While other players in the healthcare field in India have been focused on developing telemedicine for tertiary and secondary care, Sameer Sawarkar has been focused on making telemedicine accessible where it is needed the most—primary care for rural citizens. Through telemedicine, he is now providing the possibility of universal access to primary healthcare in rural India.
The New Idea
Sameer is finding creative solutions to build both the back and front end architecture required to increase access to healthcare through technology in rural areas. He is addressing challenges such as lack of infrastructure, absence of appropriate medical technology, and social issues in rural areas that are obstacles to public health.
Sameer is working to demonstrate that telemedicine can be effective for rural primary care and can scale in a sustainable manner. Sameer’s company, Neurosynaptic Communications, has developed technologies that allow doctors to remotely perform consultations for patients in villages. The company has also created a completely new set of processes, training and capacity building, which are integrated with the company’s technology. These tools are essential to ensure that healthcare delivered though this channel is accessible, affordable, and appropriate. Implementing such technologies and processes through diverse providers, including the government, citizen organizations (COs) and private hospitals, he has developed a blueprint of implementation models that can be customized depending on the social and economic conditions in the area as well as the resources and needs of the implementation partner.
Over the past ten years, working with diverse partners, Neurosynaptic Communications has enabled the creation of 350 village-level centers. Sameer is now focusing on building more partnerships in order to reach a larger scale. Sameer is also identifying gaps in the telemedicine ecosystem in areas such as policy, finance and standards, which he aims to fill to enable the models to spread.
Delivering quality primary healthcare in rural areas remains a huge challenge in India. The dearth of trained medical professionals and lack of access to medicine are significant contributors to this problem. For example, while 70 percent of the Indian population lives in villages, 80 percent of the doctors and 60 percent of the hospitals are situated in urban areas. This leaves a staggering 700 million people in India without appropriate access to primary care.
To worsen matters, the absentee rate of doctors in rural Primary Health Centers (PHC) operated by the government is close to 40 percent. Rural doctors also operate in isolation with little professional support or transparency mechanisms. From a macro perspective, without a professional environment where doctors can learn and grow as medical practioners and access resources that are readily available to their urban counterparts, the isolation of rural doctors leads to poor public health planning and implementation.
The Indian government has been successful in creating health insurance systems that cover the majority of the poor population. Unfortunately, the systems focus on covering inpatient services and do not cover outpatient care. Therefore, both financial mechanisms and lack of infrastructure make primary care inaccessible and unaffordable for rural populations. Patients often have to travel significant distances to access care and buy medicine. As a result, rural citizens pay on average 1.5 times more for quality healthcare than urban citizens.
The lack of appropriate primary care has led to the creation of a black market in healthcare, which includes insufficient doctors and spurious drugs. According to the Indian Medical Association, out of 1,000 patients in search of primary care treatment, only 100 reach Bachelor of Medicine/Bachelor of Surgery (MBBS)-qualified doctors (credible, degreed doctors), 100 reach specialists (doctors trained in a narrow field) and the remaining 800 patients are left to rely on untrained and unqualified doctors for treatment.
Telemedicine, as a way of delivering healthcare through information technology to patients remotely, emerged in the 1970s. However, it wasn’t until 2001 that the Indian Space Research Organization (ISRO) started the first telemedicine initiative in India. Its initiative continues to focus on the relationship between technology and connectivity in hospitals providing secondary care and tertiary/specialized care for teleconsultation, treatment, and training of doctors and paramedics. There are also several large national and international private organizations who provide telemedicine technology for secondary and tertiary care. However, these organizations fail to assure the impact of telemedicine into villages. Their initiatives fail to bridge the critical gap of doctors in rural India and increase access to quality care. Recently, the expansion of the ISRO network has been discontinued, due to the high cost associated with the initiative. The government and other COs have also started smaller initiatives to increase access to care. Unfortunately, besides using mobile vans to visit villages, these efforts are not focused on delivering rural primary care in a sustained manner. These efforts are highly subsidized and have not yet reached scale. Delivering quality primary care in rural India through technological means requires tailored technologies, different financial models, and unique implementation strategies.
