AcknowledgementsStrategic Direction

Lead Author

Special Acknowledgements

L.M. SinghProject Director, PAHAL

Shoumik GuhaSenior Expert - Advisory, PAHAL

Chandrima Dhar Manager, PAHAL

Nitin KesarSenior Program OfficerCommunication, PAHAL

Contents

Current Scenario in Telemedicine 7Role of telemedicine in achieving optimal health care delivery and universal health coverage in low resource settings. And its advantages, especially in the backdrop of the shift to chronic diseases

Glocal - Overcoming Scale Up Challenges 10Challenges of advancing telemedicine adoption in terms of establishing patient trust, tech-capabilities, community outreach, human resource souring and ensuring continuity of care.

PAHAL Support Through Glocal’s Expansion Journey 13

How PAHAL’s support strengthened Glocal’s scale up effort to improve access to quality and affordable healthcare to the underserved

Alignment of Telemedicine With Public Health Needs Scope for public-private-partnership (PPP) models in the Indian healthcare system

Way Forward 20Dissemination of evidence-based learnings to support mainstreaming of telehealth solutions

Executive Summary

PAHAL and Glocal Healthcare Collaboration Strengthening primary healthcare in India

2

4

15

AB

Capex

CHC

CPHC

GDP

GOI

HR

HW

HWC

LHV

MoHFW

NCD

NHM

OOPE

Opex

PAHAL

PHC

SDGs

SDH

UHA

UHC

USAID

WEF

WHO

- Ayushman Bharat

- Capital expenditure

- Community Health Center

- Comprehensive Primary Health Care

- Gross Domestic Product

- Government of India

- Human Resource

- Health Worker

- Health and Wellness Centre

- Lady Health Visitor

- Ministry of Health and Family Welfare

- Non-communicable disease

- National Health Mission

- Out-of-pocket health care expenditure

- Operating expenditure

- Partnerships for Affordable Healthcare

Access and Longevity

- Primary Health Care

- Sustainable Development Goals

- Sub-district hospital

- Universal Health Access

- Universal health coverage

- United States Agency for International

Development

- World Economic Forum

- World Health Organisation

1

List of Abbreviations

Executive Summary

2

T he Indian population lacks access to quality and affordable primary health care with inadequate

infrastructure and a significant shortage of qualified workforce in public health systems. At the same time, the country grappling with a growing dual disease burden with a rise in non-communicable diseases (NCDs) such as asthma, hypertension and diabetes. NCDs are no longer ‘diseases of affluence’ with increasing prevalence amongst the poor as also the rural population.

It is well established that improving primary health care is essential to improving patient outcomes and experience, lowering mortality and morbidity and reducing costs. And there is a compelling case for strengthening primary health care (PHC) systems. Managing the shift in disease burden and population profile at specialist levels leads to

PAHAL (Partnerships for Affordable Healthcare Access and Longevity), is a United States Agency for International Development (USAID) and IPE Global’s flagship innovative financing platform to promote health financing models and provide catalytic support to social enterprises for improving access to affordable and quality healthcare solutions for the underserved. It seeks to improve access to affordable and quality healthcare solutions for underserved communities with a particular focus on Tuberculosis, Maternal and Child Health, Nutrition and WASH.

Glocal Healthcare is a social enterprise that seeks to bring quality and affordable healthcare to the underserved population in India through an integrated model of comprehensive primary & secondary care facilities, employing rational, technology-based platforms. Glocal’s offerings include hospitals, a mobile app (Hellolyf) and digital dispensaries - a telemedicine solution that enables access to doctors and quality healthcare at affordable price points.

Through collaboration with PAHAL, Glocal scaled up its Digital Dispensaries initiative, initially setting up a retail model of 8 digital dispensaries across West Bengal and Jharkhand. Building on the foundation of these dispensaries Glocal today operates approximately 170 digital dispensaries in India, many of which are built as Public-Private-Partnership (PPP) models in a number of Indian states. The firm is now making an international foray in other countries like Mali, Tanzania, Ghana and Ivory Coast to accelerate the goal of UHC.

Glocal’s digital dispensary offering is poised to address challenges plaguing India’s health systems such as lack of adequate medical personnel, inadequate health infrastructure at the last mile and growing NCD burden among vulnerable groups.

