AA Healthcare: Challenges and Innovations in Scaling Telemedicine Services for Affordable Healthcare

Sapna Rakesh
Professor and Director, G L Bajaj Institute of Management and Research, PGDM Institute, Greater Noida 201306, Uttar Pradesh, India. E-mail: sapna.rakesh@gmail.com

Nidhi Srivastava
Professor, G L Bajaj Institute of Management and Research, PGDM Institute, Greater Noida201306, Uttar Pradesh, India; and is the corresponding author. E-mail: srivastavnidhi@gmail.com

AA Healthcare, an online platform specializing in video consultations through an innovative and cost-effective telemedicine device, has encountered challenges in expanding its services, despite a successful five-year track record. Amjad Ali's (Founder) groundbreaking solution has emerged as a sustainable healthcare option for underserved communities in Bihar and Jharkhand. The platform currently functions as a comprehensive healthcare resource, providing convenient access to doctors, hospitals, diagnostic centers, medical stores, ambulances, blood banks, etc. The growth of such firms is particularly significant in India, where affordable healthcare access remains a major concern for policymakers. This case relies on primary data collected between 2019 and 2022, encompassing personal and telephonic interviews, as well as face-to-face meetings with the lead protagonist. The primary objective of the study is to showcase the need for sustainable innovations in the telemedicine and e-healthcare sectors. Moreover, the case study aims to identify and address the challenges hindering the scalability of such services. By highlighting both the successes and obstacles faced by AA Healthcare, this case study contributes to a broader comprehension of scaling telemedicine services for affordable healthcare.

Introduction

On a rainy day, Amjad Ali (Ali), the Founder and CEO of now known as AA Healthcare, sat alone on his porch, deep in thought. The sound of raindrops accompanied his pensive mood, causing him to overlook the tea and hot pakoras (Indian savory dish) in front of him. The rain brought back memories of the devastating floods in Bihar back in 2017 and how it changed the trajectory of his life. It also reminded him of the diseases that plagued the region during that time and how his innovative healthcare device provided timely and affordable medical aid to many households in Bihar and Jharkhand. However, it also served as a painful reminder that there were still many patients who had no access to affordable healthcare.

Ali realized that his initial goal of reaching every household in rural areas had not been fully achieved. Despite the accolades received by AA Healthcare, he felt a sense of unease, as there was much to be done in the healthcare space. Some of those on priority included developing health awareness among the rural population, ensuring availability of generic medicines at the lowest cost, addressing concerns about data privacy when maintaining digital health records, and overcoming the lack of telecom network coverage in rural areas where many patients still do not have access to smartphones. These challenges contributed to the limited awareness and restricted usage of AA Healthcare app, even among healthcare workers, not just the population at large. He pondered over how AA Healthcare could overcome these challenges and grow in the near future.

AA Healthcare is a health service platform and intermediary that offers patients online/video consultations with doctors through its mobile application and in-person diagnostic facilities using its telemedicine device in remote rural areas of Bihar and Jharkhand (states in western India). AA Healthcare served as a comprehensive healthcare solution, connecting users with doctors, hospitals, diagnostic centers, medical stores, ambulances, and blood banks. The company initially introduced Bike Doc, a unique telemedicine equipment, that could be carried on a bike. This device allowed for real-time consultations, tests such as ECGs, emergency medicine administration, and sample collection or even act like a bike ambulance to transport the patient to the hospital as advised by the doctor. It also introduced OMED (Office for Medical Educator Development) Digital Clinic, a telemedicine center equipped with diagnostic, medicine, and sample collection facilities to local medical centers.

The company was co-founded by Ali and Ummi Ajami (Ajami) in 2017. Ajami is the Secretary and Chief Financial Officer (CFO) of AAHPL. Later on, the founding team was expanded to include Preetesh Anand, and Shazeb Khan (refer Exhibit I).

By 2022, AA Healthcare expanded its operations by franchising Bike Doc and OMED. Additionally, AA Healthcare introduced DroneDoc, an air telemedicine service in 2022.

