Raghav | May 11, 2015

Fellowship diaries: Critical healthcare challenges & solutions

On the corner table of ‘China Bowl’, the dimly lit Chinese restaurant in the premises of the Bangalore club, some of the ICU nurses from the city hospitals sit, along with the lone bio-medical engineer. This was during the dinner that followed the ‘Hazard Analysis’ meeting the OneBreath team conducted for critical care staff to understand the standard procedures and safety measures followed in Indian ICUs (Intensive Care Units).

The enthusiastic young nurse from one of the biggest corporate hospitals carried on from where she left off in the meeting, waxing eloquent about her hospital’s training methods, contingency measures and her own certifications. “We are well trained to handle any situation, sir. What happened once was that this patient had an emergency situation and there was no specialist doctor on call at that moment. I saved his life by taking immediate action and administering…” Listening to this, the nurse from one of the government hospitals, sitting next to me on the table quietly remarked to me in Telugu, “Maa hospital paristhithi vere sir. Maakivanni nerpaledu. Maa equipment sarigga panicheyyadu” (The situation in our hospital is quite different. We have not been trained in these procedures. Many of our equipments are not in working condition). These two contrasting viewpoints clearly highlight the paradox that is the Indian healthcare system.

While one can boast of the great advances in terms of technology and healthcare delivery systems, a large part of the country continues to be denied access to quality healthcare that is affordable. Consider this scenario:  In early 2013, the National Human Rights Commission has issued a notice to the Safdarjung Hospital in New Delhi on a complaint alleging that more than 8,200 children have died in the period of the previous five years. The RTI query also revealed that five out of 18 ventilators for children were not functional and that the conditions were unhygienic and there was an acute shortage of essential services at the hospital. If this happened in one of the largest government hospitals in the country’s capital, one can imagine the plight of critical care industry in the rural areas.


Statistics and observations like these are part of the daily learning I receive in my journey as a Villgro Fellow. Post my switch from the consulting world to join the Villgro Fellowship, I work with a Villgro incubatee company called OneBreath, a medical ventilator company that has innovated a novel technology, incubated at Stanford Biodesign, Stanford University, at Palo Alto CA for applications to critical care in constrained resource settings. I am involved in assessing the feasibility and finally building the business model to take critical care to semi-rural and rural regions in the country. Critical care industry in India has a range of challenges that need to be addressed in order to improve the overall healthcare scenario.


Lack of infrastructure
With a large percentage of healthcare infrastructure (80% of doctors, 75% of dispensaries and 60% of hospitals) located in urban India, rural and semi-urban areas lack medical infrastructure facilities. India has one of lowest ratios of beds, nurses and doctors per 1000 people in the world (0.8 beds and 0.6 doctors per 1000 people). Fully-equipped ‘Advance Life Support’ ambulances with equipment including ventilators are far and few to find in such settings.

Typically a patient in an emergency situation needs to be stabilized within the ‘golden hour’, a term used in the medical world to denote the hour immediately after a traumatic injury is sustained. As travel to the nearest critical care specialty centre might take more than 2 hours, these patients are helped to breathe through a device called Ambu bag, a squeezable device with a face mask used by rescue workers to force feed air or oxygen to the patient’s lungs. As this is a manual process that has to be done carefully, factors such as skill of rescue worker and duration of procedure come into play. Ideally, the patient has to be placed under mechanical ventilation and proper expert guidance to be stabilized within the requisite time. Lack of adequate ventilation within the required timeframe is one of the major reasons for significant losses in life in such scenarios.

Lack of skilled personnel
One of the major hurdles in delivering quality healthcare to the larger public in India is the lack of skilled personnel needed to make effective use of medical equipment.

While the nursing staff can normally handle ventilators and basic mechanisms based on instructions from doctors, most of them do not go through a formal training program. Hence, doctors do not generally depend on nurses in case of emergency situations. Also, another problem is the lack of motivation for service staff to work in rural areas owing to financial reasons and lack of infrastructure.

Usage of ventilators by untrained staff leads to under-usage of the device, need for constant attention from doctors, longer recovery time for patients and in a few cases, improper functioning and need for service.

Service and maintenance
In an urban setting, generally private hospitals have a dedicated bio-medical department which handles the servicing of the equipment. However, some of the government facilities do not have service personnel handling the repair and maintenance of the equipment, and depend on company personnel to attend to complaints. This leads to delay in service and also makes the equipment invalid for a considerable period. In rural areas, non-availability of service personnel on demand is a significant problem.


Efficient medical technology suitable to local conditions
Imports constitute around 75% of the Indian medical technology market with very less indigenous manufacturing. However, one of the key problems in terms of healthcare delivery in India is the lack of affordability and accessibility of the latest medical technology to larger parts of the country. It is further important to note that the technology innovation has to be compatible to the conditions prevalent in these areas. For example, inadequate power supply and poor support system are some of the factors that have to be taken care of while designing for Indian conditions.

OneBreath has reinvented the mechanical ventilator built on a novel patented platform and is designed keeping the rugged conditions in developing markets such as India in mind. It comes with features such as more than six hours of battery backup given the acute power shortage situation, portability etc. that will help critical care reach hitherto unchartered territories.


Business model innovation
There is a need for business model innovation across various stages of the value chain, i.e. manufacturing, distribution and marketing from the existing supply based model towards providing integrated solutions. This will help the healthcare industry provide meaningful benefits by making healthcare accessible and affordable to the larger percentage of the population. These innovations come in various forms such as financing options to help smaller healthcare providers afford technology, technology providers acting as service providers, effective collaboration with ICT companies etc. Some of the key areas of innovation to be looked at in the Indian scenario are:
* Non-traditional, novel delivery channels
* Technology combined with expert medical intervention from ‘installation’ to ‘after care’
* Medical expertise on demand

OneBreath aims to bridge the existing gap in critical care in rural India by identifying hubs in rural and semi-urban areas where ventilator services along with the expert medical help can be provided on-demand. OneBreath aims to use the huge advantage in terms of its technological innovation combined with a disruptive business model to build a full-fledged ICU solution in rural settings, thereby increasing the reach of critical care and saving more lives.

One can see that the existing situation in healthcare delivery needs much improvement. However, factors such as the heightened innovation activity in the country, especially in the healthcare domain, and proven examples of success from stellar institutions such as Aravind Eye Care continue to provide hope for innovation and improvement in healthcare delivery in India in the near future.