I’ve met with the company Medtronic a couple times now, both in Bangalore and in Mumbai. Medtronic is a huge, global medical technology development company based in Ireland, though they’ve been in India for nearly 40 years now. In Mumbai, I met with a man named Rajesh, who was the first person in India to tell me about the big As that are crucial deciding factors for the acceptance of medical devices here: affordability; awareness; and access.
Affordability is the key thing, of course: in all my interviews in India, cost comes up as the main barrier for acceptance of medical technology. Second is awareness. Both patients and doctors need to be aware, not only of what technology is out there and how it works, but also of medical issues. For example, there might be patients that are unaware that a symptom they have is the indicator for a more serious condition, so they ignore it until it is much worse. In terms of care-giving, there might be medical staff in some of the more remote areas that is not well-trained enough to recognize certain symptoms. Also, if people are unfamiliar with medical technology and its potential benefits, of course they will be less inclined to use it. This leads to the third point, access. Physical distance from healthcare and advanced medical technology – a common experience in rural areas – means that patients cannot get care in time for more acute conditions, and they have no opportunity to build up awareness.
Rajesh told me that when it comes to introducing a new technology, it’s “very important to get the doctors to become advocates.” It’s good when a patient or end user is excited about new technology, but it’s ineffective if the doctor is not excited as well. Patients might initiate a discussion with their doctor about a new technology, but if the doctor doesn’t know about it or believe that it works, they won’t advocate the technology and might steer their patients away. This made me realize that, as in Qatar, patients here generally put a lot of stock in their doctors’ opinions (whereas in Sweden, doctors and patients were more inclined to have back-and-forth discussions about various options).
I’m always interested in what influences someone to have a more positive or negative reaction to medical technology. Most people in India say the most important factor is cost, so I asked one person at Medtronic what the second most important factor would be, specifically in terms of getting doctors to use new medical technologies. She replied that the second most important factor is justifiable return on an investment – that is, to make sure that the value of the purchased device is worth its cost, and that the cost fits in one’s budget. Since this sounded like another way of saying “cost” again, I asked what the third most important factor might be. She replied that the doctor would have to have a passion for research and solving problems. She also said that leverage and clout is important. The doctor’s leverage and clout is important as well – while most doctors would be quite receptive to technology, she said, a group of doctors is more likely to get on board with a certain technology if they are encouraged by a particularly influential doctor. Like Rajesh said, doctors play a big role in the acceptance of technology.
One challenge of being an international company coming into a “cost-sensitive market,” as these big corporations often refer to India, is actually making the right product. One of Medtronic’s employees in Bangalore told me that a crucial factor for success is understanding your target user group. Making the right device is not just about reducing the cost of the products you already have by removing features; one needs to think about what will really be effective and well-designed for different rural areas. He also pointed out that you cannot simply think of “urban India” vs. “rural India,” as I’ve now seen. The cities vary widely from each other, and there are different types of rural. As I’ve mentioned, there are also different cultures and languages throughout the country’s 29 states.
I wanted to visit Medtronic in Bangalore because their Research and Development center is based there, as well as the team working on the Shruti program. Shruti is a Medtronic project to improve ear health in rural areas by equipping local health workers with medical technology to perform ear screenings. The idea is to help the 60 million people in India who are hearing-disabled, many of them due to preventable causes (http://www.medtronic.com/in-en/about-3/shruti.html).
The Shruti project centers around a device called the ENTraview developed by Medtronic and a company called IcarusNova. The ENTraview (for ear, nose, and throat viewing) is a telemedicine-enhanced otoscope allowing any clinician to screen a patient’s ears for preventable ear problems. When pointed inside the patient’s ear, the attached smartphone takes and saves a photo, which can be viewed by anyone or sent to a more knowledgeable doctor once the phone has an internet connection. This way, even community health workers (CHWs) with the most basic training and with little knowledge of ear problems can screen villagers.
The scope is connected to a de-featured Android phone with a camera and a SIM card; Medtronic saved money with the device by adjusting a pre-made phone rather than building one from scratch. The resulting ear images clearly show whether or not the ear is healthy, but the CHWs – who are trained for four weeks by the Shruti program – cannot legally diagnose an issue based on this screening; patients must follow-up with an ear doctor if something is wrong.
The Shruti team at Medtronic told me about various villagers’ responses to the ear screening. They said that with this sort of project, especially because it was offered to the villagers for free, there was very little resistance – people were happy to try something for free for the novelty factor. Also, since it’s offered throughout the village, people have a “why not?” attitude once they hear that people they know are doing it. The Shruti team told me that word travels fast in the villages, and people are always influenced by each other – so once a few people have gotten the screening, everyone else wants to do it. They also mentioned that there is no stigma associated with a simple ear screening (as opposed to a treatment, for example, or a screening for something more serious such as cancer).
Another reason the project works is because the CHWs and patients can view the saved photo of the ear. The Shruti team told me they’ve observed that the villagers like validation and evidence; the patients trust the result of the screening more if they can see it for themselves. Medtronic also attempted a needs-driven approach with the ENTraview, designing the device to be rugged, picture-based, and compatible with the local languages. It also needed to be suitable for screening a range of ear issues from wax buildup to a perforated ear drum.
In terms of who actually follows up with a doctor when something is wrong, the Shruti team told me that this “conversion rate” is about 30-50%; not great, but better than the 0% it would be otherwise. It seems that the only way to improve this conversion rate is by addressing those As again: improving access (to nearby doctors and hospitals) and awareness (the dangers of not following up with an issue). Finally, I asked the Shruti team what factors they would say contribute to a successful device. They replied that it is not only about the best technology, but also about the clinical relevance of the device, its ease of use, and (what else?) its affordability.