ASIAN CASE RESEARCH JOURNAL, VOL.
22, ISSUE 2, 385–411 (2018)
ACRJ
This case was prepared by
Associate Professor Atanu
Chaudhuri of Aalborg Uni­
versity, Denmark, Associate
Professor Venkatramanaiah
Saddikutti of Indian Institute
of Management, Lucknow,
India and Associate Professor
Thim Prætorius of Aalborg
University, Denmark, as a
basis for classroom discus­
sion rather than to illus­trate
either effective or ineffective
handling of an administrative
or business situation.
Please send all correspon­
dence to Associate Professor
Atanu Chaudhuri, Depart­
ment of Materials & Prod­
uc­
tion, Aalborg University,
Copen­hagen Campus, A. C.
Meyers Vænge 15, 2450
København SV, Denmark.
E-mail: atanu@business.aau.dk;
atanu@mp.aau.dk
© 2018 by World Scientific Publishing Co. DOI: 10.1142/S0218927518500165
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iKure Techsoft: Providing
Technology Enabled Affordable
Health Care in Rural India
An economically developed India by 2020 should be a nation
where the best of health care is available to all.
— Dr. A. P. J. Abdul Kalam, former President of India
Sujay Santra, Founder and CEO, iKure Techsoft Pvt. Ltd (see
Exhibit 1 for a brief profile), received a call on November
2014 evening from Sreyashi Dey, VP Marketing and Research
at iKure. Sreyashi was excited to anounce that the Kolkata
based company had just won the Global Health Supply
Chain Summit Prize’ in Copenhagen, Denmark for supply
chain excellence in global health in low and middle-income
countries.
Such accolades had poured on iKure over the last
3 years because their unique technology based hub-and-
spoke health care delivery model allowed them to provide
health care services in rural India at an affordable cost.
iKure charged only INR 90 (~USD 1.5) for a basic consulta-
tion, diagnostic tests and medication. It was only natural that
iKure had caught the attention of investors, funding agencies
and low-income countries. But, Sujay and his team, which
kept growing to meet demand, remained humble as they
had just started in 2010 and there was still a long way to go
before iKure could take its services to the rural hinterlands in
India and beyond.
Now, it was May 7, 2015 and while Sujay and his
team was finalizing meetings with companies in India who
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 386  ACRJ

wanted to spend their Corporate Social Responsibility (CSR)

funds to collaborate with iKure, an email from Mexico caught
his attention. After reading a World Bank blog on iKure, a
Mexican state was interested in funding iKure to provide
their services in Mexico. Sujay knew the world was taking
notice and he was already impressed with their achievements.
However, he also knew that iKure was not yet ready to take
the global plunge. In fact, iKure had already turned down
offers from the Indian state of Rajasthan as their knowledge
and ground support in that region were limited. Until now
iKure had provided its health services only in a few districts
in the state of West Bengal in India and in a few CSR projects
in the neighbouring states of Orissa and Jharkhand (Exhibit 2
shows the regions presently covered by iKure).
Sujay knew that the next couple of years were crucial
for the growth of iKure. It needed to build critical mass and
volumes to fulfil its mission of providing affordable and
high quality care to the rural population while still building
a sustainable for-profit business model. iKure operated as a
for-profit social enterprise because Sujay wanted to create a
sustainable model with built-in revenue streams so that iKure
services did not depend on grants, CSR funds and philan-
thropic support to continue. Sujay stressed from the onset:
“I firmly believe that the accountability brought about by an
organizational structure that is investor-funded and working
in alignment with market forces is effective. Thus, I see no
conflict between iKure’s social objectives in terms of the need
to make a lasting impact in improving health care of commu-
nities that have no access to it and its financial stability.”
Given that up to 800 million Indians lived in rural
areas with no or only little access to decent health care ser-
vices care demand was huge, and hence market, for iKure’s
services (Exhibit 3 introduces India’s demography, economy
and health status). However, expansion was not easy and was
fraught with challenges as providing health care required a
deep understanding of the local population and their willing-
ness to pay for health care services. Recruiting doctors and
health care workers interested in working in rural areas were
also challenging. Such considerations kept Sujay busy.

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 IKURE TECHSOFT: PROVIDING TECHNOLOGY ENABLED AFFORDABLE HEALTH CARE IN RURAL INDIA  387

Sujay and two key members of his technical team, both

sharing his passion about improving the lives of those living
in rural India through innovative, effective and low-cost tech-
nology solutions, finished work late on May 7, 2015. Both
these Master of Computer Applications graduates could get
lucrative jobs in India’s booming IT industry, but they con-
tinued with iKure where they had been key members from
the very beginning. Sujay had always focused on recruiting
talent who shared his passion because he considered the team
to be the biggest company asset.
The next May morning Sujay and a colleague headed
to Bhawanipur village in the Paschim Medinipur district
located about 60 km from Kolkata in east India where iKure
ran a mother and childcare camp. Now they were consid-
ering setting up their next Rural Health Care Clinic (RHC) in
Bhawanipur village. On their way, they crossed a tiny stream
knowing very well that come June, the stream would swell
into a gushing river making it impossible to cross. Sadly,
even in 2015 there was no bridge so villagers had to make
long detours during the rainy season. Situations were par-
ticularly difficult for pregnant women who had either to use
boats or take a long journey to the nearest hospital.
The rural health care delivery system in the Paschim
Medinipur district where Bhawanipur village was located was
inadequate and even for chronic and severe diseases villagers
relied on local quacks or untrained midwives (Exhibit 4 elab-
orates on the organisation of the health care system in rural
India). Most of the rural population (5,190,771 people) in the
Paschim Medinipur district lacked knowledge, information
and orientation as regards health and hygiene, child immuni-
zation, techniques of low cost food preparation, family plan-
ning and birth control, maintenance of personal hygiene and
good health practices. Therefore morbidity, child mortality,
dehydration, and malnutrition rates were very high.
Thus, Bhawanipur village and other rural villages in
Paschim Medinipur desperately needed health care services:
unfortunately, many other rural areas in India faced similar
situations. The local government operated primary health
care centres (PHCs) and were doing a commendable job in