The Beginning of AA Healthcare
It is unfortunate that many communities in developing and underdeveloped countries face challenges in accessing adequate healthcare facilities. This issue is particularly prevalent in countries like India, where the healthcare infrastructure may be insufficient in rural areas while medical services in urban areas can be expensive, making them inaccessible for the middle and lower-middle-class populations (refer Exhibit II). Amjad Ali's initiative, AA Healthcare, addresses these healthcare gaps through social innovation. By leveraging his experience working with reputable organizations like the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), he decided to tackle the healthcare challenges faced by rural communities in India. Ummi Ajami's background as a nutritionist, beautician, and social worker, coupled with her passion for inventions and creation, added a multidimensional approach to AA Healthcare in addressing healthcare needs.

The aim of AA Healthcare was to provide innovative healthcare solutions that are accessible and affordable by leveraging technology. As a social entrepreneurship, AA Healthcare strived to bridge the healthcare gap and improve the overall health outcomes of underserved populations. The approach of AA Healthcare aligned with the broader goals of universal health coverage (UHC) and equitable access to healthcare.

Ali and Ajami decided to collaborate with IIT Patna to incubate the idea of telemedicine device to demonstrate that it was possible to provide affordable and adequate healthcare services to rural areas in Bihar. The firm received early financial support in the year 2017 from the Bihar Government, in the form of a seed fund of $15,0001 (approx. 10 lakh soft loan) under the Bihar startup scheme. This helped kickstart their initiative. During their incubation period at IIT Patna, the duo received further financial assistance of $15,000, along with essential resources and support from the IIT Patna Incubation Center (during the year 2017-19). This included cash funding, coaching, technical assistance, marketing guidance, and other requirements necessary for building a successful startup.

Participation in various government and startup events allowed AA Healthcare to network with individuals and organizations, thus creating awareness about their innovative approach to healthcare services. This exposure helped them connect with relevant stakeholders and develop a broader understanding of the healthcare landscape. The objective of AA Healthcare's telemedicine initiative was not only to leverage technology to deliver quality healthcare services to rural and semi-urban areas, but also address the demand-supply gap without requiring the physical relocation of doctors and paramedical professionals. This approach would significantly reduce the cost of services, making healthcare more accessible and affordable for the target population.

Telemedicine Device Development
Ali's background as a doctor with an MBBS degree from Ukraine and MD degree from Patna, Bihar, along with his experience working in government hospitals and collaborating with UN healthcare entities like WHO and UNICEF, provided him with valuable insights into public health, immunization programs, and emergency relief operations. Through his involvement in health check camps and flood relief operations in 2017, Ali realized the importance of affordable and adequate healthcare services, even in emergency situations or natural disasters. He was also associated with telemedicine services that allowed him to understand the demand and supply gaps in the healthcare sector and gain knowledge about the functionality of telemedicine devices.

During his time (2017-19) at IIT Patna Incubation Center, Ali developed a telemedicine device that was more cost-effective compared to other equipment available in the market. Ali's device was available for only $3,000 (2 lakh) and offered enhanced features, while similar devices with fewer features were priced at around $22,500 (15 lakh).

The telemedicine equipment developed by AA Healthcare operated in real-time and facilitated better and quicker diagnosis for doctors. Over time, it significantly reduced the time per consultation from 20 minutes to 5 minutes, enabling more efficient healthcare delivery.

Modus Operandi of AA Healthcare
AA Healthcare also put in place a mobile app and website that served as interactive platforms. This was complemented by their 12 AA Healthcare Centers, also known as OMED in 7 districts of Bihar and Jharkhand (refer Exhibit III).

The telemedicine device was portable and enabled the implementation of the BikeDoc initiative. This initiative involved setting up healthcare facilities on bikes, equipped with pathology kits and emergency drugs. The average cost of setting up a BikeDoc facility, including equipment, medicines, and services, was around $3,000 (2 lakh). The procedure involved reaching the patient's location, connecting them to a qualified doctor through the telemedicine device, conducting prescribed tests, and delivering medicine. In cases of serious patient conditions, the BikeDoc facilitated admission to nearby hospitals based on the doctor's recommendation. In 2020, AA Healthcare was operating two centers and two BikeDocs (ambulances) and collaborated with the state government to establish these unique centers in every primary health care (PHC) facility in Patna (Bihar). They also worked with private hospitals to establish these centers on a franchise basis (refer Exhibit IV). AA Healthcare also established fully functional health centers, which cost approximately $2,800 (approx. 5 lakh) to set up. These centers provided a range of services, including doctor consultations, medicines, and pathological services (refer Exhibit V).

