Inside India's unfolding healthtech revolution

Mortality was high. “We couldn’t do much," Ramachandran says. This year, as the second wave raged, the Bidar district hospital was better prepared. “We handled it better. Our mortality rate was lower," he says. What changed? Last August, the information technology (IT) secretary of Karnataka suggested Ramachandran seek help from CloudPhysician, a healthtech startup whose digital platform RADAR connects remote ill-equipped intensive care units (ICUs) with specialist doctors.

With its hub-and-spoke model, the startup enables a centralized hub to offer medical advice remotely, improving the quality of care. Over two weeks, CloudPhysician installed a range of digital devices, including 360 degree cameras and monitoring equipment that capture and digitize patient’s data, which can then be transferred to the hub in Bengaluru.

Alongside, doctors and paramedics were trained to handle the new equipment. This had two important effects: firstly, ICU patients could be monitored remotely 24/7 by super-specialists and secondly, staff at the hospital stepped up. “Earlier, the contagion fear kept many away from tending to (the) patients. More knowledge and contactless monitoring devices helped," Ramachandran says.

CloudPhysician’s RADAR has been rolled out across 450 ICU beds in over 35 hospitals—at least 10 of them are government hospitals located in places ranging from places in Maharashtra to Leh. The startup has set up a 100-staff centralized hub in Bengaluru, equipped with doctors, ICU specialists, nurses and dieticians who remotely assist ICUs across the country. “What we do is augment hospital capacity with their existing staff," says Dhruv Joshi, co-founder, CloudPhysician.

Covid has put the focus back on India’s creaky healthcare infrastructure, which has been hobbled by issues of accessibility, affordability and availability. At 1.26% of the gross domestic product (GDP), the government’s spending on healthcare has been abysmal. When it comes to the quality and accessibility of healthcare, India’s rank is poor—145 out of 195 countries, according to The Lancet’s global disease burden study.

In a country that has pitched itself as the world’s destination for medical tourism, the private sector has a disproportionate share, providing 70% of the country’s healthcare services. Besides low public investment, there are also issues of efficiency, absenteeism, and availability of specialists in government facilities.

“There are both manpower and infrastructure shortages. Whatever we have often isn’t up to the standards," says Satyam Shivam Sundaram, partner, government and transaction advisory services, Ernst & Young.

Window to leapfrog

But there is hope on the horizon. Two decades ago, India’s telecom and banking sectors were laggards, being costly and underpenetrated. But then, sans legacy infrastructure, it managed to leapfrog. Today, India has among the most advanced, digitally-ready infrastructure in those two sectors.

Now, a confluence of factors holds out the promise to reshape India’s healthcare too—if we play our cards right. Covid has accelerated the digitization wave everywhere, including in health. And state governments as well as the Centre are finally prioritizing the health sector. More importantly, the National Democratic Alliance (NDA) government is borrowing its learnings from the fintech sector.

Plans are underway to build a digital backbone for healthcare. The National Health Authority is building a unified health interface or UHI as part of the National Digital Health Mission (NDHM). UHI is envisioned as an open network that will help connect patients and healthcare service providers, aiding them in discovery, payments and access to health services across applications. It is also working to digitize and standardize patient health records to ensure easy access and interoperability.

“The government is increasingly using digital (platforms/services) to act as a force multiplier," says Abhishek Gopalka, managing director and partner (public sector and social impact practices) at Boston Consulting Group (BCG).

This is catalyzing healthtech startups, which are readying products and services that factor in ground realities—from erratic power to low internet bandwidth. Venture capital investments in healthtech startups have surged, from $408 million across 63 deals in 2020 to $1.36 billion across 41 deals as of August 2021, according to Venture Intelligence.

According to the Internet and Mobile Association of India (IAMAI)-Praxis Global Alliance, in 2020, India’s healthtech Industry was around $1.9 billion, or under 1% of the healthcare industry. With over 5,000 healthtech startups, it is estimated to grow at a compound annual growth rate (CAGR) of 39% to touch $5 billion by 2023.

While many of these shifts have been happening for a while, they seem to be reaching a tipping point, thanks to the pandemic.

Inflection point

With 15 million blind persons (80% of the cases are preventable), costly and inaccessible care has been an issue for this segment for quite a while. K. Chandrasekhar started Forus Health in 2010 in order to focus on eye care. Its device is portable, rugged and costs less ( ₹20 lakh per unit against ₹1 crore plus for the imported one). Moreover, the device can be operated by staff members with basic training and it does not require eye dilation. The firm has five products and has sold 3000-plus units in 40 countries, including the National Health Service in UK. “We have touched 7.5 million lives already," Chandrasekhar says.

In 2018, its product was rolled out in 115 community health centres across 13 districts in Andhra Pradesh under the public-private partnership (PPP) model with Apollo Hospitals as a partner. Now, Forus is going beyond devices and morphing into a digital solutions company, offering subscription-based services to firms and governments. “We are doing a lot of automation. In two years, our devices will be smart enough to automate diagnosis so that only people who require surgery need go to an ophthalmologist," Chandrasekhar says.