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providing basic health care services. However, during Sujay's

visit to Bhawanipur village he talked to health workers and
patients and learned that PHCs offerings were not enough
because, for example, women often suffered from chronic
anaemia and malnutrition.
As Sujay headed back to iKure’s corporate office in
Kolkata he knew he wanted to establish a fully functional
RHC in Bhawanipur village within the next few months.
However, resource constraints and the need for NGO support
meant that iKure could not just scale up their business and
health care delivery model overnight.

IKURE’S BUSINESS AROUND HEALTHCARE

DELIVERY SERVICES

Establishment of iKure

Given the state of Indian rural health care (e.g., +450 million
rural residents without access to quality health care and 31%
travelling +30 km to get the needed care), there was a huge
current and future market for delivering low-cost and quality
health care in rural India. In particular, bringing health care
delivery closer to the rural population was needed. Sunjay
recalled: “Though there were 909 PHCs in West Bengal, they
were not adequately addressing the health care needs of rural
patients.” Among the 29 states of India, West Bengal, where
iKure started up their operations, ranked among the lowest
in terms of health and access to safe drinking water, hygienic
living, sanitation and a nutritious diet (Exhibit 5 provides an
overview of the education and economic background of the
population in the iKure covered regions).
iKure entered this rural health care market in 2010 as
a for-profit social enterprise with incubation support from the
Indian Institute of Technology (IIT) Kharagpur and the Webel
Venture Fund, an early-stage incubator established by the
Government of West Bengal (see Exhibits 6 and 7 about how
iKure have evolved). The first RHC opened in November
2012 after running 20 pilots over two and a half years. Since

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 IKURE TECHSOFT: PROVIDING TECHNOLOGY ENABLED AFFORDABLE HEALTH CARE IN RURAL INDIA  389

inception, iKure had started 28 RHCs in two West Bengal

districts.
iKure’s ground observations showed that rural house-
holds predominantly depended on local neighbourhood
clinics (quacks) for health care services. The average cost of
treatment at these clinics ranged between INR 15 (USD 0.23)
to INR 100 (USD 1.5). The practitioners running these rural
clinics did not possess professional qualification and many
did not practice allopathy. For consultation with a qualified
primary doctor and basic diagnostic facilities rural patients
usually had to commute 7– 40 km but such effort did not
always guarantee doctor availability. In fact, in PHCs govern-
ment doctors offered only general consultation and prescribed
medicines, but often lacked medicines and the facilities to
perform many of the needed tests. This was one reason why
iKure decided to provide not only doctor consultation, but
also medicines and essential clinical and diagnostic tests.

Central Features of iKure’s Health Care Delivery Services

Four factors were essential to iKure’s business around health-

care delivery. First, a hub-and-spoke health care delivery
model connected a number of RHCs with an advanced hub
clinic (see Exhibit 8). RHC locations were selected based on
population density, the presence of existing facilities and
family income above INR 150 (USD 2.25) per day. The pres-
ence of local NGOs to provide ground support was often the
deciding factor when establishing a RHC in a new location.
iKure managed the hub clinics in district towns, while the
rural clinics were developed and managed with the support
from local NGOs. Second, a self-developed cloud based tech-
nology (called Wireless Health Incident Monitoring Service,
WHIMS) was central as it integrated service offerings in the
hub-and-spoke model and beyond. Third, collaboration with
NGOs based in the rural areas and finally corporate organi-
zations interested in investing their CSR funds in iKure and
their activities had been necessary for growing the business.

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Service Offerings and Advantages Provided by iKure’s

Healthcare Delivery Services

iKure’s setup made it possible to provide service offerings

and advantages (see Exhibit 9), which spanned general con-
sultation, medicines, and diagnostic tests. iKure also provided
regular monitoring and screening of diseases for pregnant
women, mothers and children, which facilitated early detec-
tion of diseases which saved on treatment costs. iKure’s set-up
meant they delivered good quality, doctor consultation ser-
vices for INR 90 (USD 1.5), including medicines amounting to
approx. INR 35 (USD 0.58). Other service charges ranged from
INR l00 (USD 1.6) for dressing of serious wounds, INR 60
(USD 1) for an electrocardiogram to INR 10 (USD 0.15) for
blood pressure measurement or providing an injection.
iKure services had by now benefited more than 110 vil-
lages and served over 80,000 patients. The setup also limited
travel distances to 3–4 km in the covered areas. A survey of
308 patients conducted by iKure showed that a typical male
and female patient was between 25–60 years. Four percent of
iKure patients reported gastrointestinal disorders, nine percent
reported hypertension, 16 percent joint pain, 31 percent weak-
ness and 40 percent cough and cold. Moreover, iKure had
helped to profile 58 diseases and screen 1,350,000 people.
The patient survey also showed that average cost
savings for iKure patients were INR 120–480 (USD 2–8) when
compared to similar services elsewhere. For rural villagers,
RHC hence represented an affordable and accessible option
that ensures they do not lose a day’s wages (about 59% of the
population iKure served was daily wage earners who suffered
direct wage loss when sick) plus the travel costs of accompa-
nying family members (Exhibit 10 shows the cost savings of
iKure patients).

