Learning Places: Kerala, India (v.1, ch.4)

Our work takes us to many often-forgotten, rarely-talked about places. No mere tour, our aim is to facilitate exposure and learning for some of the business-world’s best and brightest.

But it’s not about taking photos or listening to speeches. Our executive participants work hard to develop new approaches to value creation for the underserved majority. Sustained hard work is driven by the Power of Purposeful Engagement.

Inspired by our project partners and the incredible work produced by our participants, we compiled a series of reports that repackage the core ideas and outcomes from field projects. (Not everyone wants to read the full 100-slide PPT business plan).

The first edition was published earlier this year. We call it Learning Places: The GIFT Report

We hope you enjoy this excerpt from Volume 1, Chapter 4: Providing Indian Emergency Response with a Single Touch.

    A Model for Mobile Health Technology in India

    One night, Indian entrepreneur Shaffi Mather’s mother awoke, choking and unable to breathe. The Mather household called for an ambulance, but almost an hour passed without any news from the hospital. In the end, the Mathers chose to drive her to the hospital themselves. A few days later, on the other side of the world in New York, Shaffi’s colleague Ravi Krishna had the same situation: his mother collapsed and needed immediate medical care. Unlike in India, New York’s ambulances attended to Ravi’s mother within minutes.

    This is a common story in India (and elsewhere in the developing world). Many bystanders in India, when asked how they would respond in a medical emergency, said they would transport patients themselves if they could, or face a significant wait for an ambulance if they could not. India, with its increasing number of cars, suffers from thick traffic, which significantly slows response times. But inefficiencies stretch further than emergency response. Waiting times in India’s public hospitals can span for hours, which has driven many to the private sector where they must pay for healthcare costs out-of-pocket.

    As incomes in India increase, the rise of “lifestyle conditions” means that people will require more consistent care, which increases health costs further.

    India faces a particular problem when it comes to providing health care. The country has an enviable resource of human capital, due to its early investments in healthcare. It has some of the best medical training facilities in the developing world, and thus some of the best doctors. India is able to provide world-class healthcare at prices cheaper than the developed world and thus has developed its well-known medical tourism industry. However, it has not been able to provide better healthcare to its massive and still largely poor population, both because the supply of doctors is still insufficient, and because its healthcare system does not efficiently apportion its existing human capital India already has.

    With this challenge in mind, Shaffi Mather launched a new company called MUrgency: a tech start-up that would connect emergency responders with patients in emergency situations over the mobile phone network. MUrgency had successfully piloted its system in the United Arab Emirates and the Indian state of Punjab, and were able to respond faster than existing public services.

      However, once the technological question was solved, a new one emerged: how would MUrgency make money?

      Participants recommended MUrgency organise its service platform into three categories:

      • “Emergency,” to provide rapid emergency response;
      • “Community,” to drive user engagement; and
      • “Connect,” to facilitate urgent and preventative care.

      The model would capitalise on MUrgency’s network of medical professionals, and spread primary health coverage to more households, offering more convenient and price-competitive care than clinics or hospitals.

      This expanded MUrgency model was launched in India, but can be transplanted to other developing economies as well. Many health issues in India are consistent with other developing economies, including Indonesia, Vietnam and China.

      Any country with a growing middle class, an increasing prevalence of lifestyle conditions (such as diabetes, obesity and heart disease) and relatively cheap labour presents an opportunity for the MUrgency model.

        Healthcare in the Developing World

        While economic development has done much to improve public health in the developing world, it has not come without cost.

        First, the developing world’s infrastructure — medical and otherwise — has not kept up with demand, even though more people are now able to afford healthcare. For private hospitals, increased demand leads to increased costs which, combined with an underdeveloped health insurance system, has led to greater costs paid out-of-pocket.

        In contrast, public healthcare systems see increased crowding and wait-times, where those with non-emergency, but urgent, needs can wait for hours for an appointment. These long wait-times often encourage people to go to the private sector — which increases prices paid in hospitals — or to delay treatment until their condition becomes an emergency.