For each service offered through the franchise health center, AA Healthcare earned a service charge2 of $0.28-0.70 (20-50). This was the main source of income for the organization.

The health centers in 7 districts of Bihar and Jharkhand (including franchisees) offer all services and provided consultations and services with deep discounts ranging from 20 to 80%, depending on the nature of the service. For instance, a doctor consultation through AA Healthcare would cost only $1.40 (100), as opposed to the standard consultation fee of $7.0 (500) for the same doctor. The $1.40 consultation fee was shared between the doctor and AA Healthcare in an 80:20 ratio as per the arrangement.

Covid-19 and Scaling of Operations
During the Covid-19 pandemic, the services of BikeDoc, OMED and the online consultation platform offered by AA Healthcare gained significant attention and utilization. These innovative concepts, which were initially introduced in rural areas of Bihar and Jharkhand, received widespread recognition. The BikeDoc facility especially proved to be crucial during the Covid-19 crisis, as it allowed healthcare volunteers to provide essential medical services directly to patients at their doorstep. This included conducting tests, consultations, and offering medicines without the need for patients to visit healthcare facilities. This initiative played a vital role in minimizing the risk of virus transmission and ensuring timely access to healthcare services for those in need. Additionally, the online consultation platforms offered by AA Healthcare, facilitated through AA centers established in remote rural locations like Siwan and Champaran in Bihar, became a popular service during the pandemic. This platform allowed individuals to consult with doctors remotely, eliminating the need for physical visits and reducing the risk of exposure to the virus. The convenience and safety offered by online consultations made it an attractive option for patients seeking healthcare services during these challenging times. Overall, the combination of the BikeDoc facility and the online consultation platform provided a comprehensive and accessible healthcare solution during the Covid-19 pandemic, especially for individuals residing in rural areas with limited access to medical facilities. These services proved to be instrumental in ensuring the continuity of healthcare delivery and addressing the specific challenges posed by the pandemic.

After the outbreak of Covid-19, the number of patients and consultations through AA Healthcare increased significantly, reaching up to 20-30 times higher than before. There were 3-4 enquiries before the pandemic, which increased to more than 50 on an average for a given day during the pandemic. This surge in demand for healthcare services continued even after 2021. According to Ali, "Although there might be some periods of stagnation, the momentum gained during Covid-19 kept the growth of the service consistent."

AA Healthcare also collaborated with various organizations and startups (Vivo Doc, Starx91) that shared a similar goal of improving rural healthcare services in India. These organizations integrated the telemedicine devices with their health centers and utilized them to connect their patients with a team of doctors from reputed hospitals, such as Kurji Holy Family Hospital.3 Hospitals, doctors, and diagnostic centers had to subscribe to the software developed by AA Healthcare for appointment bookings through their device or app. The subscription charges for accessing a customized dashboard used by these healthcare institutions ranged from $14 (1,000) to $140 (10,000) annually. Whenever a patient booked an appointment, whether online or offline, a service charge of $0.70 (50) had to be paid to AA Healthcare. This service charge was already included in the consultation fee, and patients did not have to pay any separate subscription charges to use the app. These partnerships and collaborations allowed AA Healthcare to expand its reach and impact by leveraging existing healthcare infrastructure and connecting patients with a wider network of doctors and diagnostic centers. The subscription model and service charges ensured a sustainable revenue stream for AA Healthcare while providing affordable and accessible healthcare services to patients.

In early 2022, AA Healthcare collaborated with IP Global, a US-based organization, to work in seven districts of Bihar and Jharkhand. IP Global provided funding of $70,000 for telemedicine initiatives. They deployed 500 community health facilitators or health workers who were responsible for visiting households and ensuring decent health and hygiene standards, with a particular focus on women's health. Each health worker had to visit around 10 to 20 houses per day that provided a minimum of 500 consultations per day to AA Healthcare. The collaboration aimed to address various health issues, including menstrual hygiene, anemia, and malnutrition. These health workers were employed and paid by IP Global to carry out their duties effectively.