1

Its successful transition to a public-private-partnership (PPP) model in several Indian states powering last-mile healthcare also provides strong evidence of the central role for the private sector in contributing to and even driving India’s social and developmental goals.

2

The enterprise’s growth journey provides us evidence that by focusing on patient-centric care that is contextually adapted, telemedicine models can gain patient volumes by nudging health-seeking behavior and ultimately generate community acceptance.

3

Such primary care telemedicine models also highlight the need to shift policy focus and disproportionate investment flow from tertiary care hospitals to primary and community health centers that form the bedrock of a robust health system.

4

high costs and poorer health outcomes. To address the gaps in Indian health systems, several innovative technology-driven solutions in primary healthcare are working towards bringing in greater equity in health access, reducing costs and boosting quality.

3

4

The public health expenditure in India has remained close to 1.1% of GDP, far less than

the world average of 6%1. As per the National Health Profile 2019, daily per capita public health expenditure was less than INR 5 in 2017-18. At the same time, we are grappling with a growing dual disease burden with rise in NCDs such as asthma, hypertension and diabetes. NCDs are no longer ‘diseases of affluence’ with increasing prevalence amongst the poor as also the rural population. India also has very low physician density at less than 8 doctors per 10,000 people2. The number of medical professionals estimated to graduate from medical and nursing schools is not nearly enough to meet the needs of the burgeoning population.

Given that improving primary health care is

PAHAL and Glocal Healthcare Collaboration

1 - Ministry of Health and Family Welfare, 2 - World Health Organization

5

PAHAL, a joint initiative of USAID and IPE Global, aims to provide catalytic support to social enterprises in developing affordable & quality healthcare solutions for the urban poor. PAHAL is a collaborative platform which seeks to connect, capacitate and catalyze innovative social enterprises focused on improving health outcomes among urban poor communities.

One of our partners, Glocal Healthcare Systems Private Limited (“Glocal”) is a social venture that seeks to bring quality healthcare solutions to the underserved population in India. In addition to operating hospitals for secondary and acute care, Glocal has developed technology enabled primary healthcare centers - ‘G1 Digital Dispensaries’. Glocal aims to provide patient-centric healthcare at affordable rates in India. The firm uses technology extensively to ensure efficiency of operations and learning across both the clinical and administrative aspects of healthcare delivery.

Glocal’s Digital Dispensary is a telemedicine solution, which enables access to doctors and quality health care at affordable price points. It is manned by a set of qualified nurses, laboratory technicians and pharmacists and provides consultation, investigations and medication services. Through collaboration with PAHAL, Glocal scaled up their Digital Dispensaries initiative, initially setting up a retail model of 8 digital dispensaries across West Bengal and Jharkhand.

The PAHAL Platform Provides Unparalleled Access to Market

3,000+Doctors

15,000+Health

Digital Dispensaries Mobile App (Hellolyf)9 hundred bed hospitals

in 4 states across India

Hospitals

Workers

essential to improving patient outcomes and experience, lowering mortality and morbidity and reducing costs, there is a compelling case for strengthening PHC systems.Managing this shift in disease burden and population profile at specialist levels leads to high costs and poorer health outcomes. To address the gaps in Indian health systems, many innovative technology-driven solutions in primary healthcare are working towards bringing in greater equity in health access, reducing costs and boosting quality.

The objective of the PAHAL partnership was the demonstration of G1 Digital Dispensaries as an integrated, technology-led model for delivering comprehensive quality and affordable primary health care for the underserved. PAHAL also provided advisory to Glocal for raising impact investments for strengthening and scaling up G1 digital dispensaries. Building on the foundation of these initial dispensaries, Glocal today operates approximately 170 digital dispensaries in India, many of which are built as PPP models in several Indian states. It is now making an international foray in other countries like Mali, Tanzania, Ghana and Ivory Coast to accelerate the goal of UHC.

While our first report on Glocal’s digital dispensaries published in 2017 focused on the structure and components of Glocal’s retail and PPP models, early trends and anticipated challenges, through this report we aim to describe their scale-up journey since and the transition to a predominantly PPP model.

Mainstreaming of telehealth solutions remains a challenge and market forces alone will likely be insufficient. To make a case for investment in and adoption of telehealth applications we require better marshaling of instances that show that the telehealth model works, as well as, where and in what context. This case study can provide insights into the various ways by which the Glocal digital dispensary model aligned itself to the public health systems and began to overcome typical challenges around telehealth services.