Financial Performance of iKure

In fiscal year 2013–2014, iKure registered total revenues of

USD 49,474 (INR 2.97 million) and total operating costs of

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 IKURE TECHSOFT: PROVIDING TECHNOLOGY ENABLED AFFORDABLE HEALTH CARE IN RURAL INDIA  391

USD 35,692 (INR 2.14 million). EBITDA was USD 13,782

(INR 0.83 million) and a net income of USD 3,802 (INR 0.23
million). Revenues from iKure’s business were estimated at
USD 204,979 (INR 12.29 million) for FY 2014–2015 and pro-
jected to increase to USD 1.47 million (INR 88.49 million) in
FY 2017 (see Exhibit 11).

MANAGING IKURE OPERATIONS USING A

HUB-AND-SPOKE MODEL

iKure’s corporate headquarters was based in Kolkata while

the health care operations was organized using a hub-and-
spoke model (see Exhibits 8 and 12). The hub and spoke
model enabled iKure to meet the demand for quality health
care (like general consultation, medicines, and diagnostic
tests) in the catchment area and cover patients from a larger
geographical area.

The Hub-and-Spoke Health Care Delivery Model

iKure operated three hub clinics and 28 RHCs. Each hub

clinic employed between one and up to six medical teams,
each consisting of nine people. Of these nine people one
group worked at the hub clinic  (a doctor, an nurse, a para-
medic and two health workers) and another group traveled
to the RHCs (a doctor, a paramedic and two health workers).
The two groups rotated meaning that each group visited
RHCs on alternate days and worked from the hub clinic
on other days. Each medical team of nine people attached
to a hub clinic managed six RHCs and thus in full capacity
one hub clinic managed up to 36 RHCs. RHCs were located
within a radius of 20 km from the hub clinic which ensured
same day travel by the medical team.
Hub clinics were physical clinics (approx. 250 sq. ft.)
with clean and hygienic environment and with separate
doctors’ chamber. Moreover, they were located near a railway
station to improve access and reach. Hub clinics offered

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 392  ACRJ

different care services, including diagnostic tests, discounted

pathological tests, generic and branded medicine and more
seamless hospital escalations. Each hub clinic also tied up
with a centralised Pathology and Radiology laboratory,
thereby making it possible for patients to get services at a dis-
count and allowing iKure to centralise data management for
pathological tests for all patients attached to the hub clinic.
Besides the hub- and rural health care clinics, iKure
operated a van named a mobile medical unit (MMU), which
distributed and provided the necessary medicines and essen-
tial clinical/diagnostic services to the RHCs. The Wadhwani
foundation supported the MMU van through their CSR funds.
iKure with the help of partners like NGOs provisioned medi-
cines and other resources.

Health Care Staff and Operating the Hub and Rural Health
Care Clinics

iKure staff included doctors (Bachelor of Medicine and Bach-

elor of Surgery, MBBS), nurses, pharmacist and trained health
care workers. To ensure availability of doctors, iKure offered
MBBS graduates the opportunity to practice as doctors because
they often faced difficulties in setting up their own rural clinics
and having to compete with quacks. Moreover, iKure offered
competitive salary and provided learning opportunities; for
example, through working on collaborative research projects
with leading universities in USA (see Exhibits 11 and 12).
iKure also provided doctors with food and accommodation
and logistical support to visit their homes on a weekly basis.
The close collaboration with Narayana Health also provided
an opportunity for doctors to get continuing professional edu-
cation. The trained health workers in the RHCs came from the
local areas to ensure a sense of belonging. The health workers
helped build relationships and overcome resistance among
villagers who often mistrusted private organizations. The
health workers received basic medical training by iKure,
but basic education and prior related experience were also
expected. A health worker earned INR 4000 (USD 60) per

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 IKURE TECHSOFT: PROVIDING TECHNOLOGY ENABLED AFFORDABLE HEALTH CARE IN RURAL INDIA  393

month, which also allowed them to provide some financial

support to their family.
The work in the hub and rural health care clinics relied
on guidelines, which determined the interaction between
the medical team and patients such as history taking, noting
of basic signs, blood pressure check. Guidelines also guided
how the trained rural health workers should identify patients’
ailments. In carrying out their work, rural health workers
used tablets to capture health data, upload and store it using
WHIMS, which synchronized when internet access was avail-
able. In return, corporate office staff based in Kolkata mainly
interacted with patients to get feedback and address griev-
ances, if any.
Usually, two types of communication connected a hub
clinic and attached RHCs: (1) guidelines determined the inter-
action between the medical team and patients such as history
taking, noting of basic signs, blood pressure check; and (2)
guidelines guided how the trained health care workers should
identify patients’ ailments. In their work, health workers
used tablets to capture health data, upload and store it using
WHIMS, which synchronized when internet access was avail-
able. Relatedly, corporate office staff based in Kolkata mainly
interacted with patients to obtain patient feedback and address
grievances, if any.

