Neuroscience, and is the co-author of the seminal Handbook on Multisensory Processes.