6

1

2

3

Happy Patients!

Parients receives prescription

Patients receives medicine from automated medical despensary

Online consultation with vitals checks up, rapid investigation tests, ECG, Blood biochemistry, digital documentation, X-ray scanning, ENT probing, dematology probling

Waiting in Queue

Booking at the Desk

4

5

6

Current Scenario in Telemedicine

7

Telehealth adoption has witnessed significant growth globally in recent years. A more

conducive policy environment has supported the strengthening of the supply side with new players joining the sector and incumbents expanding their telehealth capabilities. While acknowledging that disparities in health outcomes continue to adversely affect those in the most vulnerable groups the recent WHO declaration of Astana, 2018 has noted that advances in information systems and technology could be key to improving access to health care, health service delivery, quality of service and patient safety, and increasing efficiency and coordination of care3. Closer to home, integrating m-Health, e-Health and telemedicine linkages for service delivery has been identified as a key activity to ensure delivery

3 - https://www.who.int/primary-health/conference-phc/declaration,

8

Telehealth is increasingly being recognized as a potential solution for the achievement of UHC in the backdrop of an evolving epidemiological profile in India and across the world. Health systems now face a rising chronic disease burden coupled with an ageing population. Apart from affecting quality of life over a prolonged period, chronic diseases also lead to high healthcare utilization. The complex health needs of patients with multiple morbidities necessitate a rethinking of our health systems and healthcare delivery mechanisms.

In India, we have achieved a sharp decline in morbidity and mortality caused by communicable diseases, but also witnessed a concomitant increase in the incidence of NCDs such as cardiovascular disease (CVD), diabetes, chronic pulmonary obstruction disease (COPD) and cancers. As per the WHO, NCDs are estimated to account for 63% of all deaths in India (2016).

Notably, the UN SDGs’ agenda includes reducing premature deaths from the four main NCDs by one-third by 2030 and three of the nine health targets in SDGs also focus on NCDs-related issues. After the endorsement of the World Health Assembly resolution 66.104, India became one of the first countries to develop specific national targets and indicators in order to reduce premature deaths from NCDs by 25% by 2025. This is in line with WHO’s Global action plan for the prevention and control of NCDs 2013-20205. As per this action plan, governments are urged to:

As per the MoHFW, the share of NCDs in OOPE in India is estimated to be more than 47%. Furthermore, the WEF estimates that NCDs account for about 40% of all hospital stays and roughly 35% of all recorded outpatient visits in India. Our government has set national targets for premature mortality and morbidity arising from NCDs and achieving these targets calls for integrated and multi-sectoral coordination. However, India is also facing a significant shortage of medical, nursing and allied health personnel. A large population in remote locations in India already suffers the economic burden of travel for seeking healthcare at tertiary medical facilities. Telemedicine is especially valuable for removing these barriers to healthcare access, reducing the cost of seeking healthcare and achieving continuity of care.

4 - Ministry of Health & Family Welfare, Government of India, 5 - https://www.who.int/features/2015/ncd-india/en/

Set national NCD targets for 2025 based on national circumstances1

Develop multi-sectoral national NCD plans to reduce exposure to risk factors and enable health systems to respond to reach these national targets in 20252

Measure results, considering the Global Action Plan.3

of a comprehensive package of services at different levels of health care by the Indian government.

Health promotion and opportunistic screening using telemedicine are cost-effective measures that can mitigate NCD related behavioral risk factors. Long-term disease management and control can also be achieved through telehealth solutions. Behavioral risk factors as seen below play a predominant role in the disproportionate rise in NCDs and these can be very effectively managed using telemedicine resources for tailored patient education. For e.g. the Cardiovascular Intervention Improvement Telemedicine Study (CITIES) found that telemedicine related assistance could potentially improve medication adherence and reduce medication barriers allowing for better control of CVDs.