Optimal Resource Utilization

iKure’s aim was to keep costs low so that health care was
affordable. For example, iKure had initially planned to build
hub clinics with glass doors and other amenities, but because
such facilities would only add costs, which had to be passed
on to patients or absorbed by iKure, they rejected this option.
Each medical team was also supposed to spend an entire
working day in one RHC, but ensuring optimum utilization
of resources required bringing down the breakeven volume.
By making each medical team visit (a) multiple RHSs on the
same day and (b) each RHS on alternate days the breakeven
number decreased from 67 to 33 patients per medical team

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 394  ACRJ

per day; i.e., roughly 10 patients per day per clinic in each
hub-and-spoke set-up. Similarly, iKure realized it needed to
provide additional health care services like pathology and eye
care as patients needed these, and it provided higher earning
margins. Currently, diagnostic services for the hub were out-
sourced, but iKure were planning to acquire in-house diag-
nostic facilities.

THE COLLABORATIVE MODEL OF IKURE

iKure operated by partnering with NGOs as well as corporate

organizations (see Exhibits 13 and 14). These trained health
care workers’ with clinical skills while iKure trained the tech-
nical side, for example, how to use WHIMS and the tablets in
practice. iKure also partnered with NGOs possessing knowl-
edge and access to the local areas as that knowledge helped
to assess service demand and whether consumers would pay
for iKure services. Collaboration with local NGOs also helped
to build trust with the rural villagers. Finally, NGOs often
had existing facilities that could be utilised to help deliver
quality, efficient health care. NGOs in turn found iKure inter-
esting because the technology enabled health care delivery
model provided better health care services and allowed
NGOs to get better access to the rural population.
iKure’s technology had also caught the attention of
pharmaceutical companies as WHIMs allowed monitoring of
actual drug usage, thereby making it possible to plan inven-
tory better. iKure’s rural reach had also encouraged medical
device companies to supply health care products free of cost
in rural areas as part of their CSR activities. One medical
device manufacturing company had developed low cost
blood pressure measuring instrument using mobile phones,
and for whom iKure tested the product and provided cus-
tomer feedback in return for a nominal service fee.
A leading global medical equipment manufacturer pro-
vided soft skills training and trained ECG technicians. This
collaboration benefitted the medical equipment manufac-
turer because trained technicians became available to operate

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 IKURE TECHSOFT: PROVIDING TECHNOLOGY ENABLED AFFORDABLE HEALTH CARE IN RURAL INDIA  395

the equipment in rural areas. iKure in turn received access

to trained labour for the diagnostic services they intended
to provide in future. iKure also collaborated with an Indian
cement company about their CSR project in Salboni in the
district of Paschim Medinipur, West Bengal, which ensured
that +6,000 people got health screening through iKure’s
regular health camps.
Finally, iKure collaborated with a leading private hos-
pital chain (Narayana Health) that allowed iKure patients
to get discounts during hospital visit. This collaboration
also improved patient’s image of iKure and represented an
opportunity for iKure doctors to get continuing professional
education.

THE TECHNOLOGY SOLUTION: WIRELESS HEALTH

INCIDENT MONITORING SERVICE (WHIMS)

As setting up health centres was not enough for efficient

operation, iKure developed the patent pending software
called Wireless Health Incident Monitoring System (WHIMS).
WHIMS was a cloud-based, award-winning application
running on low internet bandwidths using mobile network.
The Software-as-a-Service (SaaS) had defined flows and pro-
cesses with multilevel secured credentials and highest level of
data encryption.
WHIMS worked on tablets and smart phones built on
android platform. WHIMS used the Elastic Compute Cloud
(EC2) by Amazon Web Services, a world leading cloud ser-
vices provider, which enabled scalable, failure resilient enter-
prise class applications. Amazon’s EC2 service level agreement
provided assurance of 99.95% availability of its instances and
its auto-scaling and elastic load balancing features powered
iKure’s high performance under varied load scenarios.
WHIMS acted as a virtual doctor to the rural patients
as it served as the human interface between the software
and patients, which made it possible for patients to be in
touch with health experts around the clock, thereby bringing
emotional security and support. WHIMS supported basic

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medical equipment like electrocardiogram (ECG), glucom-

eter and phonocardiogram. Data transfer was seamless as
WHIMS had plug and play capabilities to work alongside any
existing Health care Management Information System (HMIS).
WHIMS also stored reports of image-based data (scopic pro-
cedures and radiology) and made them available online at the
point of care.
The rural health workers using WHIMS took readings
for blood pressure, blood sugar, body temperature, electro-
cardiogram (ECG), pulse, etc. These readings wirelessly trans-
ferred into the system to help doctors remotely monitor the
patients. Based on the patient’s test results, health workers
prescribed medicines as and when required. In case of com-
plicated patients, they were referred to special medical advice.
RHCs equipped with WHIMS allowed for central-
ized monitoring of key metrics such as doctor’s attendance,
treatment prescribed, footfall, pharmacy stock management.
Besides connecting hub clinics and RHCs, WHIMS also sup-
ported effective communication, integration and contact
between a RHC and those city-based multi-specialty hospitals
and private doctors iKure tied up with. For users of WHIMS
the application offered the following list of features important
to meet rural health care needs:

• User friendly and highly customized services.

