Piramal eSwasthya: Attempting Big Changes for Small Places – in India and Beyond

PREPARED BY : DIXON DOMINIC PALETT

Mission & Vision

To democratize healthcare

To provide reliable primary healthcare services at people’s doorsteps in the very remotest villages of rural India

To improve the quality of life and reduce the burden of disease in 100,000 villages up to 2013.

Piramal eSwasthya

Founder:- Anand Piramal (son of Ajay Piramal)

Founded:- March 2008 (40 pilots)

Sites:- Bagar, Bissau, Khatu, B’haleri (Rajasthan), Thirupathur (TN)

Annual Budget:- $500,000/-

By April 2010:- Treated over 25,000 patients, backend call center in Mumbai, MDS with capacity of 10,000 villages

Healthcare in Rural India

7/10 people in rural India; 600,000 rural villages; lacked basic infrastructure and facilities

India would remain predominantly rural for decades to come – business model has long term scope.

In theory, country’s health care problem was already solved

In practice, the system in theory failed

Healthcare in Rural RajasthanHome

Remedies

Self MedicationMom &

Pop Stores

Ayurvedic

Traditional Healers

NursesJholach

aap Doctor

sCompounders

Private Practitioners

Attempted Solutions• Bring doctors in vans at specific times• Reached sustainability but not scalable• Lack of doctors willing to take the van ride• Patients couldn’t time their illness

Mobile Medics

• Part of Piramal Healthcare• Use video conferencing to connect with rural patients• Pilot lasted six months and failed• Technical Issues coupled with lack infrastructure

Telemedicine Initiative

• Systematic community transformation initiative• Health centers along + water & education initiatives• Trained local leaders to take over administration late• Health hotline, mobile van service, telemedicine service (video

conferencing)• Most OPEX handled by Govt.

Andhra Pradesh Project

• Disha by Philips:- Sent out vans but used telecommunication with hospitals for diagnosis

• World Health Partners:- Franchise model connected with telemedicine center for diagnosis asistance

Other Projects

Introduction to Piramal Family and Healthcare Affluent families with rural roots feel a sense of identity and

responsibility towards those areas

Piramal Family:- farmers -> cotton traders -> relocated to Mumbai -> bought Nicholas Laboratories (Indian Subsidiary) -> grew it big time

India’s third largest medicine manufacturer

Given roots in rural Rajasthan and pharmaceutical experience, Anand expected his venture would work

Challenges:- pharmaceutical industry different from health service industry and he hadn’t been to Bagar since he was a child.

Inception of Piramal eSwasthya

Only 30% Indians have access to modern medicine; Anand wanted to do something about it.

Researched health data, convinced colleagues to join, spoke to Unilever about Project Shakti and talked to Prof. CK Prahalad

Warnings:- unfavorable women social position in Rajasthan and need to be in the venture for a long haul (atleast 5-10 yrs.)

3 patients/day will be enough for the project sustainable

“Our dream is to democratize health care and give the average Indian access to what many consider a luxury today”

Idea strikes the Professor Only readily available service in rural areas was mobile phones

AI + rule based nature of primary care = simple diagnostic software

Combining both a model can be created with nearly equal reliability as a licensed doctor

Preliminary survey conducted by Anand showed positive reviews and model was scalable

Model to be used:-“Sophisticated doctor and village woman connected via a mobile phone with the help of a diagnostic software”

Starting the Pilots (Rajasthan)

Women were selected as frontline providers

Flat salary Rs.1,500/-

Spoke to village Sarpanch and other key male figures

Publicized using loudspeaker

Distributed pamphlets to people gathered

Selected candidates for PSS (Piramal Swasthya Sahayikas) and trained them in basics

The Model

VillagesPSS Mobile

PhonesMedical Kit

Mumbai Call CenterDoctor’s ApprovalDiagnosisReferrals

Advantages of Competing Services

Parameter Quack Pvt. Clinic e-Swasthya

Treatment of time Immediate Delayed ImmediatePractitioner Qualification Unknown Doctor Doctor +

CDSSTreatment Quality Questionable High High

Medicine Quality Low Pharmacy Dependent High

Patient Care None Low HighLoss of time Minimal High MinimalLoss of wages None Entire day or more None

Unexpected Outcomes Sahayikas received less than 1 patient/day on an

average

Growth was very slow

Patient loyalty was hard to determine

Multiple actors actively but subtly marketed against the PeS service

Government Providers Patients wanted a one stop solution, referring to other

providers by PeS made them bad mouth about it.

PeS visit proved futile in case of complex health issues.