46%

36%36%

24%

9%

0%5%

10%15%20%25%30%35%40%45%50%

Source: Rural Health Statistics, India, 2018-19

Source: Ministry of Health and Family Welfare

Social determinants of health and NCDs

Vacancy in Health Manpower at Rural SCs and PHCs

HW (Female)/ANM

Doctors atPHC

HW (Male) LHV/HealthAssistants(Female)

HealthAssistants

(Male)

9

Raised blood pressure Overweight / obesity Raised blood glucose

Raised lipids

Tobacco useUnhealthy diet

Physical inac�vityHarmful use of alcohol

Social determinants of

health

Globaliza�onUrbaniza�on

Popula�on Ageing

NCDs

Unde

rlyin

gdr

ivers

Beha

viour

alRi

sk Fa

ctor

Met

abol

icPh

ysio

logic

al

Risk

Fact

ors

Even with the availability of low-cost telemedicine applications that are clinically

useful, scalable and suitable for low-resource settings such as those in India, these applications have not been as readily adopted due to various barriers to adoption. Both patients and caregivers often resist such service models that are different from the traditional face-to-face encounters or they lack the technological literacy to use these telemedicine approaches.

10

Glocal - Overcoming Scale Up Challenges

11

Patient and care-giver related barriers

Adequate IT infrastructure and connectivity

Linguistic and cultural differences pose some of the most challenging barriers to the adoption of telemedicine services in India owing to its diversity. However, Glocal is an experienced telemedicine player with presence in several Indian states such as West Bengal, Rajasthan, Odisha and Gujarat. The company understands that for a telehealth initiative to be well adopted its systems should be patient-centered, proactive and well-coordinated. Glocal notes that in the absence of continuous community engagement, outreach programs and free sampling, telemedicine adoption is not adequate. They have found that as the catchment population begins to benefit from the superior services available at its digital dispensaries, there is a noticeable rise in telemedicine acceptability and patients shift away from unqualified medical practitioners in the area. This approval is further strengthened by the availability of good quality medicines that Glocal sources from reputed companies in the pharmaceutical industry with stringent quality control processes in place.

Real - time or synchronous telemedicine solutions, that require the patient and caregiver to be simultaneously present for the immediate exchange of information, are often weighed down due to slow internet bandwidths. The combination of the recent data ubiquity in India and Glocal’s technological innovation has drastically reduced the time-outs and connectivity faults experienced during video conferencing at G1 digital dispensaries. This has immensely improved the patient health-seeking experience with the result that the catchment population strongly prefers visiting digital dispensaries over seeking healthcare services from far flung secondary and tertiary care facilities

Challenges of HR sourcing and retention in remote areas

Public-Private Partnership

12

To tackle these challenges Glocal’s management successfully leveraged its past experience in scaling up and managing 27,000 common services centers as part of the world’s largest digital divide program in a PPP model between SREI Infrastructure Finance Ltd., GOI and state government of 6 states - West Bengal, Uttar Pradesh, Assam, Odisha, Bihar and Tamil Nadu.

Workforce shortages not only prevent access to quality healthcare in remote areas, but they can also quickly drive up the unit costs of healthcare. Telemedicine is a potential solution for addressing shortage and asymmetric distribution of qualified medical personnel in India. Nevertheless, telemedicine players also have to ensure that caregivers are adequately motivated and trained to fully embrace the telehealth solutions. Glocal has adopted a local hiring policy wherein the firm sources HR personnel from local colleges within one hour from the digital dispensary. The selected candidates are then provided classroom as well as practical training monitored by local digital dispensary employees and centrally placed trainers. Additionally, to ensure adequate monitoring of its current workforce, the company has introduced facial recognition software at their dispensaries.

Under Glocal’s current PPP model, the physical space for setting up digital dispensaries is provided by the respective state governments. Typically, these are vacant government buildings close to Gram Panchayat Bhawans and/or Sub health centers which are then outfitted by Glocal as G1 dispensaries. One of the challenges faced by Glocal is the lack of visibility on civil infrastructure facilities at these locations, such as availability of assured water supply, sanitation, unreliable power supply or adequate residential space for service providers. This leads to a delay in operationalization.

There are several determinants to a successful telemedicine model such as the model’s

technological capabilities, the model’s ability to address the barriers to telemedicine adoption amongst both patients and caregivers, its ability to attract adequate financing and last but not the least the policy and legislation support that it enjoys.

