“Just creating an app does not mean you have a company. The key key question is: are you solving a problem?” These were the opening words of Pradeep K. Jaisingh, Founder of HealthStart India, at the VC Panel at #FTR4H program at MEDICAL FAIR India in New Delhi. Panel was organised by HealthStart. The main aim was to highlight VC perspective on the digital health startups scene in India.
As said by Mr. Jaisingh, the basic background of technology needs to be that it improves the outcome. A solution needs to solve a problem and be sustainable. From the macro perspective, potential for disruptive innovation in India is big, said Mr. Jaisingh. Especially in terms of diagnostics, treatment and management of chronic diseases.
The doctor’s expectations in the near future are high. Artificial intelligence can be utilized to effectively synthesize patient information before his visit in the hospital or a doctor’s office.
What do the doctors need?
Private Equity Professional Mayur Sirdesai, Director at Somerset Indus Capital Partners, warned, the key issue in digital health technology and innovation is probability of adoption. “When a doctor has a line of patients in the waiting room, he can’t be bothered by entering data in the computer,” he mentioned. The second challenge is payment for digital solutions. Revenue model of a startup is crucial to implementation of a solution in practice. In India, most payments are still out of pocket which might change with the development of the insurance market.
From the perspective of Shuchin Bajaj, Founder Director at Cygnus Medicare, a big potential in India is in putting more effort into medical education of other specialists and healthcare providers, apart from doctors. “We are to doctor-centric. I am a big fan of personalized medicine and “ayurveda” in that sense. These sciences look at the patient as an individual while medicine takes the patient as a dataset. Ayurveda does not treat the disease,” he said.
Needs and payments
Partha Dey, Healthcare Leader and SME at IBM India mentioned the need for more collaboration: “It is clear and we agree we need to walk together and collaborate. Technology can work as a platform and our idea is to use it to solve real life problems. We are working on longterm solutions. The first issue is always the business case. What do users need? What are they prepared to pay for? A lot of startups have ideas, but struggle with translation and implementation in practice.”
Vikram Gupta, Founder and Managing Partner at IvyCap Ventures Advisors described India as a unique market because of the payment system. “In the developed world insurance takes care of healthcare. Our environment drives behaviour. Hence healthcare consumption is different compared to the rest of the world. The opportunities here are of different nature than in other countries. One thing to look at is infrastructure. Ratio of hospitals does not match population needs.” Huge opportunities lay in financial assistance for healthcare, concluded Vikram Gupta.
FTR4H is in full preparations for MEDICAL FAIR INDIA 2017. Before arrival, we talked to Incubators, Companies, Start-ups, Experts… Here’s what you might find useful if you’re thinking about doing business in India.
1. Make good market research
India ranked at 130 out of 189 economies in 2015 according to the World bank. 4% of the GDP go to healthcare; around 60% of expenses for healthcare are out of pocket, according to OECD. Almost a third of the population is supposed to own a smartphone by 2019, claims GSMA report. All this goes in favour to digital health or at least mHealth solutions, but keep in mind plenty of good startups on the ground are busy tackling everyday issues.
The country is extensively working on using all the advantages of digital solutions to improve people’s lives and health. Heard of Aadhar? It’s unique-identity number issued to all Indian residents based on their biometric and demographic data such as eyes and finger prints. Nishal Arvind Singh, Founder NASS & Associates IPR Boutique law firm and Legal policy advisor to Honourable Health Minister Satyendra Jain of the Delhi Government explains the plan behind the project: “All payments will be linked with aadhar, to avoid duplicity, promote increase in online payments and disbursement to beneficiaries under many governmental schemes for education, pension etc. This will enable direct transactions into beneficiaries bank account, which will prevent corruption,” says Arvind, adding that in time, it will be connected with healthcare. The unique identification number of a person will prevent duplication and confusion in data management and insurance claimes with others with the same name.
2. Do you have enough time for business here?
According to a World bank report from 2006, it takes 56 procedures and approximately four years for a simple commercial contract in India. As explained by Prabhu Guptara, a distinguished Professor of Global Business, Management & Public Policy at William Carey University, India, a Member of Boards of different companies in the UK, Germany and Switzerland, the problem is the bureaucratic system. It takes years for the legal claims to be processed, let alone enforced. It is a slow system, so brace yourself with energy and patience to conquer it.
