Lessons from Gramin Healthcare Model for Rural India

By Arunima Rajan

What if there were an easy, low-cost way to bring medical care to the masses? A method that didn't involve the cost of setting up costly clinics? Gramin Health Care uses technology, village pharmacies and rural medical practitioners to combat this very lack of access to care in hinter-land India.

Technological innovations are changing the structures of society, from politics to the labour market. The healthcare system also needs to create new tools and approaches to fit this new context.

What is Gramin Health Care (GHC) 's prescription for rural India's healthcare system? The startup wants to transform the healthcare industry by making it more affordable and accessible. It wants to reach out to the rural population and integrate the local community into the model.

Healthcare facilities for rural communities are one of India's significant challenges in 2021. In a complex world where people don't have access to basic healthcare facilities, medical experts and therapeutic infrastructure, it's no surprise that many don't want to step into the rural healthcare service delivery sector.

Gramin Health Care's focus and purpose is to equip and empower primary healthcare services to rural India. A deep and abiding faith leads the organisation in creating a sustainable healthcare ecosystem for rural areas. The team was conscious that it needed to focus on job creation, bridge the gap between gender spaces, and provide affordable and accessible healthcare services to under-served communities.

The Long Journey of Gramin

Ajoy Khanderia is the founder and Chairman of Gramin Healthcare. He narrates, "We started by being consultants in the healthcare sector. There are thousands of hospitals in India promoted by doctors of some variety. So, if the promoter is orthopaedic, he starts an orthopaedic hospital, but he doesn't have cardio practice. If the promoter is a cardiologist, he doesn't have an ortho practice. Our goal was to set up an intellectual property in those hospitals on an outsourced basis. We found out that most of our doctors wanted to stick to tier-one cities, and our aim was to reach out to hospitals in tier II or lower strata of cities. It didn't work so well. So, we moved out from there to pure consulting because we sort of thought we knew what sort of changes to make at tier II or tier iii hospitals to make them profitable. People make some very apparent errors because they come from the medical fraternity and don't necessarily know human behaviour as much. But eventually, we realised that even this does not look like something we would get paid for. The next round of exercise we did was to do a second opinion for medical surgery, and we had practically every major doctor in India on our panel. Again we found that people are entitled, and they would call me and say, can you take me to this doctor, rather than doing it through technology. And that again became non-scalable, because everybody wanted to meet either Naresh Trehan or Devi Shetty and not the third and the fourth guy."

Around this time, a friend of Khanderia, an investor with ICICI ventures, joined IFCO. And his friend asked Khanderia to work with him. That’s how he started working for rural India.

Khanderia recalls that initially, it was going to be pure telemedicine and mobile vans. "But we found out that we were not fulfilling the need in the market, which is to provide healthcare. We were giving some advice. From there, we moved on to where we are right now. We provide medical consultation, provide diagnostic services and make genuine and affordable medicines accessible," he adds.

Today it's impossible to miss the powerful and decisive role played by Gramin Healthcare in the Indian rural healthcare space. But it was not an easy journey when it was established in 2016. The startup saw how disproportionately the shortage of healthcare resources had hit the rural population. The organisation's core message was to bridge this gap in a holistic, self-sustaining and scalable manner.

Despite disagreements, people everywhere are worried about universal concerns— the cost of healthcare, quality of education, and ensuring that their children had better opportunities than they had.

Change from the Inside

Gramin Healthcare addresses one of these significant concerns through institutionalised primary and preventive healthcare, one of its central pillars. The GHC team also believes that the best way to address people's concerns is to adopt a multi-pronged approach. The institution saw that meaningful change could come from forging strategic trilateral alliances across the government, industries and communities. They built a genuine alliance to meaningfully improve people's lives and offered comprehensive solutions which include products of international standards at affordable cost.

The Importance of Technology

The startup has also adopted a pragmatic, results-driven approach for delivering healthcare to Bharat. It relies on a mixture of on-ground presence and technology. GHC didn't try to blow up the existing system but wanted to deliver better results through brick and mortar centres and assisted telemedicine. They also use an efficient Health Information System (HIS).

Redefining Rural Healthcare

This is how the GHC chased its audacious goal. It sounds a bit like an ideal future. The health centres cater to villages within a radius of 5-10 kilometres. A Polyclinic supports a cluster of 10 health centres. Polyclinic offers specialised doctors, diagnostic services, in-house pharmacy and other services.

Breaking down the Cycle of Care

Khanderia believes that he and his team were just lucky. "We were in the right place at the right time. Most of our senior team had worked with me at some point in time. Many of them come from a tech background, telecom or the likes. So most of the team members have known each other for a while. It's a shared vision that all of us had, and it had worked out decently in that sense."