PAHAL provided technical assistance aimed to de-risk and scale up the market-led model for Glocal Digital Dispensaries. Glocal benefited from PAHAL’s expertise in terms of the nuances of operating an open market model in primary healthcare especially in the backdrop of poor health seeking behavior. PAHAL also provided advisory to Glocal for raising impact investments for strengthening

13

PAHAL Support Through Glocal’s Expansion Journey

Glocal encountered significant challenges in operating a retail model that led to inadequate patient footfalls. Customer acquisition costs and training costs were very high in the retail model. The franchised model also did not take off due to high capex requirements upon the franchisees. PAHAL has highlighted the challenges of such customer-pay models in its report on Private Primary Care Models. Such models take a long period of time to achieve sustainability due to high overhead costs, local competition from qualified as well as unqualified medical practitioners and poor health seeking behavior. We noted that employing a third-party payments models be it from the government, insurers or others can prevent the premature failure of PHC models.

Glocal also made a conscious shift from the retail model to a PPP model, after recognizing the role for the private sector in addressing the evident gaps in India’s primary healthcare system. The public healthcare system provided a natural alignment in that there was a necessity to improve access to quality healthcare in remote areas and Glocal’s cutting edge technology could help facilitate high-quality medical consultations without the need for local doctor deployment. All this could be done through a low maintenance and scalable digital dispensary model.

14

Owned and operated by

Glocal

All invest-ments and costs borne

by Glocal

Patient pays Glocal for services

Owned FranchisedInitial equip-

ment and backend

support by Glocal

Space and infrastructure provided by franchisee

Owned and operated by Glocal

Patient pays Glocal for services

and scaling up these dispensaries. Today Glocal has scaled up to over 170 locations across the country, providing quality primary healthcare services to over 1 million underserved. The market-led model that was operated by Glocal in the initial phase is briefly described below:

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Telemedicine applications can adequately address the gaps in our primary health care

systems be it shortage of qualified HR, improper referral linkages or effective management of NCDs.We believe that the current policy environment offers the perfect opportunity to transform India’s health care systems through telehealth solutions.

Policy support has strengthened in a number of ways and in order to provide health care services to the remote and isolated regions/locations of some States, the NHM has plans to start telemedicine services as a tool to enable delivery of services. An ambitious plan is to connect District Hospitals with SDH/PHC/CHCs at remote/rural locations in the ratio of 1:10 in the first phase of the National Telemedicine Network project. The District hospital in turn is to be networked with a Medical College

Alignment of Telemedicine with Public Health Needs

Several Indian states are recognizing that private sector participation can act as a catalyst for achievement of universal health care. We provide some examples below of recent state-led proposals seeking telemedicine services from private sector players. While the objectives and terms of such engagement may vary from state to state, telemedicine solutions are clearly being acknowledged for their unique value proposition in the Indian context.

Vision for citizen-centric services at Government Healthcare Facilities utilizing Telemedicine platform in every State/UT

16

3 4 45

2001 2013

20051996 2017

2020

Deployment of First Indigenously Developed Hospital Information system Software by CDAC Noida at SGPGIMS, Lucknow, UP

First telemedicine network between three institutions AIIMS-New Delhi, PGI-Chandigarh & SGPGI-Lucknow

MoHFW constituted Indian Task Force or Telemedicine

National Programme for Strengthening of e-Health and Telemedicine Service

National Digital Health Blueprint recognizes Telemedicine as a high priority given the low Doctor-Population ratio in “unconnected”, digitally illiterate, remote, hilly and tribal areas

Initiation of establishment of NMCN (National Medical College Network) and NRTN (National Rural Telemedicine network)

in every State. Meanwhile, INR 45 crores have been set aside for Telemedicine in the Approved Outlay for NHM for Annual Plan 2019-20. There are also several initiatives to improve the last-mile connectivity in India for e.g. the National Optical Fiber Network (NOFN) is an ambitious plan to provide broadband connectivity to over 2,50,000-gram panchayats and nearly 6,25,000 villages in India. While such initiatives can create a robust infrastructure set up that could support the adoption of telemedicine solutions, a lot still needs to change in terms of poor utilization of digital infrastructure, implementation delays of fiber laying activities etc.