PHC made PeS referrals wait longer

“They were being ethical by sending people to licensed medical doctors when they couldn’t offer the highest quality care”

Even local quacks didn’t turn patients away – bad publicity compounded.

Local Private Practitioners Steroid injections gave instant relief which PeS won’t offer –

quacks are more effective + placebo/nocebo effect

Differing beliefs in terms of cause and effect

Delayed effect of antibiotics

Payment flexibility of quacks

Admonished or threatened villagers to withhold care

Villagers wanted to see commitment before changing habits

Swasthya Sahayika ( PSS )

Reasons why families allowed PSS Chance to use their education

Addition to family income

Status ( a new opportunity was available and got selected )

Swasthya Sahayika

CULTURAL OBSTACLES Young women’s general status - low

After marriage – lowest status in home

Held responsible for households

Purdah ( veil ) – separation from adult males outside family

Swasthya Sahayika

Women represented family virtue – REPUTATIONAL CONSEQUENCES

Never intended to be a village salesperson

Family sought negligent if let to wander around , visit homes & talk

Kal ki chokri – made it difficult for PSS respect & credibility

Couldn’t accept girl as a respected healthcare provider

Swasthya Sahayika

Majority of PSS felt comfortable operating within a narrow circle of people

Complex social structure – overlapping caste , class , religion , gender & age

10 communities of 150 people each = 1 village

WRONG ASSUMPTION – catchment area – whole village

Swasthya SahayikaREALITY of Disadvantaged communities Diverse

Multiple unassimilated groups

Competing for positions of power and access to resources

Family reputation mattered : high reputation – more patients

Relation to Sarpanch helped

RESULT : access of PSS was 1/10th of expected

Swasthya Sahayika

Succesful case : PSS convinced family – work from home & earn

Thanked Piramal for providing transformative opportunity Confidence increased

Received Sahayika award ( Exhibit 11 ) Displayed trophies & awards – WOM

Swasthya Sahayika

Many PSS felt entitled to their salaries

Assumed Piramal as a wealthy family which could afford to pay

Expectations of charity

PeS – Incentives – But patronage attributes created barriers

Excess free time – other activities – created perception : unavailable ( like public service )

What to do ?

ENGAGE COMPETING PROVIDERS : Ayurvedic system vs. Modern medicines – Traditional healers waning

IDEA : Partnerships with Public health doctors – Educate QUACKS about harmfulness of steroids

Assesed the willingness to stop injections -ve response : ( steroids were cheap , high margin & markup )

IDEA : increase PSS per village ( cost issue )

What to do ?IMPROVED INCENTIVES STRUCTURE Commision per patient

Training fee

Security deposit for drugs and medical kits – better care for equipment

ROI 44% even with 300Rs. per month

Lowere attrition rates

Cut salary costs

Lower salaries – weakened motivation

What to do ?ENHANCED MARKETTING IDEA : Short movie – too costly & less opportunity to screen

Game – recreation for rural women – same people played

Referral program 5 loyal patients – chance to earn a discount – PeS Ambassodors It was unable to penetrate past narrow network of people

What to do ?HOME VISITS & HEALTH CAMPS Brought people from outside village 20 households / day along with PeS support staff or Female Field Force Skepticism to outsiders : It helped spread information about PeS Patient count rose

SMS program – negligible Reminder + Dosage Disease of the month – themed HV and HC Technology - Differentiated from QUACKS

What to do ?ENLARGE THE STAKEHOLDERS & EDUCATE MARKET Enlarge circle of stakeholders Identify Village leaders & Train them – Increase managerial capacity

PuR – Educated children ( Pakistan & Morocco ) NGOs already on ground ?

What to do ?

ENLARGE THE SCOPE & ADD SERVICES Partnership with Vision spring – reading glasses – additional

revenue Considered including water purification tablets

Related products & services ? Change strategy ? Train women to administer injections ?

What to do ?

DRIVING SUCCESS FURTHER WITH SUCCESS

Small success stories – scabies

UNDERSTANDING Alter model to fit village realitiesAverage number of patients grew – But slowly (5 – 10 yrs expected )

Stay in business or exit ?

Force Field AnalysisCurrent State:-Average of 1 patient/day

Desired State:-Average of atleast 3 patients/day

Driving Forces Restraining Forces

Additional Family Income

Status

Exists a need for such service

Transformative Opportunity (Veil)

Trophies/Awards

Lack of Awareness

Bad Mouthing by Competitors

Cultural & Social Obstacles

Reputational Consequences

Excess free Time

Referral Discounts

Entitlement to SalarySkepticism to Outsiders

Thank You!