        The rise in incomes has also spurred a rise in the incidence of non-communicable diseases, such as obesity, diabetes, cancer, cardiovascular disease, and other chronic conditions. Such conditions are more expensive to treat than acute diseases, as they need more constant monitoring, care and medication to keep under control.

          Piloting New Models for Healthcare Services

          India is a good place to test innovative business models, especially in healthcare, first and foremost because of the pressing need for better access to care for India’s massive population. The Indian government does not have the money to dramatically expand health provision, nor do ordinary Indians have the income available to purchase health services largely taken for granted in the developed world.

          This lack of resources is a challenge for those seeking to import business models from more advanced economies, especially for those based in technology.

          In many countries, e-commerce is exclusively paid for through credit and debit cards. However, the rarity of payment cards in India means that e-commerce firms like Flipkart allow cash payment on delivery — a phenomenon unheard of in the developed world.

          India has significant human capital. Its early investments in education and public healthcare gives it a large population of well-educated professionals, especially in the medical sector. While not enough to cover the full demand for healthcare, this professional class makes interesting new business models possible.

          In India, expertise is cheap. The cost of using doctors, teachers and other skilled professions is significantly lower than the equivalent in more developed regions. The growth of medical tourism is a case in point: complex surgery in India is cheaper than the same procedure in the United States or the United Kingdom, reflecting India’s advantage in human capital, albeit in a way that does not directly improve the lives of ordinary Indians — medical tourism largely benefits richer foreigners from the West or from the Middle East.

          Health costs are increasing. Constraints in public health services have driven people to the private sector, increasing prices in private hospitals. Costs are also driven upwards by an underdeveloped insurance system that only covers care if it includes hospitalisation.

          Now, over 60% of India’s healthcare expenses are paid out-of-pocket, compared to 35% in China and the United States, and 9% in the United Kingdom.

          A final reason why India is fertile ground for testing new business models is its federal system. Provinces in India demonstrate great variance in regulations and economic conditions. Each province is also large enough for innovative new businesses to start-up and grow to scale simply through the local markets. States like Bihar (population of 103 million), Punjab (27 million) and Kerala (33 million) are as large as many countries and thus offer meaningful opportunities to test business models as a proof of concept.

            Emergency medicine is a very young discipline in India. The Medical Council of India only recognised it as a specialty in 2009, and it remains a niche area of study for most medical graduates. Emergency departments cited two constraints in the development of emergency response: Traffic congestion and unclear communication and dispatch systems.

            The growth in car ownership and lack of new roads have made congestion the norm in India’s cities, even in relatively smaller ones like Kochi.

            Gridlock has forced some hospitals to adapt their emergency vehicles, and indeed Kochi’s Aster Med City has developed “bike ambulances” to quickly reach patients in need. “Bike ambulances” are motorcycles outfitted with a first aid kit, a defibrillator and a siren, designed to transport an EMT quickly through traffic to the scene of an accident.

              The lack of a centralised communication and dispatch system is equally problematic. A single location in India will have multiple emergency numbers: a national number, one for the city, one for the district, one for the state, and specific numbers of hospitals in the vicinity. Numbers are also not standardised amongst locations and people often do not know which number to call. There is also no efficient dispatch system to direct a request to a hospital or ambulance company. As a consequence, many patients, rather than waiting for an ambulance, are transported directly to hospitals by private transportation.

              Perhaps most worryingly, India is experiencing a dramatic increase in non-communicable conditions.

              Its growing middle-class, due to a combination of greater consumption and longer lifespans, are suffering from higher rates of chronic conditions like cardiovascular disease and diabetes. Hospitals in Punjab and Kerala noted that the second-largest cause of medical emergencies was heart attacks. Chronic conditions require more active and consistent primary care. However, getting this care is expensive, and so people often delay treatment until a medical emergency — which ends up being costlier.

                Introducing MUrgency

                Urgency was founded by Indian entrepreneur Shaffi Mather in 2014 as a technology start up that aims to deliver rapid emergency medical services through a mobile application.