Another startup, Niramai Health Analytix, founded by Geetha Manjunath in 2016, is building low-cost portable devices that help diagnose breast cancer. An early diagnosis can dramatically improve survival rate. With 22 patents granted in the US, Japan and Europe, it uses a thermal camera and sensing technology to detect early-stage breast cancer via a simple breast scan. The device, roughly the size of a water bottle, costs a tenth of a mammography machine, has 100% sensitivity rate, and doesn’t involve exposure to harmful X-rays. It is also easy to operate. The device has been deployed at 25 government hospitals already, including in Maharashtra and Madhya Pradesh.

Niramai Health is now building a mobile-based artificial intelligence (AI)-enabled medical device that would be smart enough to measure and analyse data on its own and give a report with a green, red or yellow status that can be transmitted to remote telefacilities for expert advice. “With this, overwhelmed health centres can focus on only those cases that need doctor consultations," Manjunath says.

Prashant Warrier started Qure.AI about five years ago. It uses AI to interpret radiology images and cut time and costs. “In smaller towns and cities, it is hard to get quality medical professionals. We wanted to change that with technology and AI. You can buy machines but not people," says Warrier. With five patents, approved and endorsed by the US Food and Drug Administration and World Health Organization for tuberculosis detection, The firm’s product qXR uses AI to augment human expertise and reads scans that are faster, more accurate and accessible in remote parts. The firm plans to expand the use case to other diseases such as brain strokes, lung cancer, and head CT scans, among others.

Sigtuple, launched in 2015, has built AI-enabled software and hardware that help digitize tests for pathology and radiology. Its AI layer automates clinical insights. “In radiology, our platform can cut costs by half or a fourth while making it faster by 20-30%," says Sigtuple founder Tathagato Rai Dastidar. These startups make reports available on the cloud, thereby, enabling virtual consultation and collaboration with doctors via remote access of data.

AIndra, focused on early detection of cervical cancer at low cost, launched its first device in 2020. “Instead of being sent to a lab for analysis, our AI-enabled device can analyse samples then and there," says its founder Adarsh Natarajan. It can give a report within 30 minutes.

Now, the government is finally joining forces with these innovators. As a pilot, ASHA workers in Ramnagara, Karnataka, have been given hand-held devices to capture and send data on key parameters including blood sugar and oxygen level of individuals during their home visits.

Manish Diwan, head (strategy and partnership) of government outfit BIRAC, says they conducted Jancare, a last-mile hackathon as part of which 25 technologies were presented for rural and low-resource areas—such as a device that can transmit ECG data over low bandwidth or hand-held defibrillators with no batteries.

Also helping the healthtech startups in their journey is India’s AMTZ or Andhra Pradesh Medtech Zone. Set up in 2016 and spread across 270 acres of land with 84 companies and 40 startups already, AMTZ is India’s first medical device manufacturing facility. It has built an ecosystem offering end-to-end facilities and services—from incubators to R&D, testing labs to design, 3D printing to a manufacturing facility, entrepreneurs and startups looking at manufacturing. At the forefront of India’s battle against covid-19, AMTZ helped make products such as N-95 face masks and covid-19 testing kits, high-end CT scanners to oxygen concentrators locally. “We quickly identify the root cause of our national dependencies and try to indigenize it," says Jitendar Sharma, chief executive officer, AMTZ. In fact, AMTZ is the reason why India is able to produce covid-19 testing kits at a scale and price required by the country.

The road ahead

While these are exciting times, this journey will not be easy. There should be intent and investments, both of which must go up sharply to help millions of poor people access better healthcare services. “The government has to prioritize where it spends (the) money and ask what its role is? Also, instead of one size fits all, policies and models must be customized to specific geographies to make it more effective," says Nachiket Mor, who has worked extensively in the health sector.

India is short of healthcare professionals by at least 6.4 million. At a policy level, it needs a more flexible, practical and modular approach to train and upskill healthcare professionals. In Ethiopia, nurses can train to upgrade themselves to become surgeons. Alaska trains Class 6 girls to become primary caregivers. India could do the same with ASHA workers. “This is not about band-aid solutions. What we need is long-term systems change for it to be sustainable," says Joshi of CloudPhysician. Government health centres may be deficient in infrastructure and (workforce) but the biggest bottleneck it faces are attitudinal issues. “There is an accountability crisis. There are very limited implications for poor performance and outcomes," says BCG’s Gopalka.

There are other problems too. For example, government healthcare, focused on women and children in primary care, must also accord attention to other areas that deserve attention such as diabetes. Its entire machinery is fragmented and works in silos. There are different programmes for different diseases, from HIV to TB. And there are two parallel systems—one funded by the state governments and the other centrally funded under the National Health Mission—which often do not coordinate with each other. “It isn’t just about cost efficiency but also effectiveness," says Gopalka. Add to all this, huge geographical variations in infrastructure and outcomes, especially in BIMARU states. Some of these fault lines got exposed during the covid crisis. Hopefully, India has learnt its lessons well and will leverage all it has got to beef up its health infra on priority.