Up close and personal

For 11 years after completing his MCA in 1999, Sujay Santra, by his own admission, led the perfect “geeky” existence — from his first job with the National Remote Sensing Agency, to running a web services business, dabbling in palm recognition software, and then working with IBM and Oracle in Bengaluru. Then, an experience with his father’s health, while he was at Oracle, changed things. Santra’s father, who lived in Kharagpur, had begun to show symptoms of acute stress and a heart condition.

Santra took him to Bengaluru, where he was hospitalised, advised medicines by a cardiac surgeon, and asked to return after six months. Back home, after some problem, a local doctor included some new medicines. But the problem wouldn’t go away. Six months later, what the Bengaluru doctor said shocked Santra. His father had been taking the wrong medicines, when adjusting the dosage of the original prescription would have been enough.

“This is common with remote patients. Once they leave the clinic, the doctor loses all contact with the patient till he goes back again,” says Santra. Patients typically visit a local doctor for follow-ups, where experiences like this can happen. “That was the starting point in thinking aloud: can modern technology help people reach the doctor in times of need?” he says. 

Telemedicine was one solution but it wasn’t suited for remote locations, needed high capital investment, high bandwidth lines and, importantly, doctors had to be available in real time for consultation. “It hasn’t been successful for these reasons,” says Santra. Remote monitoring was the answer. With the help of STEP — the Science and Technology Entrepreneur Programme at IIT Kharagpur — he came up with the idea of measuring patient health data such as blood pressure, blood sugar and ECG and sending it wirelessly to a specialist at a city hospital. iKure’s proprietary software WHIMS (wireless health incident monitoring system) is registered with IIT Kharagpur and is due for patent soon. It records patient data, footfalls, treatment prescribed and medicine inventory.

The main advantage of WHIMS, according to Santra, is the low resource requirements of its software. “Our entire ERP works at 10 kbps speeds,” he says. On the other hand, it costs ₹10 lakh to set up a telemedicine operation, and there’s the issue of low bandwidth and internet speeds. WHIMS is a cloud-based platform that is available on a subscription model starting at ₹2,000 a month.

WHIMS’ first trials were held at Jubilant Kalpataru Hospital at Madhyamgram in North 24 Parganas. Santra initially sold the software to hospitals and worked with CSR arms of MNCs to augment their healthcare initiatives. The trial of the iKure model was at Salboni in West Midnapore district as part of JSW Steel’s CSR activity. “We found that the technology had application in CSR programmes, NGOsand corporate hospitals in eastern India. But this wasn’t enough to create an impact as each deal took time to materialise,” says Santra. The idea of the iKure Rural Health Centre (RHC) was thus born.  

Booster dose

In November 2012, iKure opened its first centre after running 20 pilots over two-and-a-half years. “These are an alternative to government-run Primary Health Centres (PHCs).” Though there are 922 PHCs in West Bengal, Santra observed they didn’t adequately address the healthcare needs of rural patients. “They have issues of health and hygiene, and often the doctors aren’t available,” he says. 

iKure operates two RHCs — one in Keshiary block in West Midnapore district, its first centre, and another in Surul village near Santiniketan. While Keshiary is in association with the Rotary Club of Calcutta Metro South, for the latter, it has tied up with local NGO Surul Foundation, and operates out of its premises. iKure’s centres’ charges range from ₹100 for major dressing and ₹60 for an ECG, to ₹10 for BP measurement or an injection. For general consultation with the doctor on duty, a patient pays ₹80 per visit, which includes medicines for five to seven days. “We help in early detection of diseases, which saves on treatment costs, so total cost of cure comes down.” 

For people in the villages, it’s an affordable and accessible option that ensures they don’t lose a day’s wages plus the travel cost of accompanying family members. Each centre has one lady attendant for female patients, a doctor, a pharmacist and a centre coordinator. With an average billing of ₹100 per patient — what he calls the $2 model — Santra says, “We need 40 patients a day to break even.” The Surul centre in Bolpur has been running for four months; Santra says it’s a couple of months from breaking even.

iKure’s model is linked to tertiary hospitals operating in smaller towns. It has tied up with Mission Hospital in Durgapur, around 35 km from Surul, and Sanjiban Hospital in Howrah’s Fuleshwar town for its Keshiary RHC. Associations with local NGOs are equally important. “Building trust takes time, and the NGO is a known entity in the village,” he says. Surul Foundation, for instance, has been working on issues like sanitation, women’s empowerment and education for over 10 years now. Apart from Sanjiban and Mission, second opinion cases requiring further intervention are referred to Nanavati Hospital, Mumbai. 

Santra says he plans to turn this into a viable proposition for doctors. “We plan to give them career progression,” he says. Moreover, doctors get a wider variety of cases among rural patients, and they’re interested in such stints. “Around 40,000 MBBS doctors graduate every year in India. Of these 20% get access to specialist courses such as MD or MS. The remaining 32,000 become general practitioners or RMOs (resident medical officers) in hospitals. They’re required to spend 40 hours a week at the hospital, which they complete in 2-2.5 days. This leaves them with over four days a week for their own practice, and not every one has their own chambers,” says Santra.

