Ideation to Execution

Scaling up is often a nightmare for several young and ambitious entrepreneurs. From attracting the right talent to managing cash flow, Team HE brings you few tips to ignite innovation in a start-up.

For Indian entrepreneurs of today, the key word is investment. Attracted by the sheer excitement of adventure, awesome reports of funding and the fame that hangs in around star start-up founders like Rahul Yadav, the desi entrepreneur has hit the road.

Clearly, the average age of healthcare entrepreneurs who were able to get large funds and scale their business fast had dropped by about ten years. Take the youthful healthcare start-up, PSTakeCare, Goqii and Lybrate- all of them are as imaginary as real.

A twenty year old something bagging funding from hedge funds today doesn’t surprise us. However, not all is well in Eden. Indeed, many entrepreneurs were shocked about media reports about failure of a national eye chain, which tried to replicate its successful ‘southern model’ in North India. At another time or in another place, these incidents would have been labelled as sporadic outbursts but not in Indian healthcare sector.

What next, is a question that is being asked as the realisation dawns on a growing tribe of young entrepreneurs, accustomed mostly to urban patients, that future is going to involve building a market in smaller towns. All the leaders are well aware that to engineer growth, they will have to align with communities as well as government agencies and put forth a credible alternative in front of people.

Avoiding hasty scaling death trap

“Market size of healthcare sector is huge and the growth is also high for the industry, which makes it very lucrative for entrepreneurs. Healthcare industry is expected to be an 280 billion USD market by 2020 and the growth rate expected is close to 40 percent. Hundreds of people start new ventures in India, and of those that survive, majority remain small. It’s only a few high impact firms, who contribute to the healthcare sector. Eventually many growing firms get sold to big players and a rare few grow up to become big. No one provides a complete solution for the sector,” says Bharat Bharadwaj, co-founder and chairman of the online portal, TopDoctorsOnline (TDO). TDO offers online content, real time online consultation and booking for diagnostic tests for more than 60 million users in the country.

He points out four key elements to scaling the growth curve which include attracting and retaining skilled employees, crafting a unique strategy, planning an error-free execution and maintaining cash reserves.

Bharadwaj explains his strategy about content. The content of the website is created by doctors and polished by content writers. “It’s true that Google provides you lot of information. But when it comes to healthcare, the information available online is often confusing. Healthcare is an extremely dry subject and our writers convert it to easily consumable packets of information. If a healthcare customer has a query, his first point of interaction will always be with a doctor.”

When TopDoctor ventured in to the market in 2009, they were a B2B enterprise. The company created white labelled portals for service providers like Vodafone and Airtel. The website was launched in 2012. “We are one of the cheapest healthcare providers in Indian market. Our basic subscription model is priced at Rs 7 for a day,” says the chairman.

When Bharadwaj ventured in to the healthcare sector, he was aware of the lack of trust about online healthcare solutions. “The mainstream sentiment in 2009 was that Indians wouldn’t use healthcare portals and that online payment gateways would create hurdles for start-ups. However, we believed that the gap in healthcare sector can be bridged only with the help of technology.”

Funding

Bharadwaj is a believer in the power of internet and how brick-and-mortar players will not be able to provide solutions quickly to patients in Indian towns. “Many patients travel with their families to cities for better treatment. The cost of care can be brought down by use of technology or digital technology,” explains Bharadwaj. He also adds that they were lucky that they did not need support from external players. “We have come a full circle in 2016. We have built standing relationships with the medical fraternity, senior thought leader as well as mobile companies. Currently, we are looking for some equity,” he explains.

Bharadwaj’s approach was driven by his own experience in the healthcare sector and his interest in digital healthcare. He admits that the digital healthcare space across the globe is still in a very nascent stage. “There is no solid model in the digital healthcare space. Internet is a medium that brings level voice to the world. However, in India there is no clarity regarding the rules that govern the sector, be it telemedicine or a mobile application. The recent ban on selling medicines online is an example of this ambiguous nature of policies. It’s too early to predict whether digital healthcare models will ring in more moolah than the traditional models,” adds Bharadwaj.

“The challenges that we face now are very different what we faced during our early days. In 2009, customers were reluctant to use their credit card for an online portal. Smart phone penetration was low. In 2012, we moved from internet to mobile. Today, the challenge is to be unique from other players with a good business model. We try to stay ahead of the competitors at least by one year. To cut to the chase, processes are very important,” concludes Bharadwaj.

Heroes and Unicorns

Not many decisions to scale, of course are made with an eye on the country’s linguistic and cultural differences in each state. Explains Shiv Kumar, President of Swasti, a health resource centre established to provide health services to socially backward communities: “To scale up a business from a handful of employees to something significant, a company needs to focus on deliverables like reduce time for operational activities and realign everything else to drive execution and results.”

