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!