Stabak Sarkar, 30, is the doctor on duty at the Surul centre. He did his MBBS in 2006 from Guwahati’s SGMP Medical College. Sarkar is based in Surul for four days, from Thursday to Sunday, every week. He divides his remaining time between the West Bank Hospital in Andul, a doctor’s chambers in Madhyamgram, and his duties as a medical officer for Tanishq in Kolkata. Sarkar says that doctors from Kolkata who are not affiliated to iKure charge close to ₹300 for a single visit to Surul, making the firm’s ₹80 charge much more affordable for patients. “Treating patients here gives me greater satisfaction,” he says. That, and the chance to gain wider experience. Sarkar is pursuing a diploma in cardiology, which will qualify him to identify cardiac-related symptoms, understand ECG reports and alert a cardiologist if necessary. 

Getting wings

iKure’s first round of external funding of ₹75 lakh came from the WEBEL Seed Fund in 2010. This was followed by an MSME grant of ₹6 lakh for technology innovation in 2011, and a ₹10 lakh grant from Nabard early this year. Recently, it received angel funding of ₹20 lakh in two tranches from Jayesh Parekh, co-founder of Sony Entertainment Television, and Nandan Maluste, president, CSO Partners, both angel investors with the Intellecap Impact Investment Network (i3N). “We are closing a second round of ₹40 lakh from i3N and Calcutta Angels. We are also in talks with investors for a Series A round of investment,” says Santra.

Maluste remembers that he was initially sceptical about the model, and took almost a year to buy into Santra’s idea and the ability of the team to deliver the service. “They did not have all the answers but were willing to think through them, and take suggestions,” he says, adding, “Our investment has given confidence to VCs, and the flow of capital will only improve if it delivers value on two counts — valuable service to the community, and a path to profit.”

The path to profit is surely underway. Revenues for iKure come from three streams — RHCs, sales of its WHIMS software to hospitals and CSR projects where companies bear the cost. With ₹30 lakh in revenues during FY13, Santra expects the FY14 figure to touch ₹60-70 lakh and profits to be in ₹12-14 lakh range. This year, Santra estimates software sales and RHCs to contribute 40% each to revenues, with the rest coming from corporate tie-ups. “We are targeting 1 million paid patients over the next three years,” he says, adding that iKure’s two RHCs have had over 3,000 paid patients so far, and an equal number of non-paying ones in its free camps in neighbouring villages. “Each of our centres has the potential to cater to a population of 100,000,” he adds. 

With three new centres coming up by mid-September in Dwaranda, Ruppur and Jadavpur, Santra says iKure will add a total of 10 centres (three each in Howrah, South 24 Parganas and Puri in Odisha) in the next eight months. Employee count will also go up from 20 to 50 in a year’s time. Sourcing of doctors and staff for its RHCs continues to be a key challenge. Scaling this model outside West Bengal, where iKure’s business is concentrated, will depend on socio-economic conditions that vary by region. “We are scouting for locations in Odisha and Bihar since eastern India has roughly similar conditions,” says Santra.

It helps that iKure has an asset-light model. The current capex for an RHC is around ₹1.5 lakh, including furniture, equipment and medicine, which will come down further with scale. “Doctor’s fees are a major component of our costs. We currently pay them ₹1,800 a day [₹54,000 a month] since we source them from staffing agencies. Going forward, we plan to have doctors on our payroll at ₹35,000 a month,” says Santra. “Our plan is to utilise the team of doctor, pharmacist, nurse and centre/cluster manager to move in rotation through two-hour slots, covering three villages a day in a 15-km radius. Though we will add transportation costs, we’ll be able to bring down the operational cost per centre significantly,” he adds. 

There’s another opportunity in epidemiological data that iKure plans to tap into. Maluste explains: “Such data is primarily available through government sources, and is usually not reliable. Here we have an opportunity to sell aggregated data. There could be ethical ways of comparing different lines of treatment.” Maluste feels three kinds of organisations can benefit from iKure’s network and reach — pharma companies wanting to market-test their products; public health networks such as WHO and government organisations looking to understand what kind of treatments are efficacious, who need to be plugged into what kind of epidemics are developing (saving them data collection costs); and those who want to conduct medical research, including students looking to understand a disease. “This kind of data is valuable both from a social (in terms of preventive care) and commercial aspect,” points out Maluste. 

iKure is already working with the Association of Community Ophthalmologists of India, mandated by WHO to screen and prevent eye diseases, to develop an ophthalmology module. “We’ve been able to crack the code in terms of technological feasibility and the business model,” says Santra. If iKure can successfully manage to win over pharma companies and government bodies in its endeavour, that will prove to be booster dose.