• Patient Management: WHIMS captured patients’ demo-
graphic data during registration and created unique ID
numbers, stored centralized and local appointments and
enabled data entry at later stage from centralized places to
keep clinic operations unhindered.
• Billing Rules Engine: This offered end-to-end solution for
the billing system required at RHCs. WHIMS maintained
consultation, treatment tariffs, and gave comprehensive
reports on payment collection, dues and allied services
amounts. This financial data was available in real time.
• Medical Information: WHIMS provided complete patient
health profile and treatment-related information created
over multiple patient visits. This module managed diag-
nosis, treatment plan, prescriptions and diagnostic reports.

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 IKURE TECHSOFT: PROVIDING TECHNOLOGY ENABLED AFFORDABLE HEALTH CARE IN RURAL INDIA  397

Various types of health survey forms were also incorpo-

rated and digitalized using the android platform.
• Patient Escalation: WHIMS made it possible to upload
patient reports and provide diet plans to patients escalated
to urban hospitals.
• Materials & Inventory Management: This feature encom-
passed purchase and store functions, which enabled
defining master data, transactions, transfers, reconciliation,
returns and expiry and all types of stocks such as Medi-
cines & Inventory. A recently added feature made it pos-
sible to track the location of iKure’s trained health staff.
This meant that if patients made an emergency call, then,
based on the location of the health staff they could quickly
dispatched.
• Data analytics: WHIMS had the potential to gain insight
from clinical and other data repositories to support care
decisions. Potential benefits included detecting diseases at
earlier stages when they can be treated more easily and
effectively, managing specific individual and population
health and detecting health care fraud more quickly and
efficiently.

FUTURE CHALLENGES: SCALING UP

Health care needs varied from state to state in India. For

example, Ayurveda medicine was popular only in Southern
states. Keeping the medical teams motivated and com-
mitted to deliver high-quality services was also not always
easy. Challenges also included adapting to the needs of the
rural community and establishing a community engagement
model. The areas where iKure operated were also remote and
harsh.
For scaling-up, iKure furthermore needed knowledge
of the health profile of the local people and language and
logistics support. Thus, to make iKure’s current health care
delivery model work, a good local NGO partner was essential
for mobilizing resources in every rural area because NGOs
had knowledge of the local population, livelihood of the area,

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 398  ACRJ

was able to talk to the local village headman and in obtaining

rental space for running a RHC.
Managing resources in multiple locations and planning
for infrastructure while keeping prices affordable were other
scale-up related challenges. Sujay did not consider franchising
a viable solution before perfecting the existing business and
health care delivery model. CSR activities, on the other hand,
represented a potential way forward as organizations in India
in the future also have to spend two per cent of their three-
year average annual net profit on CSR activities in each finan-
cial year. The relevant companies included those with at least
INR 50 million (USD 0.75 million) net profit, INR 10 billion
(USD 150 million) turnover or INR 5 billion (USD 75 million)
net worth. However, companies could only fund NGOs so
iKure contemplated establishing its own NGO subsidiary.
Despite having developed a technology enabled health
care delivery model and providing much needed health care
services to some parts of rural West Bengal in India, Sujay
needed to figure out how to provide more health care ser-
vices to meet patient needs and to take iKure’s services to
other parts of rural India. iKure also needed to be financially
stable without losing focus on the quality of the healthcare
services provided. Thus, key decisions which iKure needed
to take were deciding on the portfolio of services to offer,
in which locations to expand and which other revenue gen-
erating opportunities to pursue. Specifically, should iKure
add additional services in its existing RHCs and hub clinics
or also start expanding in West Bengal and other states at
the same time? Should iKure focus on health care delivery or
actively try to identify other revenue generating opportunities
using the WHIMS platform? Would focusing on additional
revenue generating opportunities remove focus from health
care delivery, or could both be pursued successfully? Sujay
did not have the answers yet but he wanted to act fast.

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 IKURE TECHSOFT: PROVIDING TECHNOLOGY ENABLED AFFORDABLE HEALTH CARE IN RURAL INDIA  399

Exhibit 1

Brief Profile about Mr. Sujay

Sujay started his career as a Software Development professional in 1999. With an MCA
degree from IETE, Hyderabad and strong technical knowledge in Siebel CRM, Analytic,
Business Intelligence and R&D, he worked for more than 12 years in IT firms like
IBM and Oracle. In 2010, Sujay formulated his social entrepreneurial venture named
iKure. With the vision to improve the quality of health in rural India, the company
has established a network of Rural Health Centres to provide affordable and accessible
primary care up to the last mile using technology. Sujay conceptualised a low-cost
WHIMS application to connect the rural patients with urban doctors. As iKure strived
to create a sustainable health care model using technology innovation, skills training and
capacity building, the innovative health care model has been extensively covered across
major publications like The Economic Times, The Times of India, Outlook Business, Money
Today, Entrepreneur, etc. His inventive software built-up has won him several awards and
accolades like the Ashoka Fellowship (2016), ISBA Jury Award (2013), Frost & Sullivan
Award, Tech4Impact Accelerator (2013) powered by CIIE and village capital, IIM
Ahmedabad, and Action for India, to name a very few.

