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Advancing rural telemedicine: An interview with Sameer Sawarkar

12 June 2009

The challenges of health care delivery in rural India are several and familiar: poor infrastructure, insufficient supply of skilled doctors, and dispersed poor populations, all of which make affordable care hard to achieve. Sameer Sawarkar, founder and CEO of Neurosynpatic Communications, says technology can bridge this deep divide.

In this video interview, he discusses ReMeDi—his low-cost telemedicine solution that aims to connect rural patients to urban doctors via the Internet. McKinsey’s Clay Chandler interviewed Mr. Sawarkar at Neurosynaptic’s Bangalore office in April.

Constraints of sustainable care

You see, traditionally, 70 percent of the people in India live in villages. The population has been slowly, steadily migrating to urban areas because of the facilities. But by and large, 70 percent—close to 70 percent—are still in villages where the infrastructure is not very good, the connectivity is not very good, the resources and linkages are not very good.

While you see many doctors available in the urban areas, where they’re easily accessible, you see that a villager—or even a pregnant lady—has to walk some five kilometers or ten kilometers to reach to the doctor for basic health care. The resulting fact is that not many people attend to their medical needs in the early stage of the disease cycle. And so, consequently, they reach the doctor only when things become very serious. That results in much more expenditure, and you find that about 20 million families get pushed below the poverty line every year because of health care expenditures alone.

What we saw is there were three critical problems. One was there is no electricity or there are various outages of electricity. Even in urban areas, you see something like two- or three-hour outages in a day. That’s routine. Whereas in rural areas, if you get something like 8 hours of electricity or 12 hours of electricity in a day, it’s considered very good. The second [problem] was really the skill set available. Now today, what we have in these rural areas is mostly either some sort of nurses who cater to the health care needs or some traditional health workers who have been practicing out of experience—also some doctors who have formal degrees in medicine, but not always. There are traveling doctors who come in on scooters and visit these villages one day a week. The third problem really is the technology aspect of it—which means unless there is bandwidth available or connectivity available, unless there is equipment and devices available that are cost effective, it wouldn’t be possible to provide these services at an affordable price point.

Technology-enabled solutions

Essentially, we started with a question in mind: can technology bridge this health care gap? You have a hugely disproportionate amount of doctors in urban areas compared to rural areas. So the first thing that we did was we said, “There is probably no point at this point in time to go and try to set up simply medical equipment there.” What we need is the right kind of reach into the village, which we identified initially as these village kiosk setups. A kiosk is a place where there is the necessary setup of equipment and a person to run it.

So, we ended up building what we call ReMeDi. That is, remote medical diagnostics. This technology comprises a device that runs on two watts of power. It’s a very, very low power-consumption device. What we did was, we actually integrated this device and software that has audio–video conferencing. This audio–video conferencing runs at 32 kilobits per second. You can simply run it over a telephone line, if it’s reliable, with the normal modems that we get; and you can have it over any form of connectivity. We also integrated a patient-record center. The patient records would help the doctor in recording all of the health-related issues that the patient came in with and in treating them.

ReMeDi: A remote diagnostics tool

The device came out of the need [for doctors to have] more information about the patient before making a decision. We started with an initial set of parameters. We said we need a stethoscope, we need a thermometer, we need a blood pressure meter, and, as specialty care, we also will put an ECG in. So those are the basic set of parameters that are there. It needs to operate in a very bandwidth- or power-constrained situation, so it consumes only two watts of power, which is even available in the USB port. And you need a webcam, of course, if you want certain pictures.

If you do not have connectivity, you can actually use “store and forward,” which means you capture all the parameters and then, whenever there is connectivity, a physical transfer is possible. In the other mode, if the real time bandwidth is available at more than 32 kilobits per second, then you can connect and transfer all the parameters in real time—so the stethoscope sound is heard in real time, while the chest piece is put to the patient. Actually, the doctor guides the operator to put the stethoscope chest piece at a particular place on the chest. There is a chart showing various positions of the stethoscope chest piece on the chest and on the back and [that shows the correct] breathing. The operator is trained in all of this initially. So we evolved these processes quite a bit as went along in the experimentation.

We have not yet initiated efforts where we directly tie up with hospitals and run the service, but we have taken a path of identifying partners—mostly those who are good at the delivery logistics.

Our strategy is always to partner with a more in-depth health care company that understands the health care issues much better than [we do], and we understand the technology issues much better—that’s the kind of synergy that will work.

Looking ahead

Now we are getting into much larger-scale experimentations from these understandings. We are partnering with various agencies now who have expertise in the health-care delivery part and working together with them to set up some really large networks. We have a very good acceptability [rate of our] solution: about 40 percent of patients actually come back. On any [given] day, of the traffic that we have—or of the people visiting the center that we have—40 percent have visited us earlier for their earlier episodes of illnesses. Also, we observe that about 75 percent of the people do not have to travel to the next town for their health care needs. Seventy-five percent of the needs get satisfied there and then. There’s a great amount of affordability, because the final model that we have allows them to get access to this health care for less than a dollar.

Comment [19]

Agree? Disagree? Let us know what you think. Please include your full name with your comment. Comments may be edited.

Good work. Here in Alaska there was ans is a similar problem in access to health care and doctors. While most of our villages have clinics they are staffed by health aides that are by in large very competent health care givers but at a basic level. Telehealth is starting to take off in rural (bush) Alaska but is very expensive not only for the telephone unit but also in terms of setting up support system. Sounds like the unit described would work here as well and reduce the cost and increase capabilities of the whole system since the current units here are limited to 3-4 functions. Good start.