To create the technological architecture that would allow healthcare providers to extend quality primary healthcare services to rural citizens, Neurosynaptic Communications began by identifying key needs and tools for accurate diagnosis. Since this tool is a crucial first step, Neurosynaptic conducted detailed consultations with some of the leaders in healthcare. This team narrowed the required scope of important medical metrics down to measurements of temperature, blood pressure, respiratory health, ECG, pulse measurement that, along with the patient’s self-reported symptoms, is sufficient to make a correct diagnosis in 75 percent of cases. Neurosynaptic is planning to incorporate some additional diagnostic devices, including a non-invasive blood test, which will make service at the village level even more comprehensive.
Sameer and Neurosynaptic then focused their attention on developing technologies and software that could overcome the challenges related to the lack of connectivity and electricity in rural areas. While studying the average bandwidth coverage in rural areas, Neurosynaptic realized that there is 32kbps of Internet bandwidth available in 60 percent of Indian villages (with more than 2,000 people). With this insight, Neurosynaptic created ReMeDi—a remote diagnostic device that allows video conferencing at this low level of Internet connectivity, to connect doctors with patients in villages through a health center at the village level. This technology allows doctors sitting remotely to hear the heartbeat of a patient through videoconference, which allows the doctor to direct the actions of the operator. Further, ReMeDi was developed as a USB device to preemptively overcome frequent electricity shortages, allowing the operator to store data offline and forward it once connectivity is restored.
Since the development of this technology in 2003, Neurosynaptic has identified key partners among COs, and public and private healthcare providers who were willing to expand their coverage to rural areas. Through their pilots with diverse partners, Neurosynaptic has developed a deep understanding of different system design possibilities and variations that would best fit a variety of rural contexts. Neurosynaptic’s engagement with these partners is therefore not limited to supplying and servicing the technology. At the launch stage, Sameer and his team play an active role in defining the entire architecture of the project. They bring this knowledge to support partners in revising the financial model, identifying and training the operators, defining the consultation workflow, setting up and managing the medicine supply chain, building access to laboratories, and customizing healthcare data management.
Neurosynaptic has accordingly designed appropriate models for the delivery of health service through its technological platform. The delivery model typically consists of a health center in the village equipped with ReMeDi and a center with trained doctors at the receiving end. Depending on the partner as well as the context, a non-medical person, a nurse or a doctor manages the health center. For instance, in the case of CO partners, the health center operator is an independent village entrepreneur who invests in setting up the center. This traditionally tends to be someone already involved in providing care, which helps to establish a level of comfort among the patients. In the case of government partners, the platform is introduced in the PHC and is operated by a doctor or a nurse. Finally, in partnerships with private hospitals, the center can either be run by an entrepreneur or belong to a hospital and operated by the nurse. The cost of setting up one center is approximately INR. 1.5 lakhs. This includes the purchase of the ReMeDi, the laptop, and the space.
Depending on the background of the person managing the health center, Neurosynaptic customizes the appropriate operation and consultation protocols. Thus, while a trained doctor or nurse can independently perform certain tests, the non-medical person can only conduct procedures under the supervision of the doctor through a videoconference. For cases that require additional tests, the health center refers patients to an established network of diagnostic laboratories. Since it is critical to ensure that the drugs are locally available, Neurosynaptic recommends the partner establish a routine supply of generic drugs to existing pharmacies. To keep the system efficient, Neurosynaptic developed software to track the consumption and availability of these drugs at every location and identifies the need to replenish stock in advance.
To date, Neurosynaptic’s technology has been used to set up telemedicine health centers in seven states—130 centers in three districts in Uttar Pradesh, ten centers in Madhya Pradesh with World Health Partners, 400 centers are in the process of being setup in seven districts of Bihar with support from the Bill & Melinda Gates Foundation, and one district each in Karnataka, Tamil Nadu, and Maharashtra. Several centers have been deployed through partners in Andhra Pradesh. In the last year alone, more than 100,000 direct, real-time consultations were done through the network. The cost of the consultation is minimal, at US$1 or INR. 100, which brings an average of 40 percent savings for the patient per case of illness. Since the village centers are located in rural and remote places, the cost of accessing equivalent quality healthcare would cost the patient approximately Rs 300 to 500 or US$4.80 to $8).
Neurosynaptic has also executed several pilots with government hospitals. Moving forward, it plans to scale these partnerships. Neurosynaptic will connect government hospitals in districts to PHCs in villages. ReMeDi would allow PHCs to function effectively with or without a trained doctor. These systems allow rural doctors to consult with more senior doctors on complex cases as well as develop professional connections to create more of a cohesive environment between the urban and rural medical communities. In addition, since all patient records must be entered into the common platform, the system aids in effective health data management. The software developed by Neurosynaptic provides the ability to identify patterns or frequencies of occurrence of the particular illnesses and diseases spread over large geographies. Neurosynaptic is exploring the full potential of this technology to affect public health planning and implementation.
