In 2001, the Indian government’s space agency and a private hospital chain did an experiment: they established a satellite connection between a 50-bed hospital in the rural village of Aaragonda, in the southeastern Indian state Andhra Pradesh, and a specialty hospital in the city of Chennai, with the goal of helping the rural facility improve its quality of care. From that point on, when the staff in Aaragonda came across unfamiliar patient issues or needed a surgical consult, they had a direct video conferencing line to the advanced team of doctors and specialists in Chennai, and soon after, across the hospital’s nation-wide network.

The project partnership between the Indian Space and Research Organisation (ISRO) and Apollo Hospitals Group is widely cited as India’s first foray into telehealth. In a country where 70 percent of the population lives in rural areas like Aaragonda, but 75 percent of doctors are based in cities like Chennai, it seemed a promising development in improving access to affordable, quality healthcare for the masses. The ISRO has gone on to facilitate satellite connections between hundreds of urban, rural and mobile healthcare facilities since the Apollo pilot, while a surge of other government, private and non-profit organizations have jumped into India’s telehealth sector as telecommunications technology and connectivity has improved in recent years.

India is in tremendous need of promising healthcare solutions, particularly for its rural population. India has only one doctor for every 1,674 people, compared to global average of one doctor per 670 people, according to the Medical Council of India and the World Bank. In rural parts of the country, the ratio is closer to one doctor per 3,000 people. India has a public healthcare system; however, most of the patients who use public services live more than 15 kilometers from the nearest clinic. The high cost—both in time and money—to reach a provider discourages poor, rural Indians from seeking anything other than critical care.

Non-communicable diseases account for half of deaths in India and are projected to cost $6.2 trillion between 2012 and 2030.

“The patients tend to ignore problems because they can’t afford to travel to town and find a doctor. Or [they] go to [someone] who is not qualified but still provides consultation to the patients,” says Rajeev Kumar, COO and co-founder of telehealth company, Neurosynaptic Communications. The result is a huge population suffering from treatable conditions like diabetes or heart disease. Indeed, non-communicable diseases account for nearly half of deaths in India and are projected to cost the country $6.2 trillion between 2012 and 2030, according to the U.N. and World Health Organization.

Neurosynaptic Communications is one of the hundreds of telehealth organizations in India trying to fight the country’s high costs and limited availability of quality healthcare. The for-profit company has more experience than most, however: its founders launched their platform in the early days of telehealth, in 2003, after an initial start in neurotechnology. They estimate that their telehealth equipment and accompanying software has facilitated doctor consultations for up to three million people across 10 Indian states and in seven countries in Southeast Asia and Africa. Most of those who receive care from their service travel less than four kilometers.

Three million consultations stacked against the hundreds of millions of rural Indians who need basic care may seem like a drop in the ocean, but Neurosynaptic’s progress is reflective of India’s overall telehealth market, where few models have achieved scale. Even established specialist players like Apollo admit that telehealth has not yet moved the needle in India’s overall healthcare sector. In 2012, Krishnan Ganapathy, Apollo Telemedicine Networking Foundation’s president, told India’s Business Standard that his firm had captured only .001 percent of India’s potential telehealth market. At the time, his company had provided 70,000 specialty consultations across 105 telehealth centers. (The company’s website currently reports 84,000 consultations across 160 centers.)

“The market potential for telemedicine is obviously enormous,” said Ganapathy, in an article by Wharton Business School’s Knowledge at Wharton that same year. “Estimates suggest that the telemedicine market is at least for 800 million Indians. Even if half of these 800 million need to consult a specialist once a year, [that still amounts to] 400 million specialist consultations per year. Even if 10 percent of these are enabled through telemedicine, we are talking about 40 million consultations per year from rural India alone.”

Sameer Sawarkar, who co-founded Neurosynaptic alongside Kumar, is familiar with these estimates. “Though the market is large, certainly there are many hurdles involved, including health and technology skills, infrastructure, and behavior,” he counters. “Then there is the affordability question—how much people can pay [for the technology].” Sawarkar and his team have directly confronted many of the barriers inhibiting the reach and impact of telehealth, and they have had to reevaluate their own solution and approach multiple times in light of these barriers.

A new healthcare model

When Sawarkar and Kumar launched Neurosynaptic, they started from a different place than notable specialty players like Apollo. The pair came into the field as electrical and software engineers who had worked for Motorola India and built Neurosynaptic from scratch, with no physical infrastructure, hospital network, or team of doctors and nurses backing the endeavor. Familiar with the potential of India’s mobile and telecommunications networks, Neurosynaptic’s founders focused on how to pair basic health services with a reliable software platform that connects remote patients to medical experts. The solution they devised is based around a portable point-of-care box called ReMeDi. The box, about the size of a tablet, contains an array of diagnostic tests, including electrocardiogram (ECG) and blood pressure equipment, a stethoscope, and a pulse oximeter, which measures the amount of oxygen in the blood. ReMeDi also includes imaging equipment to scan for ear, eye and skin diseases, as well as blood and urine tests. It is designed to work in low-power and limited connectivity conditions, operating on only two watts of power and a 32-kbps bandwidth speed.