GHC had to abandon the status quo and find a brand new approach to the care cycle to achieve the impossible. For example, instead of a thought process that focused on brick and mortar models, doctors and diagnostic labs, they centred more on "First-Principles Thinking", where they were left with the core of healthcare: patients and care. This opened the door for innovative delivery methods— like Electronic Health Record (EHR) and assisted telemedicine.

Attracting Larger Pool of Human Resources through Polyclinics

Their approach involved patients visiting primary clinics or health camps where qualified and trained nurses/ health assistants conduct physical checkups, take vitals and create an EHR of patients. Doctors can access EHRs and give consultations through assisted telemedicine; and if required, prescribe further diagnostic tests. Regular doctor visits are conducted at primary centres. Diagnostic facilities and medication are also available at polyclinics.

Furthermore, GHC addresses secondary and tertiary care by fostering partnerships with multi-speciality hospitals. It has partnerships with several hospitals, including hospitals empanelled with the Ayushman Bharat. Advanced treatment is made available to the patients at a subsidised cost.

Reframing the Problem

Turning an impossible dream into an achievable goal requires reframing the problem. One of the first ideas that GHC thought about was patient management through a cloud-based EHR system.

It helped in easy and timely access to patient's records by the clinical team to identify any criticality and provide appropriate treatment options.

Pre-COVID Model

The whole model is similar to Avengers, where each character has a specific role to play. So, primary health checkups are done using tech-integrated diagnostic devices and inputs are directly linked to the patient's EHRs. Similarly, clinical consultation uses assisted telemedicine. Nurses use the GHC app on their tablet computers to relay patient cases to doctors to enable consultations. It allows the nurses to transcend the usual hierarchy and create better social bonds with patients, giving them more time to interact.

Avoiding blindspots using technology

The cloud-based system also sends triggers and enables periodic follow-ups for patients with various health issues. It enables increased patient adherence to medications and treatments, even during their post-care and rehab.

Addressing the issue of Secondary and Tertiary Treatment

GHC uses a technology-based system to send patient referral communications to partner hospitals and follow up with patients. It also provides affordable stays to patients and their families or caregivers during treatment through integration with quality accommodations aggregators. It also uses integrated communication channels such as SMS, Whatsapp, etc., to deliver information about upcoming camps, doctor visits, prevention of diseases etc.

Bringing a Balance between Man and Machine

Gramin Healthcare doesn't spend much on technology and understands the importance of human touch in the healing process. "We spend 20% of our budget on technology. We integrate the existing technology into our infrastructure. We are very clear that we don't want to be in the technology space. We empower the healer to do the right thing. And bringing them to our platform helped us to reduce our operational expense by 80%. And that's where Artificial Intelligence and technology comes in. For example, we are in the process of bringing in pink eye technology for the diagnosis of COVID," says Khanderia.

Impact of COVID

Ajoy Khanderia points out that the biggest realisation from the pandemic was that the under-served community of India continues to be under-served. "We haven't taken vaccines, cures or treatments to rural India yet. The rural population is in fear of contracting the virus due to cost concerns. Due to this, they stopped coming to our clinic, so we changed our model for the time being to a pure telemedicine model working with the GOI and educating the masses about how to stay safe, get treatment and tests. For a few months, we did that, and we educated 5-6 million. It was a big achievement for us, even though we know that this is just a drop in the bucket. From there, we moved on to the click-and-mortar model i.e. a physical and telemedicine-based model, as 30-40% of clinical treatment require a physical examination. We are also using telemedicine and o bring quacks on a legitimate platform with doctors," he adds.

Major Milestones

Khanderia points out that the milestone for Gramin is not the number of people they treat or the number of clinics they have set up but the number of lives they have touched. "We also do camps for educating women on female hygiene, their rights and entitlements. From time to time, we feel that we have achieved something when the quality of life of a person has improved. On paper, we can see that when you open a clinic or when you achieve 500,000 patients, it is a milestone. But that is not the impact that we are looking for, we are looking for something intangible in that sense. If I can say this month, we were able to improve the quality of life of 100 people that would be worth more than 10,000 patients we have treated," he adds.

Balancing Future Goals with current Challenges

Khanderia points out that one shouldn't try to boil the ocean because it doesn't work. "One should take small steps to achieve better results. We used to say that village quacks need to go away because they are not trained or legal. But that's the way our society works. I would bet you that's the way our society would work for the next 100 years. We are trying to bring them on our platform rather than become competitors because these are the people who have ties with the community. They become our touchpoints in the villages. When there is an acute problem requiring medical attention, they consult our team. With this approach, we should reach from our current 1000 village outreach to 100,000 village in three years. We are not trying to disrupt anything. If you can't beat them, then you should join them," he adds.