Telemedicine in Action

How do you connect patients in remote areas with qualified doctors? How do you make IT-dependent programs financially sustainable? How high-tech should you go? Such topics were discussed by participants during a telemedicine-focused webinar hosted today by Dr. Shahida Saleem, CEO of [d.o.t.z Technologies]( and [Sehat First](, a chain of for-profit telemedicine franchises near Karachi, Pakistan.

This was the first of a series in CHMI’s virtual dialogues on innovation, a new effort to forge connections between people implementing innovative health programs around the world. The kick-off discussion of the series focused on programs using information technology to extend access to healthcare, of keen interest to many. This discussion was open to people running programs profiled on the Center for Health Market Innovations; future discussions may include a broader set of participants, depending on the topic.

Dr. Saleem started off the conversation by discussing challenges Sehat First (Health First) faces in startup and daily operation. The social enterprise provides basic health care and pharmaceutical services across Pakistan through self-sustainable franchised tele-health centers and many challenges she voiced were familiar to others on the call: The difficulty acquiring appropriate software to meet their needs, maintaining computers in dusty, remote areas with wildly varying voltage inputs, power outages, and the principle challenge of securing adequate revenue flows to sustainably provide high quality health services at low prices.

_**Technology Platform**_

Sehat First’s solutions are highly customized but have the potential to be replicated elsewhere. To get around costly technology platforms, such as those run on high maintenance desktop computers, they designed their own software system that runs on Samsung Star video phones, which can be plugged directly into internet cables and work over very low bandwidth connections. These phones are extremely simple to operate, require almost no maintenance, but still allow for virtual person-to-person connectivity over the small video screen. Prescriptions given by the doctor over video phone can be printed at the clinic and then taken to the pharmacy.

In the Sehat First model, a female health worker takes a patient’s vitals and dispatches these to trained physicians, mostly women who for cultural reasons cannot work outside the house. Sehat First is experimenting with other diagnostic linkages between the point of care at the remote center and the physician, using the [ReMeDi system]( developed in Bangalore.

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_A female health worker taking a baby's vitals, which can then be sent to a qualified physician elsewhere._

“We haven’t had any acceptability challenges on the patient side—doctors, on the other hand were hesitant to use telemedicine, so we work with them to feel comfortable seeing patients this way,” said Dr. Saleem.

_**Financial Model**_

Many questions from the discussion participants—program managers in Bangladesh, Brazil, Ghana, India, and Pakistan—centered around the financial model. Where does the investment come from, and what is the revenue stream?

Dr. Saleem explained that the franchises, run by entrepreneurs who compete for the opportunity to invest 20% of the $10,000 capital required for startup and first-year operating expenses, have multiple revenue streams to secure sustainability. The most important revenue sources are from the general store and pharmacy, not the health services, for which patients pay just 10 rupees (about 10 US cents). A partnership with Unilever Pakistan provides high-demand items like soap and rice, guaranteeing foot traffic and revenue (Sehat First centers get between 300-500 patients per month). They are aiming to reach 30% profitability; currently, 2 centers break even and one makes a profit.

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_A example of a Sehat First general store._

“Our entrepreneurs can come up with innovative marketing schemes to generate revenue,” said Dr. Saleem. “One allows fisherman to take goods to sea for a month and pay shops back when they come back with their catches,” she explained, saying that their flexible model allows for this setup in coastal areas outside Karachi, whereas a wholly different kind of scheme would be setup in other areas like the Punjabi farmland.

Another revenue source is providing data to pharmaceutical companies, which Dr. Saleem explained was highly valuable service; a participant from Brazil agreed and said he had also built a successful model on a data sharing relationship.

_**Challenges to Scaling**_

Participants asked about Sehat First’s expansion plans. One opportunity to scale further, said Dr. Saleem, would be to take over public health clinics currently run by local health ministries, which are currently under-staffed and sometimes sit empty. Yet many local ministers are unfamiliar with for-profit health models and are put unacceptable demands on the business. One Sehat First center was shut down as a consequence.

“The community fought back, saying, we need this service desperately,” said Dr. Saleem. “The local people were using the center, which was along the coastline in a remote fishing community, extremely poor.” Ultimately community’s outcry led to the franchise being reopened.

_**Next Steps**_

“It was great to be able to interact with so many different people from different places in the world,” said Dr. Saleem after the virtual discussion, “I’d love to ask questions to other entrepreneurs now.” If you have more questions for Shahida Saleem, register with CHMI [here](, then click to send a message on the [Sehat First program profile]( (click “Contact this program ” at right).

Please also take our survey about topics for future virtual discussions [here](

_**Use the window below to see Dr. Saleem's presentation and the subsequent discussion in full!**_

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