RFP for Telemedicine Services Setup, Operations, Maintenance & Management

• To improve the accessibility of quality healthcare services through qualified medical professionals

• To eliminate distance barriers resulting in reduction of patients travel cost and time

• To support medical education through virtual means

• To upgrade the infrastructure of the PHCs• To build required capacity into the front-line

paramedical staff• To capture online electronic medical record• To enable NHM with databased decision systems

and user level advance/real-time analytics

• Capex for civil work of each Hub and Spoke will be paid by NHM

• Payment of Opex on a monthly basis based on actual consultations

• Selected agency will have to deploy adequate manpower

• All costs (Capex on account of setting up of Telemedicine Centre, providing IT Hardware, Telemedicine Software, Medical Equipment / Lab Equipments (with reccuring cost of reagents) and internet connectivity) to be borne by bidder

• Selected agency will have to deploy adequate manpower

• Service Provider shall be paid at the end of each quarter upon submission of invoice

• State will provide safe and secure room and required civil infrastructure and paramedic Staff

• Selected agency will have to deploy adequate manpower

• Service Provider shall be paid at the end of each quarter upon submission of invoice

• District authority will bear the cost of the civil infrastructure

• Service provider will manage & operate telemedicine centres with provision of manpower, internet connectivity, laboratory & pharmacy facility with generic medicine

• Opex payment will be made on a monthly basis

• Sustain general and specialty telemedicine services

• Reduce distance barriers and improve access to quality health services

• Document the challenges in provision of quality tele health care

• Avoid unnecessary travel time to meet health professionals

• Access to specialist health services for patients through tele-medicine

• Reduce the cost of patient transfers• Knowledge transfer through remote education

and research

• Eliminate distance barriers and improve access to quality health services

• In emergency/critical care situations where moving a patient is undesirable and/or not feasible

• Facilitate patients and rural practitioners’ access to specialist health services and support

• Lessen the inconvenience and/or cost of patient transfers

• Reduce unnecessary travel time for health professionals

• Ensuring UHA with a target of serving on average at least 90% of population of catchment area once in a 1-year period

• Providing minimum set of investigations within the same area to ensure prompt diagnosis

• Creating linkages with existing secondary & tertiary healthcare facilities

Madhya Pradesh

Himachal Pradesh

Gujarat

Odisha

State Objectives Payment Terms

17

Under one of the largest public healthcare schemes in the world Ayushman Bharat, India has also set a target of operationalizing 1.55 lakhs HWCs by 2022. Through this vision, there has been a steady policy shift from a selective healthcare approach to a CPHC paradigm. This follows India’s 2017 National health policy’s stated objectives of achieving UHC by covering all aspects such as health financing, health service delivery, health workforce, and health infrastructure and quality assurance mechanism. This ambitious Ayushman Bharat initiative will require rethinking the role of the private sector, given its ability to provide access to quality care at affordable costs in ways that go beyond replicating traditional health models. In recent years, there have been some notable examples of successful PPP-led health and wellness models already being run in the states of Andhra Pradesh, Maharashtra, Karnataka, Rajasthan, Odisha and Madhya Pradesh.

Apart from the urgent need for operationalizing HWCs, with the rapid epidemiological shift, the Indian healthcare system also needs solutions that can tackle the screening for NCDs and management of complications arising out of NCDs. Telemedicine solutions from firms such as Glocal with extensive local experience in India can fit in perfectly to plug the Indian public health system gaps. For e.g. Glocal’s in-house technology team is already working on hardware integration to include various point of care devices in their LitmusDx telemedicine suite to be able to offer adequate chronic disease management. For this purpose, it is looking to align national and international funds that support R&D on hardware development, healthcare delivery in low-resource settings and industry-academia collaboration.

“A strengthened health system directed towards addressing NCDs should aim to improve prevention, screening, early diagnosis, and sustained management of people with or at high risk for major NCDs in order to prevent complications, reduce the need for hospitalization and costly high-technology interventions and premature deaths.” - National Multisectoral Action Plan for Prevention and Control of Common Noncommunicable diseases

Gaps in conversion to HWCs

“The government has invited corporate and philanthropic entities to invest funds into ‘health and wellness centres’, which shall be set up as part of the government’s flagship National Health Policy 2017” – Budget 2018 Speech by Hon’ble. Finance Ministerr

18

SHC HWC Rural PHC HWC UPHC HWC

GapConverted to HWC

20000

400060008000

1000012000140001600018000

The G1 digital dispensary under Glocal’s PPP model offers a scalable solution for India’s public healthcare system. Glocal incurs a fixed cost of approximately INR 72,000 per month (with variations based on location) of which approximately 65% is allocated for doctor costs. The Odisha model features a doctor distribution of 70% general physicians, 25% specialists and 5% super-specialists. The company estimates that drug costs at Odisha dispensaries are around 17% of revenue and other fixed costs are around 18%. Given its extensive experience in operating such telemedicine centers, Glocal has calculated that around 10% of the catchment population typically requires one doctor’s consultation per year and that in an open-market setting a catchment population of around 50,000-60,000 per center would help it achieve break-even. The ramp-up period to reach this scale is close to 6 to 8 months.