“An operator [in a remote village], who acts like a doctor’s assistant, facilitates a consultation between patient and doctor,” Kumar explains. The operator does this by connecting the device to a computer’s USB port and launching a Neurosynaptic’s proprietary application that transmits test results and medical data to a doctor at a different location. Tests can also be run in store-and-forward mode if internet access is not available, which happens about 25 percent of the time, Kumar says.

What’s more, the device is simple to use. “ReMeDi requires minimal training for health workers in the village. It can be deployed even with personnel who are not medically qualified but can use the software and medical devices,” he adds.

Neurosynaptic Communications telehealth model, with ReMeDi

Neurosynaptic’s solution is unique in that it is a hybrid hardware-software platform, whereas other telehealth companies in India offer one or the other. Focusing on both hardware and software means that Neurosynaptic is able to tackle multiple aspects of the healthcare chain. This makes its solution attractive to other organizations and agencies working in rural healthcare delivery, but it also means that Neurosynaptic has to solve for both technical and service gaps.

The first gap the company had to address was how to put the diagnostic testing equipment between rural patients and doctors. The first release of ReMeDi was designed to be housed within a health clinic or kiosk, rather than part of a roving field team of health practitioners. Neurosynaptic first considered building a chain of its own health centers but quickly recognized the costs would be steep: $15,000 in upfront construction, plus the cost of each ReMeDi and its software. (Neurosynaptic’s team declined to comment on the cost of ReMeDi of the software.) Medical supplies, emergency generators, and wear-and-tear expenses would add to operating costs—all for a center that would serve, at best, several thousand patients. Given the limited financial means of its target customers, it would have been difficult for the company to recoup these expenses through health services, so it looked for other deployment models.

Neurosynaptic shifted its focus to implementation partnerships instead. Its biggest patrons are the Indian Army and international and local non-profits like World Health Partners and Meenakshi Mission Hospital and Research Centre (MMHRC), all of which purchase Neurosynaptic’s equipment and software for use in remote areas. MMHRC, for example, is an 800-bed hospital in the southern city of Madurai that has been using ReMeDi for its rural extension network for nearly seven years. Its senior resource and development manager, P. Sundarraj, says that among a growing crowd of telehealth companies and services, what sets Neurosynaptic apart is its software. Sundarraj notes that he has spoken with other companies that offer similar services to Neurosynaptic, but none have exclusive connection and consultation software, which MMHRC needs to successfully run telehealth services.

For Neurosynaptic, the value of the partnership model is that it allows the company to streamline its resources and expand its reach without building its own infrastructure and doctor and specialist networks. Nevertheless, the model does not completely insulate Neurosynaptic from the high costs and logistical challenges of doing business in India’s remotest regions. Video conferencing is often unavailable because of slow internet connections, for example. “In most parts of the country, we can get connectivity but what bandwidth [strength] we get is a challenge,” says Sawarkar. “[Sometimes it’s] not even 100 bytes per second—that is a huge challenge for video conferencing.”

Doctor availability could affect telehealth uptake if rural health providers are unable to make it a priority for their network doctors.

Neurosynaptic’s system includes multiple back-up options. Operators can switch off video and do an audio-only call between patients and doctors, or patients can call the doctor on the telephone. Doctors are still able to review and edit electronic records and file prescriptions without video or audio conferencing, which the rural operators can download when the connection improves.

Many of Neurosynaptic’s clients, accustomed to connectivity problems in rural areas, have their own back-ups as well. MMHRC uses a satellite link for service, for example; it still runs into problems with service speed, however. “Sometimes we are unable to get a connection because of the low profile of the network. We are dealing with patients [and they] are waiting [for results],” Sundarraj explains.

Connection reliability and speed pose enormous barriers to telehealth in a country where medical resources are already severely strained. India currently faces a shortage of at least 750,000 doctors, which means that while there may be more qualified medical staff in urban areas, urban personnel can only take on so many rural patients. As a telemedicine product and service vendor, doctor availability is not an immediate concern for Neurosynaptic; however, it could affect long-term business if rural health providers are unable to make telemedicine a priority for doctors in their own networks.

By comparison…

These issues are not unique to Neurosynaptic; they affect most telehealth providers. But they raise serious questions for those like Neurosynaptic that wish to both address a critical need and build financially self-sustaining operations. Other start-ups in the space that have tried to build telehealth models from scratch have also been forced to make strategic changes in light of the high costs of rural service delivery.

Shelley Saxena founded SevaMob in 2011 to provide primary healthcare and low-cost health insurance to rural families in his home state of Uttar Pradesh. The company’s model centered on dispatching low-cost healthcare workers to villages to provide check-ups and basic health services and make specialist referrals as needed, all via tablet. Recognizing that 80 percent of healthcare costs in India are paid out of pocket, the company also sold low-cost, government subsidized insurance plans to cover additional care needed. The company successfully signed up hundreds of subscribers in its first year, but ultimately could not sustain its rural village-to-village field teams.

