Piramal e swasthya :attemptiong big changes for small places - in India and Beyond

Piramal e-swasthya : attemptiong big changes for small places - in India and Beyond : hbs case sutdy

1. Piramal eSwasthya : Attempting Big Changes for Small Places – in India and Beyond Prepared By : Dixon DOMINIC Palett

2. 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.

3. 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

4. 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

5. Healthcare in Rural Rajasthan

6. Attempted Solutions

7. 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.

8. 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 ”

9. 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 ”

10. 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

11. The Model Villages PSS Mobile Phones Medical Kit Mumbai Call Center Doctor’s Approval Diagnosis Referrals

12. Advantages of Competing Services Parameter Quack Pvt. Clinic e- Swasthya Treatment of time Immediate Delayed Immediate Practitioner Qualification Unknown Doctor Doctor + CDSS Treatment Quality Questionable High High Medicine Quality Low Pharmacy Dependent High Patient Care None Low High Loss of time Minimal High Minimal Loss of wages None Entire day or more None

13. 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

14. 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.

15. 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

16. 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 )

17. 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

18. 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

19. 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

20. Swasthya Sahayika REALITY 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 1/10 th of expected

21. 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

22. 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 )

23. 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 )

24. 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

25. 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

26. 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

27. 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 ?

28. 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 ?

29. What to do ? DRIVING SUCCESS FURTHER WITH SUCCESS Small success stories – scabies

30. UNDERSTANDING Alter model to fit village realities Average number of patients grew – But slowly (5 – 10 yrs expected ) Stay in business or exit ?

31. Force Field Analysis Current 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 Salary Skepticism to Outsiders

32. Thank You!