Healthcare innovation in India: Addressing challenges, understanding progress and offering opportunities

Addressing complex challenges and understanding the need for innovation

India suffers from a double whammy of communicable diseases and exponentially rising non-communicable diseases (NCDs). A multitude of factors—ageing population, sedentary white-collar lifestyle, economic advances, rising disposable income and urban migration—put healthcare services in a crippling and challenging situation.⁵ Out-of-pocket expenditure associated with the chronic nature of the treatment of NCDs puts an additional burden on the healthcare expenditure of households. The majority of expenditure associated with NCDs is on inpatient care, and mostly by the rich in private facilities.⁶ This creates an opportunity for innovations to focus on the affordability of treatment related to NCDs.

Addressing healthcare challenges and offering innovative solutions requires a thorough understanding of the continuum of care. Healthcare offers three windows of opportunity for innovation at three different levels of care:⁵

1. Prevention: Screening for diseases, behaviour change communication, health awareness and education

2. Provision: Diagnostic and treatment services

3. Protection: Long-term follow-ups, preventing relapses, monitoring patterns.

Innovation is also driven by external factors and stakeholders involved in the delivery of care. These stakeholders with their varied interests and responsibilities add to the complexity. This enormity and diversity of challenges faced by an equally diverse and non-uniform market calls for large-scale, all-encompassing, out-of-box, innovative approach to yield the desired results.

India: The golden bird of frugal innovation

Frugal innovations are products and services that offer quality care at a much more affordable price by factoring in local parameters. India has always been familiar with the culture of frugal innovation—what is often called ‘Jugaad innovation’. Foreign companies have to factor in power outages, voltage fluctuations, high levels of dust and pollution and intensive equipment use to ensure the sustainability of their product.⁸ With the ‘Make in India’ initiative, the focus has now shifted to building products locally from scratch, rather than improvising parts of a product. To ensure low cost, sustainability and affordability of a product in India, it needs to be adaptive to local needs, which are just as varied as the Indian terrain. Andhra Pradesh MedTech Zone (AMTZ), established as a medical equipment manufacturing and testing facility and incubation centre for MedTech start-up companies, offers a perfect environment for medical innovation to grow and prosper in India.

Frugal innovation may not necessarily mean delivering low-cost devices. It encompasses delivering low-cost, high-quality services. Aravind Eye Care System and NH are representative healthcare models of frugal innovation in the private sector. Both these institutions have attained delivery of high-quality, low-cost, high-volume healthcare services through cross-subsidization, economies of scale and lean manufacturing.^9,10

Low public investment in preventive healthcare, poor health awareness and education, weak public healthcare infrastructure, lack of advanced laboratory facilities and equipment, low penetration of health insurance, unaffordability of treatment and an inadequate health workforce, along with a poor healthcare delivery mechanism, are some factors driving the healthcare ecosystem in India.⁵

Land of challenges or a sea of opportunities?

Social security and healthcare assurance should be the motto of any government aiming to provide safe, affordable and quality care. India with its 460 million daily internet users, 730 million mobile phone users and affordable mobile and data services provide a perfect opportunity to build sustainable and innovative healthcare solutions.¹¹ Medical tourism is another rapidly growing sector that has still not realized its full potential. Due to the relatively cheap healthcare expenditure while maintaining high-quality and international standards, Indian hospitals have become a hotbed of medical tourism. This offers a rare opportunity for India to provide accessible healthcare to patients from both high- and low-income countries outside the South Asia region.

A single biometric-enabled ‘smartcard’, specific to healthcare needs and issued to every person, provides a plausible option to integrate all healthcare services under a single entity, without deviating from the provision of personalized medicine. The features of Ayushman Bharat––National Health Protection Mission, resonates with that of the ‘smartcard’ features. It includes all private and public healthcare services under one umbrella, operationalizes a robust, modular, scalable and interoperable information technology platform; and delivers paperless and cashless benefits. It will provide a rare chance for us to universalize healthcare provision across India, without any added costs and still maintain our focus on personalized medicine. This ‘smartcard’ will contain immunization and delivery details for a newborn, antenatal check-ups, long-term treatment plans for people with NCDs, past medical and surgical history, schemes for which the beneficiary is eligible, and monitoring programmes such as Directly Observed Treatment Short-Course (DOTS). Specialized facilities such as AMTZ that can act as medical device manufacturing hub and incubation centres for start-ups working in healthcare are great initiatives that should be encouraged and replicated by every state government to encourage the development of low-cost, high-quality medical innovation.

The success of the Indian pharmaceutical industry is well known and often cited as an example of growth for other sectors. The industry has been at the forefront of healthcare innovation in India for its employment generation and massive ability to export. The specialty generic business and cost-competitiveness model of Indian pharmaceutical industry is the perfect case study on what, why and how to grow in a cut-throat and often hostile environment.

Opportunity for an innovative solution also lies in the supply and services of medical equipment to a low-resource setting. Simple and effective interventions will bring widely transmissible benefits. Methods to cut costs while maintaining quality include a hub-and-spoke delivery model, bundle pricing, task-shifting, telemedicine and focus on primary care. Multinational companies such as Amazon with their established sourcing and delivery model may offer opportunities for medical supply services, Apple can play a major role in remote patient monitoring, while Microsoft can help with clinical decision support. What we need to learn from global corporations is the need to provide a good consumer experience. Once we understand this, the quality of care will automatically improve.

Exponential growth in any sector comes with its fair share of regulatory framework involving checks and balances to discourage unethical practices. It has been a challenge in India to enforce a regulatory or quality assurance mechanism in healthcare. Roll-out of Medical Device Rules and modification of Bureau of Indian Standards to include medical devices ensures a uniform and evidence-based policy to regulate the development and marketing of medical devices. Strict and inflexible guidelines have been partly responsible for the slow growth in the medical device sector in India. The Central Drugs Standard Control Organisation, which regulates the quality of medical devices in India, has to balance its flexibility to encourage new developers while maintaining a strict control on the development of medical devices. Simultaneously, Indian regulatory and enforcement agencies need to create an ecosystem that encourages manufacturing of medical devices. India could thus provide a platform that offers opportunity for innovation in both manufacturing and servicing of medical devices.

Any big reform requires an equally big effort towards building it. The sustainability and scalability of healthcare innovation and translating ideas into action depends on an equally innovative teaching and training model. Healthcare providers in the future will face a painful transition if they are not adequately prepared for it. Bringing the benefits of innovative healthcare models and devices to the most vulnerable populations relies on the ability and expertise of providers. Physicians and managers of care must be well-versed not only in medical know-how, but also in the implementation of innovative and disruptive solutions in low-resource settings.

An innovative reform in medical education will produce future thought leaders. Inclusion of health policy, advocacy, diplomacy, management, leadership and innovation within the traditional education model will result in socially conscious and adaptive professionals. Many medical schools in the USA have included ‘scholarly concentrations’ such as global health, ethics and humanities; health policy and medical education into their curriculum. It has been shown to give students a solid foundation in critical thinking and problem-solving.¹² Medical Hackathons, popular in western countries, offer an opportunity for multidisciplinary collaborations, recognizing the unmet needs and quick development of low-cost, high-quality medical devices and services. Programmes such as ICMR-IIT KGPIIMA Med Tech Internship Award and School of International Biodesign (previously Stanford-India Biodesign) programme encourage medical entrepreneurship through needs-based innovation process and bring the technology to masses. Institutions have to be trained in grant management, philanthropic fund-raising and endowments, intramural funding, mentorship training, career development and networking opportunities.