The vision of AA Healthcare was to improve the health index in the region, particularly in the seven districts of Bhojpur, Nalanda or Bihar Sharif, Patna, Gaya in Bihar, and Hazaribagh, Dhanbad, and Bokaro in Jharkhand (refer Exhibit VI).

To achieve this, AA Healthcare aimed to strengthen its network of health centers and expand its panel of doctors. They also established health centers in each block of the covered districts, offering digital health services, digital enrollment for government funding schemes, and assisting individuals in obtaining an Ayushman Bharat card. AA Healthcare was in the process of installing its telemedicine devices at these centers and appointed pharmacists with drug licenses. However, during the community facilitators' visits, it was observed that 10-20% of the patients required hospitalization or immediate medication, which telemedicine alone could not provide. To address this issue, AA Healthcare impaneled 20 hospitals in the region, allowing for the hospital admission or inpatient care of these patients based on the recommendations of doctors consulted through their telemedicine devices or health centers, with the assistance of community facilitators. The empanelment of hospitals by AA Healthcare provided significant benefits to the hospitals in the region. These hospitals were able to save a substantial amount on marketing expenses as AA Healthcare helped promote their services. AA Healthcare did not receive any monetary advantage from the hospitals as they were already funded by the IP Global agency for which AA Healthcare was working. However, AA Healthcare ensured that patients admitted to the empaneled hospitals through their doctor's recommendation received a minimum discount of 20% on all services (refer Exhibit VII).

Another challenge faced in the region was the lack of health awareness among rural households. Due to limited information, patients often sought treatment from nearby quacks or unqualified individuals, leading to delays in proper medical care. In some cases, patients would only approach hospitals when their health conditions had significantly deteriorated, making it more difficult to treat them effectively. AA Healthcare addressed this challenge by providing primary consultations with qualified doctors (MBBS or above) from all over India through their telemedicine devices. This allowed for proper treatment to begin from the early stages of illness.

Service Delivery Through Drones
The team of Ali and Shazeb Khan was actively involved in the field of Rural Health and Disaster Management. Its innovative concept of delivering healthcare services through drones to disaster-affected rural areas gained recognition at a global event on Disaster Management organized by the United Nations in Bali, Indonesia (refer Exhibit VIII). The concept was among the top 10 entries worldwide and garnered attention and appreciation for its innovative approach. The idea behind using drones for healthcare delivery in disaster-affected areas (especially in Bihar and Jharkhand) originated from the challenge of providing medical assistance in areas with no network connectivity or infrastructure due to disasters like floods or earthquakes. During such situations, access to medical assistance, including online consultations, becomes extremely difficult. To address this challenge, the founders integrated the concept of online consultation systems with drone technology, allowing healthcare services to be delivered within a range of 20 kilometers.

They developed a lightweight device weighing less than 2 kilograms, equipped with a video display, audio capabilities (similar to a walkie-talkie), and non-Internet-based communication. The device, along with essential medical devices such as a blood pressure monitor, temperature monitor, pulse monitor, and a box of medicines, would be transported to the affected area by the medical team operating within a 20-kilometer radius. The patient in the affected area could consult with the medical team using the device and utilize the medical devices and medicines provided. This innovative approach of using drones for healthcare consultations and delivery of medical devices was considered a breakthrough by AA Healthcare. They applied for a patent for this technique as they believed it was a unique method of connecting patients with healthcare providers and had not been reported or used anywhere else in the world. While drones have been used for the delivery of medicines, vaccines, and organs, the concept of consultation through drones was a novel and pioneering idea.

Road Ahead
AA Healthcare had an ambitious plan to establish health centers in every block of the seven districts they operated in. These centers would be equipped with telemedicine devices for remote consultations, pharmacies staffed by qualified pharmacists for dispensing medicines, and pathology collection facilities for diagnostic tests. The goal was to provide comprehensive healthcare services to patients who do not require hospitalization. To understand the healthcare requirements of the region, AA Healthcare planned to compile the prescriptions generated by these health centers. They also aimed to make generic medicines available at the lowest cost to patients, striking a balance between recommending imported or expensive medicines and cost-effective options. This approach involves identifying the branded cheapest medicines available in the Indian market. Ali also aimed to further reduce the cost to approximately $1,500 (1 lakh), making it affordable and accessible to all sections of society, even in the remotest locations. The estimated cost of the services offered by AA Healthcare had increased from $15,000 (10 lakh) to $ 30,000 (20 lakh) due to the rising prices of the resources they were consuming. Amjad Ali mentioned that the revenue for the year 2021-22 was in the range of $70,000 (50 lakh) and projected it to reach $150,000 (approximately 1 cr) for the year 2022-23.