Under its current operating model in Odisha, Glocal receives INR 225 from the Odisha government per patient transaction. The company has close to 258 such centers and its extensive scale can be evidenced from the fact that it conducts close to 1500-1700 consultation per day across all its centers. Apart from scale the digital dispensary model also offers flexibility for contextual state needs - for e.g. in Gujarat their dispensaries only employ telemedicine consultations for specialist consults. Case-studies conducted by PAHAL point to increasing patient volumes and community participation for Glocal’s digital dispensary model.

The Glocal solution has received recognition internationally as well with the assignment to upgrade most of the CSCOMs or Community Health Centers in Mali, Africa to digital dispensaries. Mali has some of the poorest health indicators globally with high MMR and IMR, high malnutrition and morbidity. This is in the backdrop of an overtaxed health system and unusually low utilization of health services (0.48 consultations per person per year). Much like in India, the country’s policymakers are focused on making meaningful health reforms and adoption of technology to provide primary healthcare to the masses.

Typical G1 Digital Dispensary - A highly scalable solution to gaps in Indian health

19

200 square feet area

Opex INR 72,000 per month

EquipmentINR 11 lakhs

Site renova�onINR 4 lakhs

Capex INR 15 lakhs

Way Forward

20

At PAHAL we focus on supporting social enterprises that are working to improve access

to affordable and quality healthcare solutions to the underserved. We have closely analyzed the challenges faced by such enterprises in terms of lack of market access and linkages, as well as funding issues. Through their scale-up journey these enterprises successfully adapt to the contextual needs of their operating environment to emerge with solutions that could drastically improve health outcomes in India. We believe dissemination of evidence-based learnings from our collaboration with such enterprises can contribute to a stronger healthcare ecosystem and support India’s achievement of UHC.

UHC is a WHO global priority and is also central to the UN SDGs. In India, achieving universal access to affordable and quality primary healthcare has been a key goal for the NHM. As healthcare policies embrace a more comprehensive concept of wellness and health promotion, as opposed to a model of hospital-based acute care, there will be a need to integrate health delivery processes. Provision of healthcare at a distance via telehealth can be a key component of such integrated care.

The evidence from pilots and other implementations of telehealth solutions need to be analyzed and synthesized keeping in mind clinical as well as other aspects of healthcare delivery. Key aspects of digitization of healthcare include organizational interfaces, financing requirements and technology integration for everyday practice. Such evidence-based learnings could facilitate a more conducive policy environment which in turn encourages further investment in telemedicine to tackle shortcomings in infrastructure.

Glocal intends to expand its PPP model in more Indian states that suffer from lack of quality and affordable healthcare services. It’s successful transition to a PPP model powering last-mile healthcare has provided strong evidence of the central role for the private sector in contributing to and even driving India’s social and developmental goals. Without a rapid increase in the number of qualified medical personnel in public health systems or an improvement in local distribution of these personnel, enterprises such as Glocal can offer a feasible solution to the urgent healthcare needs of these states. Glocal also aims to improve its telemedicine suite with added point of care device integration that can improve the NCD management capability at its digital dispensaries.

The sharp rise in internet penetration, rising disposable incomes and higher health awareness can give a boost to patient-centric solutions that leverage technology. The move towards telehealth solutions can reduce unnecessary overhead costs, bring cost transparency and improve process quality. Its positive impact on care quality could, ultimately reflect in improved patient experience and, also ensure recurring patient footfalls by nudging health-seeking behavior.

“If telemedicine replaced 30-40% of in-person outpatient consultations, India could save up to $10 billion and improve care for the poor and those living in remote areas.”- Digital India Report, McKinsey Global Institute

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