                MUrgency connects patients in emergency situations to available medical personnel. A patient or, more likely, a bystander will load the application and call for help. The central MUrgency dispatchers will dispatch a nearby responder to provide pre-hospital stabilisation, preventing the patient’s condition from worsening before a responder arrives.

                Responders come from two sources: hospitals and independent medical professionals.

                For hospitals, MUrgency signs up all responders in the emergency department, who are then dispatched when a request comes through. Independent responders, on the other hand, travel directly to the scene of an accident or emergency to provide care before the ambulance arrives. Users are charged for this service, and revenue is split between MUrgency and the responder. If users pay using a credit card, MUrgency receives the money, extracts a commission, then transfers the remainder to the responder. If a user pays cash, the responder is paid directly, MUrgency then billing responders for its share of the revenue.

                  Early on, MUrgency recognised that its business model would be constrained by the low “hit-rate” for emergency medicine. Ordinary users were unlikely to face a medical emergency, either as a patient or as a bystander and thus, a single user would only pay for services in rare cases: perhaps once every 2-3 years, which in itself is undesirable.

                  Even with a wide user-base, only a tiny number might convert into paying customers, and then only very infrequently. Furthermore, those in urgent need must be treated irrespective of their ability to pay.

                    MUrgency's original business model:

                      Thus, MUrgency needed a way to convert more users into paying customers. Better engagement strategies would not have solved the problem — the issue was not a lack of users downloading the app, but rather insufficient usage of the paid services. MUrgency recognised the need to expand their platform of services in order to increase the number of payments per customer.

                      Payment presented a different issue. Under the original model, the person who benefited from the service would not be the one ultimately paying. In most medical emergencies, a bystander, not the patient, would call for the responder, and therefore would be the one “on the hook” for paying. If it was a true bystander, with no relation to the person in trouble, there would be no way to ensure the right person paid for the service. By extension, running the service through cash means that MUrgency was relying on a third party — the responder — to handle payment.

                        Benefits of Expanding the Platform

                        Participants suggested that MUrgency organise its platform of services into three pillars:

                        “Emergency”, “Connect” and “Community.”

                        The app’s expanded services are based upon their “on-demand” model, but adapted for less urgent types of medical services. While more regular payments would sustain the application’s ability to provide faster emergency services, the expanded services would in turn also provide their own social benefits.

                        Certain services, such as medicine delivery and lab tests, would capitalise on the “on-demand” aspect of MUrgency, and its ability to get goods and services to people faster than formal channels. However, the most promising addition to the platform — both from an operational and social standpoint — is the provision of home care through the MUrgency application.

                          Home care is, in general, more expensive than care in a doctor’s clinic, as a doctor can attend to many more cases if he or she stays in a central location than if travelling to patients’ homes. For home care to make sense for the doctor, the fees charged must be higher to make up for the shortfall of overall visits. Thus, home care competes on convenience and quality, not on price.

                          MUrgency’s model expands the provision of primary home care to include non-doctor professionals, allowing home care to compete on both convenience and price. Nurses and emergency medical technicians will be able to offer certain non-medicated and non-invasive services at a lower price than doctors. The platform also allows them greater income potential than what they would make working just in a doctor’s office.

                          Nurses are a repository of medical skills and training. While they may not have the skills to administer invasive treatments, they are capable of making basic diagnoses, communicating basic information and conducting physical check-ups. They play an important role in monitoring the health of those with more chronic conditions, and recognising when additional treatment is required.

                          In fact, many of the basic tasks done in a doctor’s office are conducted by nurses, not by the doctor. Nurses and other non-doctor medical professionals can be included in the provision of these services as MUrgency has already developed its medical profession validation process. As it is a resource-intensive process, the ability for nurses to conduct non-emergency care dramatically improves the cost-benefit equation.

                          Employing nurses and Emergency Medical Technicians to provide non‑emergency care has operational spillover effects. Many in the community were sceptical of receiving medical advice of anyone other than a doctor in an emergency, and indeed several EMTs admitted that they would likely not respond to an emergency when they were not “on-the-job,” for fear that the community would reject their help.