3. Know that India has very good medical doctors
Top class. World renowned. There’s a reason medical tourism flourishes here. However, as Sachin Gaur warns, 80% of people live in rural areas and only 20% of facillites are there. There are different initiatives to improve access, such as the the mohalla (neighbourhood) clinics. As explained by the hindustantimes, they were started with the aim of taking diagnostics and treatment of simple ailments to people’s doorstep and reduce the footfall in tertiary care hospitals.
4. Can you make a subscription plan under a dollar a month?
India has 1.3 billion people, the majority is poor. “2/3 of the population can’t be your target market. 30% of the population lives on less than 2.5 dollars/day, another third 5 dollars/day. Which still leaves you with 400 million people you could address,” says Prabhu Guptara. However, given the number of people, if you can design a subscription model for around 20 cents, than you might address the poorer population, says Sachin Gaur, Director Operation at InnovatioCuris. Taking into account the volume you could reach, it can turn out to be a viable business model.
“If you can design a subscription model for around 20 cents, than you might address the poorer population,” says Sachin Gaur, Director of Operations at InnovatioCuris.
5. Ask, connect to people on the ground
Have you heard of HealthCode.io? It’s a platform for healthcare professionals where you can find people interested in co-creation, consulting, commercialisation, fundraising, mentoring, investing, validation. The app, as the founders claim, already has members from 52 countries, so you might find useful connections even outside India!
Be sure to check the two episodes of Medicine Today on Digital Health! Praphu Guptara speaks about differences in the healthcare systems in India, Switzerland or England. Sachin Gaur talks about the innovative solutions in India and problems of digital solutions and cyber security. You can find it on iTunes or Soundcloud.
Wearables and measurements. Which Point of Care devices are just gadgets and which ones bring actual better outcomes for patients? Here’s what’s wrong with wearables.
1. Questionable data gathering
When used for prevention, it has become clear by now, that a person gets tired of using a wearable or a health app in only a few months. It is important to note that this holds true mostly for relatively healthy people, not patients with serious illnesses.
2. We are measuring what we can, not what we should
British researcher Prof. Dr. Anthony Turner, Head of The Biosensors and Bioelectronics Centre at Linköping University Sweden: “we haven’t yet made the sensors we really need, we are using the sensors that we happen to have.” That is why in recent years investors have been more interested in other sensors: ingestibles, implantables, etc..
We are entering an era of sensors for complex chemical reactions and molecular recognition in the body. “This requires more regulation and caution in testing and development,” says Prof. Dr. Turner. However, we can expect more significant improvements and outcomes.
3. Questionable measurements
Apart from data being questionable due to inconsistent data gathering by the user, another issue is data reliability. If you wear your phone with a tracker and two tracking wearables for activity measurements, you are bound to get different results. Similar is true for home Point of Care devices. Are they then useful or harmful?
If you will ask laboratory technicians, they will tell you that Point of Care devices are far from laboratory accurate. But in which cases is that relevant? As Prof. Dr. Turner says, “from a laboratory perspective and for research purposes you always look for the best. However, Point of Care devices for patients just need to be good enough for managing conditions and early warnings. Personal devices for diabetes are not as accurate as clinical laboratory, but it doesn’t matter – they are good enough for management decision.”
You can listen the whole conversation with prof. dr. Anthony Turner here.
So what can we conclude out of all this? Wearables are simply a step in the evolution of health technology. Sensors are still promising us all a bright future. They bring:
More and more of them are embedded in the environment. Measuring is becoming seamless, taking away the issue of consistency with gathering data.
Biosensors have had a very long and successful history of miniaturization. “It took 20 years for that to happen for wearable blood glucose monitors, while glucose meters evolved from a huge instrument of 40,000 dollars to a device which today costs 7-17 dollars,” illustrates Prof. Dr Turner. For inventors, the biggest issue is, what kind of business model will work. But the final judgement from a financial perspective is clear: massive savings could be achieved.
Want to know more? Tune into the sixth episode of Medicine Today on Digital Health podcast. You can find, listen, subscribe, rate, follow, share the podcast in Soundcloud or in iTunes.