One of the major challenges AA Healthcare faced is the lack of awareness and acceptance of digital health services in rural areas. Limited network coverage and smartphone connectivity hindered the adoption of digital platforms. Additionally, many patients did not possess mobile numbers, which were necessary for creating unique patient IDs. To address this, AA Healthcare modified its user interface, allowing its facilitators to use their mobile numbers as master IDs and generate data on patients. The lack of network connectivity and smartphones did not discourage Ali from pursuing his vision, and he was hopeful that the government recognized and addressed these challenges, especially considering the potential benefits in terms of transparency and healthcare policy design. While the unique patient IDs created by AA Healthcare made medical records accessible globally with proper permission, uneducated patients in rural Bihar and Jharkhand struggled to utilize this system. The AA Healthcare App, a mobile app for free download, was available on various app stores and had already seen over 500 downloads. The app was utilized by healthcare workers associated with AA Healthcare and some of the patients. It offered features comparable to commercial platforms funded by larger companies in the market, such as Practo and Apollo Pharmacy.

The limited awareness of the AA Healthcare App among the general population remains a concern, despite the increased acceptance of digital healthcare services post-Covid. However, there has been a significant increase in the number of cases handled through the AA platform, indicating a growing demand for their services.

Ali acknowledged the major challenges that weighed on his mind. He faced decisions about prioritizing different aspects, such as developing health awareness among the rural population, ensuring the availability of generic medicines at the lowest cost, addressing concerns about data privacy when maintaining digital health records, and overcoming the lack of network coverage in rural areas where not all patients have access to mobile numbers and smartphones. These challenges contributed to the limited awareness and restricted usage of the AA Healthcare App, mainly among healthcare workers rather than the wider population. The question was: Would Ali and team realize the dream of affordable and adequate healthcare facilities and be able to address these challenges effectively?

References

1. Hirschhorn L R, Langlois E V and Bitton A (2015), "Achieving Universal Health Coverage: Technological Innovation, Smart Policies and the Role of Private-Public Partnerships", Globalization and Health, Vol. 11, No. 1, p. 49, doi: 10.1186/s12992-015-0138-2
2. Kasthuri A and Seidman R (2018), "Leveraging Technology to Improve Health Care in Low- and Middle-Income Countries", IEEE Pulse, Vol. 9, No. 6, pp. 13-16, doi: 10.1109/MPUL.2018.2873591
3. Joshi A, Kale S, Chandel S, Pal D K and Likhar N (2019), "Digital Health: A New Paradigm in Public Health Care System in India", Indian Journal of Community Medicine, Vol. 44, No. 3, pp. 207-210, doi: 10.4103/ijcm.IJCM_211_19
4. World Health Organization (2013), Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their Measurement Strategies. Retrieved from https://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf
5. Gupta N and Kathuria V (2018), "Rural Health Care: Current Scenario and Future Outlook", Journal of Family Medicine and Primary Care, Vol. 7, No. 2, pp. 183-187, doi: 10.4103/jfmpc.jfmpc_120_17
6. Pan American Health Organization (2014), "eHealth in the Americas: Advancing Universal Health Coverage with Information and Communication Technologies". Retrieved from https://iris.paho.org/bitstream/handle/10665.2/28484/9789275 118438_eng.pdf
7. World Bank Group (2015), "Health in Rural India: Opportunities, Challenges, and Evidence-Based Interventions". Retrieved from https://openknowledge. worldbank.org/bitstream/handle/10986/22746/985280PUB0978100B097808 21310580.pdf
8. Rojas D, Kumate J and Hernandez M (2017), "Expanding Access to Healthcare Through Telemedicine in Mexico", BMJ Global Health, Vol. 2, No. 3, e000285, doi: 10.1136/bmjgh-2016-000285
9. World Health Organization (2010), "Telemedicine: Opportunities and Developments in Member States". Retrieved from https://apps.who.int/iris/bitstream/handle/10665/44497/9789241564144_eng.pdf