08_S0218927518500165.indd 399 16-01-19 3:51:24 PM

 400 ACRJ

Exhibit 2

Map Showing Locations Where iKure Is Operating

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L.XUH¶V &65
DFWLYLWLHV

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VHUYLFHV

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08_S0218927518500165.indd 400 16-01-19 3:51:25 PM

 IKURE TECHSOFT: PROVIDING TECHNOLOGY ENABLED AFFORDABLE HEALTH CARE IN RURAL INDIA 401

Exhibit 3

Country Background and Demographics of India

India is a diverse country in terms of social, educational, health and economical

status and culture. According to the United Nations, the population of India
is 1.32 billion with birth and death rate of 19.3 and 7.3 per 1000 population
respectively. India has 29 states and seven union territories with Uttar Pradesh
the most populated state with 16.5% of the total population. West Bengal,
where this case is set, stands at fourth position (7.5%). According to Economic
Survey 2015–16, the per capita income of India was INR 93,231 (USD 1550) in
2015–16 against INR 71,050 in 2012–13 (USD 1180). World Bank estimates 75.6%
of India’s population live below USD 2 per day and 41.6% lives below USD 1.25
per day1. India currently has the largest illiterate population in the world: in
2011 male and female literacy rates were 82.1% and 65.5%. Relatedly, a large
part of the population has no or limited access to essential goods and services
including health care. There is a huge gap in demand and supply for health care
services in India.

08_S0218927518500165.indd 401 16-01-19 3:51:25 PM

 402 ACRJ

Exhibit 4

Organisation of the Health Care System in Rural India

Public health care spending in India is low and accounts for 1.04 percent of GDP1. Out-
of-pocket payments are high (71 percent)2 and 78 percent of outpatients and 60 percent of
in-patients rely on private providers which results in high out-of-pocket expenditure that
seriously strain rural household economy as the average monthly medical expenditure cor-
responds to five to ten percent of household income3. Among the 29 states of India, West
Bengal, where iKure was operating, ranks among the lowest in terms of health and access
to safe drinking water, hygienic living, sanitation and a nutritious diet.
Hospitals, Primary Health Centres (PHCs) and sub-centres along with private
doctor clinics are the central actors in the Indian health care system. Primary care, in prin-
ciple the first point of consultation, covers things such as check-ups, preventative care and
the treatment of common ailments4. A PHC refers to a care unit with 4–6 indoor/observa-
tion beds covering a population of 20–30,000 and in which medical officers, pharmacists,
laboratory technicians, female health supervisor, female health worker and multipurpose
health worker along with support staff such as clerk, driver and sweeper work. A PHC
acts as a referral unit for six sub-centres and when needed refers patients to Community
Health Centres (CHC) and public hospitals located at sub-district and district level. The
health infrastructure is typically underdeveloped in poorer states like West Bengal, some-
thing particularly troublesome for the rural and urban poor as it limits access to public
health services. For example, primary health centres (PHCs) and sub-centres lack qualified
doctors, paramedical staff and other clinical services.
The tertiary care level represents the most advanced form of health care delivery
and to which five public hospitals types belongs (listed from primary to specialized care):
Community Health Centres (CHC), Rural Hospitals, Government District Hospitals, Spe-
cialist Hospitals and Teaching hospitals. A CHC is a 30-bed hospital covering a popula-
tion of 80–120,000. A CHC delivers more specialized in-patient and outpatient care as they
cover specialist areas like medicine, surgery, obstetrics, gynaecology and paediatrics. Pub-
licly run specialty and teaching hospitals serving large volumes of patients and increasing
patient demand constitute the highest level of care delivery. Government hospitals are
also often overcrowded and frequently lack internal infrastructure and service amenities
to meet care needs because, among other things, beds, specialists and medical services are
scarce resources5.

1
 S. Bagcchi, Indian government proposes quadrupling healthcare spending to 2.5% of GDP in five years. Br. Med. J.
2015;(350):556.
2
 S. M. Batliboi and S. Tambe, Conceptualizing a model for improving access to medicines in rural India. J. Health
Manag. 2014;16(4):547–561.
3
 R. Meher and R. P. Patro, Interstate level comparison of people’s health status and the state of public health care ser-
vices in India. J. Health Manag. 2014;16(4):489–507.
4
 B. Purohit, D. Patel and S. Purohit, A study of organizational values in government run primary health centres in
India. J. Health Manag. 2014;16(2):303–313.
5
 R. Meher and R. P. Patro, Interstate level comparison of people’s health status and the state of public health care ser-
vices in India. J. Health Manag. 2014;16(4):489–507.

