In 2007, Zeena Johar had just finished her PhD in biochemistry from Swiss Federal Institute of Technology in Zurich, and returned to India. Though obsessed with chemistry she wasn’t keen about building a career in drug discovery. Instead, she joined the Chennai-based IKP Trust (formed with an initial grant from ICICI Bank), to do business driven research and development in the area of health. The difference between Switzerland and India became apparent during her research. Some drugs prescribed in Switzerland could cost $1000 a course, a cost that is the annual budget for some Indian families.
After traveling to Bihar and Chhattisgarh, to study community healthcare programs, some patterns began to emerge. Johar realized that health workers were not skilled, primary healthcare was largely absent and remained disconnected from the larger healthcare system. The government was still looking at healthcare through the lens of early post-independent India. At that time, Johars says, the mandate was different: a large percentage of women were dying at childbirth, infant mortality was high and communicable diseases were rampant. Since then, she says, our reactive systems for addressing these issues have improved. The real problem is with coming up with a reactive way to address bigger health problems like diabetes, cancer and cardiovascular diseases.
In 2008, with funding from the IKP Trust, she along with Nachiket Mor (president of ICICI Foundation for Inclusive Growth at that time) founded SughaVazhvu (Tamil for happy life) Healthcare to providing affordable healthcare solutions to rural communities, by leveraging technology and innovative training methods. Her work with IKP Trust also resulted in the formation of IKP Centre for Technologies in Public Health (ICTPH), a not-for-profit research organization, working towards providing primary healthcare for remote rural Indian populations. ICTPH and SughaVazhvu currently work closely to tackle rural health problems in India.
A technology and skill-based training approach:
Johar realized that just throwing technology to take on the problems will not be enough due to a shortage of trained manpower. India requires an estimated 1.2 million doctors, and with only 4 lakh registered and 30,000 to 40,000 MBBS graduates entering the system every year, this target can’t be met. Johar’s solution? Go in direction of US, where trained nurse practitioners are used. Her answer is to train and certify Ayush (Sidha, Unani, Ayurveda and Homeopathy) doctors to do some of the tasks. In India, there are an estimated 7.5 lakh Ayush doctors, 70 per cent of whom are legally allowed to practice allopathy.
SughaVazhvu has entered into a partnership with University of Pennsylvania, to create a six-month Bridge Training Program (BTP) to train and certify Ayush doctors. This will take care of the knowledge healthcare worker problem to a certain extent and also helps brings down costs that can be shared with patients. To bring about a tighter integration between primary and secondary healthcare, ICTPH has developed a health management information system (HMIS), that helps capture patient-physician interaction using a web-based tool. The HMIS handles supply chain management, monitoring and evaluation, clinical audit and integration using android-based mobile platform system. Using the HMIS tool health practitioners can diagnose upto 100 diseases. Patients who require primary healthcare are treated at the seven SughaVazhvu clinics in Tamil Nadu, which address the needs of 200,000 people, while those that need treatment at specialty hospitals are referred up. At last count, more than 50,000 patients have been served at SughaVazhvu clinics, and 3,000 have been screened for chronic diseases.
Apollo Clinic tie-up:
At present SughaVazhvu is working with Apollo Hospital, in Aragonda, a village in Thavanampalle Mandal of Chittoor District in Andhra Pradesh to test the model. “We understand how to do primary care, we know what technology is required, and we understand management. What we want to do is take a primary care functioning system of Aragonda and integrate it into higher-level care, like in the case of insulin dependent diabetic patients,” says Johar.
In India where most patients don’t possess medical history or if it exists there is no single system where the information can be accessed. SughaVazhvu’s HMIS allows for patient records to be transferred back and forth, from a PHC to a general hospital or the other way around. This is especially useful in rural areas where patients may not be very savvy in preserving medical records.
Challenges and learning so far:
Johar states that earlier the challenge in primary healthcare were supply side issues like no courier company for blood movement, no organized players in the healthcare sector, but now with new emerging players like SughaVazhvu and Bangalore-based Vaatsalya Healthcare that is slowly getting solved. The problem is now in the supply side, she says.
“Bigger learning is that we thought since there are not many healthcare players, patients will flock to us. But demand side is tough, we might think we are the best, but it takes a long time to convince rural customers to use us. Rural India is different, solutions need to be thought ground up, unit economics need to worked out, we need to be fully optimized,” remarks Johar. Since SughaVazhvu is a for-profit social enterprise, utilization of each clinic is key. At present, they have on average 8-10 patient visits per clinic, and recoup 20-25 percent of the operational costs. To boost footfalls, they are looking at reaching out to Panchayat leaders, other opinion makers and women from self help groups (SHGs).
They are also figuring out the pricing, moving from a one time user fee, to an annual subscription fee based model. An example of this is their annual diabetes package that costs Rs 1200. The subscription fee based model reduces annual cost for patients with chronic diseases by about 25 per cent. At present the user fee to subscription mix is 90:10, SughaVazhvu plans to move to 50:50 in 2014, and then 20:80 in the long-term. The challenge is not one of the upfront cost, but that of finding enough patients, who will be convinced of the benefit.
At present SughaVazhvu has seven fully-owned and operated clinics, but with plans to scale rapidly, Johar is still wondering whether a franchisee model might be the best bet. She has noticed in rural areas, peer influence runs high. If one of the households visit SughaVazhvu, then it will lead to more visits from that neighborhood. The opposite also ensues; one unhappy customer will lead to a drop in the entire catchment. “Most important is trust between physician and patient. In medicine, there is a very thin line between ethical and unethical, we should be careful about franchising. While I’d like to say more yes than no, it is not on cards yet, we want to control everything tightly, replication as mode to scale will take 2-3 years,” adds Johar.
In 2014 SughaVazhvu plans to double its network, scale their skill-based training program through a partnership with Infrastructure Leasing & Financial Services (IL&FS), gun for a partnership with the government and cash in on Apollo partnership by opening five clinics in Chitoor that demonstrates the integrated primary and secondary healthcare model.
Johar’s aim to touch a million lives by 2016. “It looks ridiculous and unachievable, but we need a big goal. We will scale up through own model and partnerships to replicate the model in five states with 50 clinics each. We will do it one village at a time, by doing it right in terms of design and unit economics, and then scale rapidly,” concludes Johar.