India's telehealth business environment

SevaMob also confronted steep patient education hurdles at the absolute base of India’s economic pyramid. “Everybody thinks, in a county of [more than a billion] people, where there’s a scarcity of doctors, telehealth is a no brainer,” Saxena says. “But there is a neighborhood doctor available in any area. Five dollars and you get a consultation.” The doctors Saxena refers to typically practice traditional medicine and are not qualified to practice mainstream medicine, yet many of them have been the only health provider in their communities for decades and are locally trusted.

Given these issues, SevaMob was forced to make trade-offs between financial viability and its ambition to extend affordable healthcare services to India’s remotest villages. “Instead of starting from scratch, we [now] try to find partners,” Saxena says of the company’s new approach. Similar to Neurosynaptic, SevaMob partners with other organizations. It continues to provide low-cost insurance plans, but primarily offers them via local institutions and employers. It is also increasingly focused on peri-urban markets and niche healthcare sectors, because that is where SevaMob’s data can provide value to government agencies and existing health providers looking for new drug and service markets. “The data [also] helps set [disease] baselines, because there are no good baselines in India,” Saxena says.

Neurosynaptic remains committed to rural customers, but the team says it also grapples with financial constraints. Most of the company’s funding comes from Indian government agencies, aid agencies and banks. Neurosynaptic also has support from angel investors, including recent backing from the Indian Angel Network, Healthquad and Axilor that will allow it to hire a marketing team, which should help the company build its customer base, says Sawarkar. But he acknowledges that attracting investors has been a challenge all along the way. Neurosynaptic’s initial plan to build its own health centers was a tough sell, because of the long commitment investors would have to make before seeing financial returns on their investment. Their current partnership approach, however, is not always an easier pitch.

Getting on with it

In spite of ongoing obstacles in the telehealth field, Neurosynaptic has seen progressive growth. The company has sold 2,200 ReMeDis in the past five years and estimates that its technology has the potential to reach more than 50 million people.

The team is now working on a new model of ReMeDi—ReMeDi-NOVA—that they hope will facilitate expansion. The new version will be highly portable—weighing no more than 2.5 kilograms and being dimensionally small enough to fit into a backpack. For diagnostics, it will include testing strips along with the standard equipment and sensors. And it will be compatible with more current telecommunications methods, like Android phones and Bluetooth. These updates will make it possible to treat patients in the villages where they live. “The whole [device] can be easily carried from place to place,” Kumar says. “[That’s] 30 to 35 diagnostics that a health worker can carry. The patients don’t need to travel to the telemedicine center.”

Neurosynaptic is manufacturing the kits in-house and expects to have them ready in 2017. The team once again declined to comment on price but said the ReMeDi-NOVA will be lower-cost that the original model and will include a monthly software usage fee. Neurosynaptic’s goal is for the ReMeDi-NOVA to reach 10,000 villages over the next four years.

“We’d like to increase our presence to 15 [states] in India and [expand in] South and Southeast Asian and African markets in a more detailed manner,” Kumar says. “The plan is to grow point of care diagnostics so fewer and fewer have to travel for care.”

New telecommunications methods like smartphones and Bluetooth are improving telehealth services and reach, but technology cannot completely overcome the rural-urban divide.

In the meantime, the company is trying to efficiently provide services across the urban-rural divide for its existing systems. Offering regular customer training and routine device recalibration has been a challenge, because the company is based in Bangalore, far away from its partners’ health operations. “We need training, so [Neurosynaptic will] have to bring people form Bangalore to train the rural employees, and the coordination will sometimes not take place,” says Sundarraj from MMHRC. To minimize clients’ wait time, Neurosynaptic employs a “train the trainer” model, where it provides basic software and device instructions to its customers, who then train their own rural staff.

Coordinating updates to its product is also difficult. Neurosynaptic’s latest software can be updated remotely, but recalibrating ReMeDi’s medical testing equipment has to be done in person. Neurosynaptic has tried to minimize the need for equipment performance testing by accounting for potential performance errors in the design and manufacturing process. For instance, during production, each ReMeDi is manufactured in an electrostatic discharge-protected environment, which ensures that body currents of factory workers, for example, do not affect the devices’ circuitry. ReMeDi is also designed to withstand the rugged conditions of rural travel and usage, with features like highly durable sensors and power surge protection. Lastly, some of the ReMeDi testing devices are built with auto-test mechanisms that report when there is a malfunction.

Nevertheless, to ensure the accuracy of ReMeDi’s test results, Neurosynaptic advises that the device be recalibrated once a year. The company sends a specialist to service each ReMeDi twice during its first year warranty period; after that, customers must either ship the equipment to Neurosynaptic’s headquarters in Bangalore for recalibration, or work with one of Neurosynaptic’s small but growing network of regional equipment servicing partners.

Neurosynaptic is fortunate in that its longstanding partners appear willing to help the company work through the logistical challenges of telehealth delivery in order to offer rural services. Rose Mary Christian, MMHRC’s head nurse, says she has personally witnessed the value of Neurosynaptic’s technology many times, particularly its detection of heart disease through ReMeDi’s ECG equipment. In some cases, she has seen patients referred for immediate surgery after the tests. “[ReMeDi] saves so many lives,” she says.

Telehealth may be wrought with obstacles, but for those patients, it delivered.