08_S0218927518500165.indd 402 16-01-19 3:51:25 PM

 IKURE TECHSOFT: PROVIDING TECHNOLOGY ENABLED AFFORDABLE HEALTH CARE IN RURAL INDIA 403

Exhibit 4 (Continued)
Parallel to the public hospital sector, a large private hospital sector exists in India,
as nearly 70 percent of all hospitals and 40 percent of all hospital beds are private. The
private sector, however, primarily cater to middle-class Indians and medical tourists. This
in turn means that a great number of Indian residents, particularly living in rural areas,
have limited access to care because of high out-of-pocket payments and because private
hospitals are located in urban areas.
Considering the status of India’s public health system, health care is high on the
political agenda of national and state governments. For example, the National Rural Health
Mission (NRHM) is one such scheme launched at national level in 2005: over 157,000 per-
sonnel have been employed and more than 130 million women have been helped in gov-
ernment facilities. States like Tamil Nadu, Kerala, Karnataka and Andhra Pradesh have
also implemented schemes to improve the health of people belonging to low income
group. In spite of these health care improvements, India still needs to develop six areas of
the health care system further6: Service delivery; Health workforce; Information; Medical
products and technologies; Financing; and Leadership and governance.
In rural India, government operated Primary Health Centres (PHC) and Commu-
nity Health Centres (CHCs) were typically the only options rural residents had to get
access to formal health care services. Even though the number had increased from 22,875
during 1997–2002 to 25,020 in 2014, PHCs were usually severely under-staffed and ill-
equipped. Even if doctor consultation was provided, patients had to arrange for medicines
and diagnostic services elsewhere and for which they usually needed to travel long dis-
tance and pay out of pocket.
Government run Community Health Centres (CHCs) provided specialized medical
care as they employed surgeons, obstetricians and gynaecologists, physicians and paedia-
tricians. Unfortunately, most specialist positions in CHCs throughout Indian states were
vacant: compared to requirement for existing infrastructure. There was a shortfall of 82.5%
of surgeons, 76.6% of obstetricians & gynaecologists, 82.6% of physicians and 82.2% of pae-
diatricians7.
For serious ailments that required hospitalization, villagers needed to travel much
longer distance and were not even sure to get the needed health care upon arrival. Some-
times villagers also had to sell off their property and travel to other parts of India to get
treated at large multi-specialty hospital. For the rural population, however, travelling to
those multi-specialty hospitals located in big cities in India like Kolkata, Delhi, Bangalore
or Chennai was very difficult and patients often not could not get appointments for weeks
or months.

6
 M. Golechha, Healthcare agenda for the Indian government. Indian J. Med. Res. 2015;141:151–153.
7
 NRHM, Rural Health Statistics 2014, http://nrhm.gov.in/

08_S0218927518500165.indd 403 16-01-19 3:51:25 PM

 404 ACRJ

Exhibit 5

Education and Economic Background of the Residents in the Region Covered by iKure

With a rural population of 5.7 million and 3.5 million respectively, Paschim
Medinipur and Birbhum districts of West Bengal fared low in human develop-
ment indices. The average literacy rate in both districts is 70 with low women
literacy rate as education for women is restricted only to primary education. The
quality of life was poor as the villagers main source of occupation are from rain
fed agriculture. However, frequent droughts and floods affect the population
causing damage to the limited agriculture in the area affecting food security of
the people living here. A majority of the population were from backward vil-
lages with a high concentration belonging to drought prone blocks. The health
care system in the region was insufficient and rural households predominantly
depend on local neighbourhood clinics (quacks) for health care services. The
average cost of treatment at these clinics ranged between INR 15 to INR 100. The
medical practitioners who ran these clinics do not possess professional MBBS
qualification and many do not practice allopathy. Given this, the local medical
practitioners may unintentionally harm patients than curing them by using inap-
propriate treatment plans or delaying the diagnosis of the underlying problems.
For primary consultation with a qualified doctor and basic diagnostic facilities
rural patients had to travel between 7–40 kilometers but such effort did not
always guarantee a meeting with the doctor9.

08_S0218927518500165.indd 404 16-01-19 3:51:25 PM

 IKURE TECHSOFT: PROVIDING TECHNOLOGY ENABLED AFFORDABLE HEALTH CARE IN RURAL INDIA 405

Exhibit 6

Evolution of iKure on Timelines

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^ƚĂƌƚhƉWŚĂƐĞ ŽŵŵĞƌĐŝĂůZĂŵƉͲƵƉ ^ĐĂůĞhƉ͗WŚĂƐĞ/ ^ĐĂůĞhƉ͗WŚĂƐĞ//

΀WĂƐƚϮzĞĂƌƐ΁ ΀:ĂŶϮϬϭϯʹ ĞĐϮϬϭϯ΁ ΀:ĂŶϮϬϭϰʹ ĞĐϮϬϭϱ΁ ΀:ĂŶϮϬϭϲʹ ĞĐϮϬϭϳ΁

9 ŽŶƐƵŵĞƌ/ŶƐŝŐŚƚ 9 ^ĞƚƵƉŽǁŶĐĞŶƚĞƌƐ 9 &Ƶůů^ĐĂůĞƵƉ

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9 ĞǀĞůŽƉŵĞŶƚ ƉĂƌƚŶĞƌƐŚŝƉƐǁŝƚŚ ƚŚƌŽƵŐŚ&ƌĂŶĐŚŝƐĞ
dĞĐŚŶŝƋƵĞ E'KƐͬ&ŽƵŶĚĂƚŝŽŶƐ ŽƉƚŝŽŶ
9 ŽŵŵĞƌĐŝĂůWŝůŽƚ 9 ƐƚĂďůŝƐŚ,Ƶď 9 dƌĂŝŶŝŶŐ
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9 ^ZWĂƌƚŶĞƌƐŚŝƉ 9 WĂƌƚŶĞƌƐŚŝƉǁŝƚŚ
9 ,ĂǀĞƐĞƚƵƉϮZ,Ɛ 9 ZĞƐĞĂƌĐŚ
9 ^ĞƚƵƉϱZ,Ɛ E'K
9 ƐƚĂďůŝƐŚĞĚŚƵďΘ ƉĂƌƚŶĞƌƐŚŝƉ
ĂĐƌŽƐƐϯůŽĐĂƚŝŽŶƐ 9 ZĞƐĞĂƌĐŚ
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08_S0218927518500165.indd 405 16-01-19 3:51:25 PM