A few weeks ago, the sixth edition of the largest global study on mHealth app has been published by research2guidance, one of the community partners of FTR4H. Its Managing Director, Ralf-Gordon Jahns, is also member of the jury of #5MAC16. In this years report, more than 2,600 mHealth app developers, healthcare professionals shared their experiences and views on the market. Here their most important findings:
- The mHealth app market is getting crowded: Almost 100,000 mHealth apps have been added since the beginning of last year, amounting to 259,000 mHealth apps currently available on major app stores (including multi-platform apps and smaller platforms). In addition, 13,000 mHealth publishers entered the market since the beginning of 2015, totaling 58,000.
“Growth rates of mHealth app store downloads are estimated to be only +7% in 2016 after +35% from the previous year, reaching a total of 3.2B in 2016.”
- Multi-platform publishing is the norm: Or more precisely, publishing on iOS and Android has become normal. 75% of today’s mHealth publishers develop for both platforms. Other platforms still don’t play a major role.
- mHealth publishers are becoming connected: Unlike the previous years, publishers now use APIs to connect their apps to third party apps, sensors or data aggregators. Apple HealthKit is by far the most commonly used API. 58% of publisher now use APIs, compared to 42% from the previous year.
- mHealth app publishers are becoming more experienced with developing: Developing an app involves using tools to develop, test, market and monitor performance. 72% of mHealth app publishers have used, for example, analytics, testing, storage or cross platform tools.
- mHealth companies are getting smaller again and are losing their altruistic motive: Last year saw a wave of new market players, which are the “Garage” type of start-ups with 1–2 founders. The share of this category increased from 8% to 13% in the last year. Perhaps with this wave of new entrants, the altruistic ambition of “we do this to help others” is still prominent and unique to the mHealth market, but it gave way to “we do this to make money” as number one motivation.
- It is still not a money printing business for all but a few exceptions: 78% of mHealth app publishers report to have made less than US$100,000 from their entire mHealth app portfolio business. 60% make less than US$1,000 per month / US$10,000 per year. Traditional app store revenue sources like IAP1, paid app download or IAA2 are the main income source for only 4- 10% of today’s mHealth app publishers. Rather, they license technology (15%), and even offer third party development services (14%).
“US$10 seems to be the threshold for which a patient is willing to pay out-of-pocket for mHealth app services: There is a strong market belief that patients/app users would spent no more than US$10 (or US$9.90) on, for example, a monthly subscription for a health chat, a one-time download of a diet plan or one-time expert feedback. Thresholds vary between service categories but US$10 is the most common.”
- Health insurance companies (HIC) are expected to become a key player in the market but are currently failing to step into their expected role: The majority (85%) of companies in the market assume that patients would be willing to share their health data with HICs in return for a cheaper plan, health recommendations or research purposes. Only 17% of mHealth practitioners rate the app portfolio of health insurance companies to be above average in quality.
- The mHealth app market is a growth market: The revenues coming from mHealth app related services will grow by 15% (CAGR) to reach US$31B in 2020. 551M users will by then actively (at least once a month) make use of an mHealth app.
- Integration of mHealth apps into the healthcare system will slowly evolve over the next five years: mHealth practioners foresee that app stores will be the main distribution channel for mHealth apps in the next years. The importance of other channels as an indication for the degree to which doctors, hospital and pharmacies are expected to integrate into the system, has declined again since the last study. It will remain a consumer and patient driven market for the foreseeable future. Business potential will continue to grow.
“Within the patient journey, follow-up monitoring will be the most influenced phase by mHealth apps: In general, the impact apps will have on the patient journey from seeking information, receiving diagnosis and treatment as well as prevention is rated high. The highest impact is seen on providing follow-up advice and coaching after the initial doctor’s visit.”
- Reducing hospital readmission rates and non-adherence to treatment costs remained as the most important cost levers for mHealth apps to pull on over the next five years: Similar to last year’s study results, more than 60% of market players believe that the greatest cost saving benefit to come from mHealth apps will be noted in reducing hospital costs. This will be due to decreasing hospital readmission rates and length of stay, as well as assisting with patient compliance to medication plans. The perceived future impact that mHealth apps will have on reducing medical trial costs have dropped by -4pp.
Download the complete report here.