                          Users do not get a choice of who arrives on the scene to help them in an emergency. This means that a nurse or an EMT could arrive on the scene when the user is expecting a doctor, thus risking rejection by the patient who might choose to wait for the ambulance. This risk increases if the nurse or the EMT lacks documentation that identifies him or her as a medical professional.

                          However, employing nurses and EMTs to provide consistent non-invasive and non-medicated care builds trust in their skills amongst the community. Thus, when they are called to handle more serious cases, such as medical emergencies, it is expected that the patient will be more trusting of their advice and care.

                            This model works best in the developing world, where labour is generally cheaper than capital.

                            In the developed world, the reverse is true, and thus it is much less economical to spread coverage using dozens, if not hundreds, of individuals. In the West, technology is relatively cheaper — hence the drive to automate much of the basic tasks of medical diagnoses and treatment. However, in the developing world, nurses and EMTs are still relatively inexpensive, making the model more feasible.

                            Furthermore, the MUrgency model not only provides operational benefits, it also presents key social benefits as well. First is the express purpose of providing home care: spreading the coverage of primary preventative care in the community. Growing numbers of “lifestyle conditions” are better served by constant care, which the model provides in a manner both convenient and affordable.

                            As emerging markets develop, and average incomes increase, this approach becomes a way to address the correlated increase in non-communicable diseases (NCD).

                            • In China 82% of the disease burden is due to NCDs.
                            • Indonesia has lost 15,000 years to premature mortality caused by cardiovascular disease.
                            • Many more need healthcare models that can better address the growth of chronic conditions.

                            There is also an efficiency benefit to splitting off basic tasks from more complicated medical procedures. Individual doctors do not have a triaging system that can determine who among their non-emergency patients must be prioritised, and given that a doctor cannot cut an appointment short if it goes overtime, wait times in the office invariably increase. If basic medical tasks, such as physicals and check-ups, could be split off into a separate category handled by nurses and EMTs, this will undoubtedly lead to more efficient treatment.

                            Last but not least, the increased economic opportunities available for nurses and EMTs is a significant social benefit of the model. They would be provided not only with additional income, but also a chance to develop their own individual skills in providing primary care, which can be the stepping stone for further career opportunities. If MUrgency succeeds in pioneering this new model, it would drive demand for nurses and EMTs in the wider population. Nursing is an aspirational career, and one of the tracks that allows people to move from the working-classes into a stable middle-class lifestyle. India is also in need of more nurses, as the country’s current average is one nurse to forty patients, while the ideal ratio is one nurse to four patients.

                              Conclusion: Application and Adaptation beyond India

                              The MUrgency model was developed in the context of India, and the state of Kerala specifically. However, it is expected that the model can be applied in other markets and countries in the developing world.

                              India is not alone in its growing incidence of lifestyle conditions. China is a few steps ahead in terms of economic development, but it also has high rates of diabetes and lung cancer — and a demographic crisis where there are fewer people able to take care of an ageing population. Indonesia will have one of the world’s largest populations in the coming decades, approaching the population of the United States — it too will be faced with the challenge of expanding healthcare coverage, especially in its traffic-plagued cities.

                              Undoubtedly there will be others in Africa, Latin America and beyond who would benefit from emergency response at a single touch.

                              Asia is a region where labour is still relatively cheap, thus health services for example can be delivered more inexpensively with people rather than relying on technology. Whereas in more advanced economies, primary care could be provided through a dedicated device attached to a smartphone, in less developed economies it could be provided by a nurse on a motorcycle.

                              Flexible labour and the services it offers is well-suited to provide services in a region with severe constraints in mobility. Massive increases in car ownership have not been matched with sufficient road infrastructure, leading to debilitating traffic congestion throughout the region. Emergency response is not the only service to have been affected by crowded streets — perhaps other service delivery would also benefit from a similar business model.

                              Finally, the MUrgency case offers an illustration of the opportunities for launching new ventures in India, whether commercial or socially-oriented. India’s states are a good testing ground for new and innovative business ideas as they have large populations that are often under-served and facing resource constraints. Even within the state of Kerala, the market is large enough for a business to achieve significant scale to provide insight into future opportunities, throughout India and abroad.

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