 406  ACRJ

Exhibit 7

Interventions/services offered by iKure from its establishment to till date

Year Intervention/services offered

2010 General Consultation, Medicines & Diagnostic services

2012 Mobile Medical Unit (MMU) services

2012–13 Corporate Social Responsibility(CSR) activities

2014 Community health workers training services through capacity

building and skills development programme

2015–onwards Research Activities

Leading US university and Canadian university, which is
examining the evidence of impact of a specific intervention
made in very remote areas in rural India
Premier medical institute and leading association of
community ophthalmologists on various ophthalmology
initiatives to bridge the gap between doctors and patients,
enable wide scale clinical data collection through surveys
Mother & Childcare project

08_S0218927518500165.indd 406 16-01-19 3:51:25 PM

 IKURE TECHSOFT: PROVIDING TECHNOLOGY ENABLED AFFORDABLE HEALTH CARE IN RURAL INDIA  407

Exhibit 8

Hub and Spoke Model for iKure’s Delivery of Rural Health Services

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ZƵƌĂů ZƵƌĂů ĐůŝŶŝĐ
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08_S0218927518500165.indd 407 16-01-19 3:51:26 PM

 408 ACRJ

Exhibit 9

Beneficiaries and Type of Social Impact Derived

Beneficiaries Type of social impact derived

iKure patients –– Increased access to formal health care

–– Savings made compared to alternate formal health
care options
–– Reduction in income loss, due to fewer man-days
lost due to illness for a majority of the patients
–– Reduced total turnaround time

iKure Voluntary –– Increase in income

Health workers –– Increase in employability through relevant skills
gained under association with iKure

iKure community –– Increase in Income

Based Health workers –– Increase in employability through relevant skills
gained under association with iKure

Rural community –– Increased access to formal health care

–– Early detecting of diseases through regular health
check-ups.

Exhibit 10

Cost Savings of iKure Patients Compared to Patients Who Accessed other Health Care Options

Health care Average cost of Average cost Cost of travel Total cost
option Doctor’s consultation of medicines (approximately)

Alternative USD 1.8 USD 4.57 USD 1 USD 7.45

health care
options

iKure USD 1.33 0 0 USD 1.33

08_S0218927518500165.indd 408 16-01-19 3:51:26 PM

 IKURE TECHSOFT: PROVIDING TECHNOLOGY ENABLED AFFORDABLE HEALTH CARE IN RURAL INDIA  409

Exhibit 11

iKure’s Projected Revenue

FY 15 FY 15 FY 16 FY 16 FY 17 FY 17
(INR) in (USD) in (INR) in (USD) in (INR) in (USD) in
million thousand million thousand million thousand

12.29 204.98 44.58 742.93 88.49 1,474.85

Exhibit 12

Organisation Structure of iKure

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08_S0218927518500165.indd 409 16-01-19 3:51:26 PM

 410 ACRJ

Exhibit 13

Research Based Partnerships of iKure

Name of partner Nature of collaboration

A leading US university Provide health care service and diagnose the

health care needs of mother and child in Paschim
Medinipur region

A leading Canadian university Examining the evidence of impact of specific health

intervention made in very remote areas in rural
Orissa

A premier medical institute of Ophthalmology initiatives to bridge the gap between

India and Leading association of doctors and patients, enabling wide scale clinical
community ophthalmologists data collection through surveys

A leading international platform for Training knowledge exchange programme

health care innovation

08_S0218927518500165.indd 410 16-01-19 3:51:26 PM

 IKURE TECHSOFT: PROVIDING TECHNOLOGY ENABLED AFFORDABLE HEALTH CARE IN RURAL INDIA 411
The Collaborative Model of iKure — NGO and Corporate Partnerships
Name of the partner /
collaborator
A leading Indian consumer
products company
A leading global medical
device manufacturer
A world leader in eye care
products
An Indian cement company
A leading Indian private
hospital chain
Two local hospitals
A premier medical institute
of India
Kolkata based real estate
developer
Leading association of
community ophthalmologists
08_S0218927518500165.indd 411
Exhibit 14
Main Business/service offered
and Location
Health care products, Mumbai
Medical devices and equipment,
MNC
Free eye check-up & dispensing
spectacle at very affordable cost
in 4 districts of Kolkata
CSR intervention to improve the
health status of rural community
in 8–10 villages of Paschim
Medinipur
Tertiary referral care and
providing financial assistance
for surgery medical procedure
through iKure’s network
Tie up for Birbhum and Paschim
Medinipur respectively. WHIMS
used for offline glaucoma form
and online Intraocular pressure
(IOP) test
WHIMS module
Providing medical consultation
to construction workers, WB
Carrying out surveys at village
level, West Bengal
Services provided
Providing health supplements
through iKure clinics
Training on technological aspects
of equipment and devices
Spectacles distribution
iKure’ role as a facilitator
helped build & nurture positive
relationship with the company
and its community members
Providing secondary and tertiary
health care services to remote
patients
Eye care service to rural patients
Delivering patient status
documentation with ID cards,
prescription with doctor
signature, photos along
with videos, data analytics
highlighting trends and disease
profile of respective health
conditions
Collect and analyze survey data
as part of ophthalmology project
of WHO
16-01-19 3:51:26 PM