Losing Sleep over Sleep Disorders in India

As per a survey by a major healthcare company in India:

These statistics are jarring – we spend 1/3rd of our lives sleeping (or at least attempting to do so) and the lack of quality sleep is linked with many chronic conditions such as type 2 diabetes, heart disease, obesity, and depression.

Intrigued by the problem, we at W Health Ventures researched the Indian sleep disorders market to develop our detailed thesis. Here are the three challenges we discovered:

1) Care seeking behaviour

According to Resmed, a minuscule 2% of Indians suffering from obstructive sleep apnea actually consult a physician in India. Low care seeking behaviour is primarily driven by the perception of sleep disorders being a “less serious” health issue and patient’s fear of addiction to sleep medicines.

• Basis the patient survey we conducted, more than half the patients suffering symptoms of different sleep disorders did not consult a doctor because they perceived this as a non-medical, lifestyle problem. In case of Sleep Apnea, snoring was in fact considered a sign of “deep, sound sleep”.
• Interestingly, when the patients we surveyed sought advice from a friends or family, the unanimous suggestion was to increase physical activity and practice meditation – rarely was the advice to consult a physician. Patients relentlessly tried to address the issue without visiting a doctor – often, with limited relief from a problem so heavily affecting health and lifestyle.
• Some patients feared consulting a doctor and be prescribed sleep medications, as they had either a relative or a friend who started consuming sleep medication and got addicted to it.

2) Diagnosis

There are 3 challenges associated with diagnosis of sleep disorders:  patients being prescribed formal diagnosis, high cost and the cumbersome nature of the same.

i) Prescription: The share of patients for whom doctors prescribe formal sleep studies is very low. For example, for none of the patients we surveyed, did the doctor prescribe a sleep study – instead they relied on verbatim symptoms to narrow down the problem. In cases where practitioners were confident of the patient suffering from OSA, they prescribed the use of a CPAP (continuous positive airway pressure) machine without even confirming the issue via a sleep study. The extent of this problem has worsened with the pandemic, in an attempt to limit elective or less severe medical interventions.

ii) High cost: An in-hospital sleep study (or polysomnography) costs between INR 10-15k and an at-home alternative costs between INR 3-5k. A sleep endoscopy (done by an ENT specialist) is also advised for patients potentially suffering from obstructive sleep apnea, however it is rarely conducted. These expenses are typically out-of-pocket spends in India given there is no insurance coverage for these tests.

iii) Convenience: Undergoing formal diagnosis for the patient is less convenient. Having to stay overnight in a hospital sleep lab, and being subject to cumbersome equipment setups (e.g., a polysomnography often involves taking 15+ inputs from across the body) is often not preferred by patients.

3) Treatment

The two key issues pertaining to treatment include:

i) Addictive nature of affordable medications: For conditions like Insomnia, doctors often advised patients to take a class of sleep inducing medicines called Benzodiazepines (like Alprax, Ativan). All patients consuming these drugs confirmed improved sleep quality within two months of starting medication, and were satisfied with the relatively reasonable cost of supplies (INR 100-200 per month). However, once these medicines provide relief to the patient, he/she has limited incentive to continue regular visits to the doctor with a pay-per-visit charge implication. Patients then tend to take these medicines for prolonged periods after failed attempts to wean off these drugs. This is a cause of concern as these medicines often have severe adverse effects (including drowsiness, confusion, slurred speech etc. over time)

ii) Low adherence for less harmful treatment options due to high cost implications: Interestingly, practitioners rarely explored solutions like cognitive behavioral therapy (CBT). This hesitation can be potentially linked to the high cost of these alternatives. For instance, undergoing CBT costs INR 7-10k per month. For sleep apnea, CPAP also sees low uptake – potentially due to high cost of the CPAP device.

While globally, an uptick in digital health solutions catering to sleep disorders has been observed, India isn’t yet on that adoption curve. For comparison, 16 sleep-focused US digital health players have raised over USD 1.2B to date. The core offerings span consultations with sleep specialists, diagnosis (e.g., innovative remote monitoring devices, at-home sleep studies), habit coaching (to embed sleep hygiene habits in a patient’s daily lifestyle), offering nutraceuticals (e.g., melatonin) directly to consumers and disruptive devices or surgical treatments for more sustainable solutions.

The Indian market is still quite nascent in terms of the innovation and solutions we have seen.

• India has more than 500 sleep labs compared to ~4700 in US. India is also not a main target market for established sleep focused devices players (~70% of their revenues come from US and Japan) or even new international start-ups.
• The diagnosis sector in India is dominated by the 2-3 major international players manufacturing equipment. They’re working on market creation and awareness in the segment.
• The market for patients to book a sleep study, is still fairly unorganized with smaller distributors and dealers controlling prices.
• For treatment, there are a few D2C wellness players demonstrating good growth on the sleep-related nutraceuticals segment. But sleep-related nutraceuticals are a low average order value with no proof point on customer lifetime value, it makes limited business sense for start-ups to pursue this play in isolation.
• Broader teleconsultation and meditation platforms are available, however not solely focused on sleep disorders.
• Except for the D2C mattress brands, all healthcare related start-ups in India have either folded or pivoted. There is practically no “virtual” sleep clinic acting as the one-stop-shop that combines all the siloed components of care needed for a patient suffering from sleep disorders.

Big takeaway: We feel the Indian market is still not ready a full-fledged “virtual sleep clinic”. Nevertheless, we believe it is a good time to start small for the digital health ecosystem by augmenting / cross-selling existing solutions (e.g., apps addressing mental health, obesity, other lifestyle disorders) with sleep-related plays, before the stage is set for an end-to-end sleep related platform.

Authors: Diksha Bahl, Dr. Nikhil Hegde and Tushar Sadhu