Posted 18 June 2009, 12:31 by P Christian
I think this is appropriate use of technology. It serves a very important role in bridging a knowledge gap in diagnosis and treatment. If it is combined with efforts to improve the physical infrastructure in the villages for delivering the care, it will work. A vast amount of really useful medical information is already avilable on the internet and can be harnessed for high quality patient care. At the point of delivery of care, you will still need a serious patient advocate! What I fear the most is the rapid permeation of the third party insurance system into the Indian Healthcare scene. These investor driven, for-profit insurance companies can be a disruptive force in appropriate care and will create perverse incentives for physicians to not do the right things for their patient. This has been the result of the failed 40 year experimentation of third party care in the United states. There are valuable lessons to learn from grand debacles.

Posted 18 June 2009, 08:10 by NS Murali
Healthcare, education and utilities (mainly water and electricity ) were and STIL ARE priorities for India and RemeDi is a step in that direction. No questions on that.

However, key to its success would lie in its cost effectiveness and sustainability.

There is need to involve locals in this initiative so that project is ‘owned’ by them. This builds commitment, sense of purpose and pride besides employment avenues. This would certainly reduce migration to cities. We must remember, the activity is for them and by them. All others who are not directly involved are mere facilitators.

I agree with Sandeep where he says we must learn from the past. Therefore all those who worked on similar initiaitive (not necessarily in healthcare, but also other societal needs of rural india) should share their experience and suggestions.

I agree with Sheety who suggested use of solar energy. With this, it would be possible to push other interventions as well, like low cost water purification systems, lighting, etc. I am sure leading players like TataBP solar (solar panels), CSIR (water purification systems) would be happy to partner.

Once it is accepted at local level, replication would happen automatically.

It’s time to …..DELIVER.

Sameer – I volunteer and would be happy to contribute to this initiative. I could be reached on hkalert@gmail.com

Posted 18 June 2009, 01:05 by hemant kulkarni
See, everyone is trying to find “Simplest” solution for healthcare delivery, but unless until we understand it’s an art which is supported by technology there is no way out. Even when I visit my Doctor the words and the support is important as that of medicines, and this fraternity is build on these concepts. The advances are on their side but understanding human value and sentiments is also important. I saw a telemedicine set up in heart of Mumbai just lying down, it is supported by ISRO but still. Why is that ….nobody bothered to explain the end-user/ power user its value (everybody knew its cost !)

Just introducing technology is not enough we need to find innovative ways to implement it and COMPLETE it!

Posted 18 June 2009, 00:31 by Dr.Nilesh Bandgar
Good work.
How then to overcome the next problem : for example, once a diagnosos is made perhaps the patient needs some medication. Access to medication in some rural areas may be as difficult as access to a doctor.

Posted 17 June 2009, 22:45 by Steve Cullen
I am impressed with Mr. Sameer Sawarkar’s work on using telemedicine for meeting health care needs in rural India where 70% of the population live. One of the problems mentioned is that rural areas get electricity for only 8-12 hours a day at present. Why not consider using solar energy for powering village kiosks on a continuous basis without break. India is well placed to tap solar energy to overcome the current power supply constraints. When this is done, telemedicine could make rapid progress there.

Posted 17 June 2009, 21:39 by Y. T. Shetty
Great!

First of all I congratulate Mr. Sawarkar and his team for taking up this work to help fill the ever widening gap in health care.

I am sure that this work will touch the hearts and minds of IT professionals, Medical Professionals, Social Workers and anyone who is thirsty of doing some good to humanity.

We have talked for so long about the value of networks, and what better networks we can dream of other than thousands of good people who are trained in medial sciences, delivery of medical services, volunteers, IT professionals and so on, who come together to help solve this basic need of – having access to health care!-

I congratulate all those who are part of this effort and wish more and more of others come together to solve problems of such scale, not only in India but wherever such needs exist.

Having and not having is not the question anymore. Having access is the question! Let it be health care, education, entertainment or whatever. We all should be involved in creating the networks, be part of them and strive to provide access to millions.

Keep up the good work!

Regards,
Chandu

Posted 17 June 2009, 11:12 by Sambasiva Rao Chandu
Excellent Concept! As an IT provider Leader, India should be benefited in terms of Rural development.We really need a mass base considerations in this heathcare sector of INDIA. All these efforts require “PUT HUMANITY FIRST” approach.I really Congratulate Mr. Sawarkar for the actions taken. I would like to partner the initiave & tubocharge it with practical Ideas as a solution to Healthcare Sector of INDIA.

Thanks & Regards,
Uday Muthe

Posted 17 June 2009, 10:00 by Uday Muthe
India has a very low rate of technological innovations and even lesser rate of social innovations. The ReMeDi endeavor by Mr. Sawarkar is commendable against this backdrop. However, the road from pioneering to stablization and systematization is fraught with innumerable hurdles in India. Our management skills, contrary to popualar belief, are constrained. We do not like to build lines of command and moreover follow these channels of command. Second, we do notmanualize our work. Rampant illiteracy and semi-literacy is indeed a major constraint in manulaizing things. But one needs to think how to circumvent this problem and manualize operations. The article foes not report about the costs involved in the endeavor. Who is paying for the costs – the end user, government, drug suppliers? Or else, is it done through volunteering?

Second major handicap in Indian endeavors is that we do not learn from past. By that I mean that, valuable experience is generated in course of such type of socio-technological innovations but there is no way the experience of all stakeholders are documented for future. If you document on various aspects of the intervention then you can review, redeploy and even throw away things wholesome or in parts when it is most badly needed.
Nevertheless, my best wishes to Mr. Sawarkar. I had seen a similar project in the World Bank Country Marketplace 2004 in New Delhi.

Posted 17 June 2009, 09:54 by Sandeep Deshmukh