Sameer is also developing partnerships with private hospitals in towns and cities to facilitate their participation in acting as nodes for the centers in the surrounding villages. An incentive for the hospitals is that it would significantly increase its target population and the number of referrals to the hospital. By sharing its technology and experience with local partners, Neurosynaptic is exploring opportunities for similar telemedicine in West Africa, Central Africa, Indonesia, and Mexico. While working on expanding the network of partners and creating a strong precedent for rural access of telemedicine, Sameer is also looking at strategies that can create a sustainable ecosystem for telemedicine in rural areas. For instance, Sameer sees that existing efforts to formulate technical guidelines for telemedicine as having an urban bias: they presuppose strong infrastructure and connectivity, which does not exist in the villages. Sameer is looking to make these technical guidelines inclusive and reflective of rural realities.
Sameer also recognizes the importance of insurance to cover outpatient care as playing a catalytic role in building a sustainable and equitable model for telemedicine-based primary care in rural India. Lacking this reinforces a faulty practice; patients only seek care when illness becomes unbearable. To reduce the burden on the poor, there is a growing movement in India to include outpatient care in insurance schemes. As a part of this larger advocacy group, Sameer is pushing for the inclusion of telemedicine services in insurance coverage.
In future, Sameer plans to actively engage in issues of accreditation for technology-based healthcare delivery, and while decentralized replication is the most effective way to spread this idea, it can compromise the quality of care. Sameer believes that the processes in telemedicine, such as qualifications and training, validation of the diagnosis, and monitoring the quality of delivery, need standardized guidelines for upcoming initiatives.
Sameer was raised in a family of social activists from rural Maharashtra. His grandfather was closely involved with the social movement for integrated rural development started by the guru, Tukdoji Maharaj. Sameer’s father, whose passion was literature, started a movement to promote Maharathi Literature and established the first Maharathi Literature magazine—Jan Sahitya. Sameer interacted with people from around India who came to meet his grandfather and to assist his father with the magazine press. This environment triggered Sameer’s passion for books. While at school, he founded a comic library in his village. Later, while studying engineering in Amravati, Sameer published several science fiction stories.
To pursue his interest in astronomy and space studies, Sameer brought together like-minded students to start an Amateur Astronomer’s Club and persuaded one of the leading astronomers in India to inaugurate it. Witnessing a number of students struggle with the subject of electromagnetics, Sameer’s club took the lead to address it. Since subject materials were insufficient, they created materials to help students solve problems. They also published a book with answers/explanations that continued to be sold on campus for several years.
Completing his master’s degree at the Indian Institute of Science (IIS), Sameer joined Motorola as an engineer. Apart from contributing to several innovations in technology, Sameer set up an initiative to address the problem of attrition within the company. He convinced Motorola to create a separate fund to recruit top-performing students from smaller colleges. Starting with his college in Amravati, Sameer gave students an assignment that he then critiqued and used to garner new recruits based on their performance over one year. Sameer’s expectations proved successful in providing students opportunities they hadn’t expected, which resulted in student loyalty to the company and high performing team members.
After five years at Motorola, a former colleague offered Sameer the opportunity to become a partner in his company and manage it with autonomy. Sameer successfully ran the company for three years and then knew the time was right for him to found his own initiative. Sameer launched Neurosynaptic in 2002, employing a few former classmates from IIS. Interested in biotechnology, they sought to start a technology company that focused on innovative technologies for health.
It was a meeting with the well-known Professor Ashok Jhunjhunwala of the Indian Institute of Technology-Chennai that changed Sameer’s trajectory. Professor Jhunjhunwala had set up an infrastructure platform called N-Logue that provided an array of technology enabled services for the rural population. Sameer was astonished by the potential impact of technology in rural India. He decided to re-focus Neurosynaptic’s work to create technology that would increase rural citizen’s access to primary healthcare. Initially, Sameer believed the problem to be purely technological. After two years of trying to layer the technology over the N-Logue infrastructure, it became clear that healthcare delivery required a different approach. It was at this critical time that Sameer defined his role as co-creator of the telemedicine field.