Kumar founded a management consulting company in 1994. He found himself bootstrapping and credits the tough times with helping him build the real founding team of the company.

“We found out that there were several NGOs and several committed doctors in the private sector. But there was a gap between the policy makers and the agencies which execute their policies. At that time, there were no public health NGOs that did modelling in public policy space. Public health is not an easy space to be in as you need a lot of evidence-based models.  Most of the solutions of the government were very Delhi-centric. We decided to focus on “meso-level interventions.” We take a very difficult public health problem and develop a very cost-effective and replicable solution and share that model with NGOs and government. When HIV interventions were modelled ten years ago, they were largely medical interventions.  Many players focused on setting up a clinic. We helped sex workers come up with an organization and devise an intervention plan, which addresses HIV and beyond. This has become one of the most studied models in healthcare space and led to several policy changes in the sector. The project reduced the prevalence of HIV from 20 percent to 6 percent. It was a sustainable intervention, which was managed by community,” says Kumar.

“We help other people replicate our model through technical support. A typical NGO would implement a policy, if you give them funds. We take grants to develop a high quality model which can be adopted by other NGOs,” he adds.

One of the defining moments in their growth story, is an app called Suyojana, which improves the quality of care provided by ANMs. “Once the training of an ANM is complete, there are very few ways in which quality assurance is done. It is not possible to give a manual to an ANM and say if the child has these symptoms, then do this. The app helps an ANM to do investigations in a systematic and organized manner, and improves the accuracy of prenatal tests. There are hundreds of apps for health worker. Our objective is to make the technology popular,” explains Kumar.

“When we were doing research for D-Tree app, we figured out that ANMs were not even touching the women. For instance, we wanted to find out whether ANMs were checking BP of pregnant women. We had configured the app to find out time gap between the previous question and the BP question. We also wrote another program to figure out whether the BP data showed variance.  At the end of the pilot project, we figured out that many ANMs were not conducting tests. A typical product person will consider technology as a magic wand that will solve all problems. However, we know the problem is much more complex than that. A senior ANM will often not use a mobile phone to do tests. You need to help them overcome the barrier. You need to load couple of games. We train her in such a way that the utilisation of the app becomes useful for her work,” he adds.

People Matter

The founders of Swasti are from the Institute of Rural Management Anand (IRMA). Currently, there are 97 members in the team. The team found Swasti in 2003. Over 13 years, the organisation has delivered several key models for the Public health sector. So, what makes a public healthcare programme tick in India?

The funding strategies in public health are always opaque to players in the space

“The funding strategies in public health are always opaque to players in the space. It often comes with lot of strings attached. It is always better to stay away from funding. We have been fortunate to generate funds through consulting and technical support,” points out Kumar.

Making people understand our work was one of our biggest challenges. “Many people did not trust our models initially as they were more concerned about whether we had doctors in our team. Brick and Mortar model was perceived as the only solution for healthcare issues. Policy Modelling was considered as an unproven business.

Basic primary healthcare does not need infrastructure. However, government officials are often reluctant to think beyond PHCs and district hospitals. People don’t understand that providing care to the marginalized is more expensive than catering to middle class. Many players underestimate the cost. Preventive care is even more expensive,” recalls Kumar.

“Unfortunately, to find skilled professionals to work in rural areas is also a big challenge. Many young doctors want to earn the money they invested in their education without much delay. One of the biggest challenges we often face is to recruit, train and retain staff,” he confesses.

PPP is definitely one of the solutions for the healthcare sector. But, its relevance is often over-hyped. Most policy makers also ignore the role of communities in such models. It cannot solve all the healthcare issues. For our PPP projects, we include local government bodies like Gram Panchayat. The government is keen to invite private players to partner in areas like ambulance service and IT. We need private players to be part of government healthcare facilities in areas like Orissa. The government also has to be fair in their policies. You cannot invite a private player and provide him a lakh to run a PHC; it’s not going to work. Attractive policies certainly need to be put in place to attract private players. It’s not wrong, if a private player makes money by running a PHC, as long as they provide quality care to poor. Tax breaks is only one of the ways to make PPP attractive. Accountability is very low in PPP. The government has provided free land for several players in Delhi and Mumbai. The condition is that 30 percent patients would be poor people. However, government has no mechanism to monitor it. Authorities should set up a body to monitor these rules.

Scaling up Imyths

Entrepreneurs are specialists in their own niche, but scaling up often requires entirely new skills like networking. But are there any myths?

“One of the biggest myths about healthcare sector is that human resources are available. Second, myth is that technology can solve all problems. There is lot of hype about how baby warmers and DIY devices can reduce serious health care issues. These are tools to make things better, but they are not an end by itself,” concludes Kumar.

Integrating with the World

Optimism does die hard. Some point that the Indian consumers are different from consumers in developed world. Says Abhimanyu Bhosle: “To come up with a business idea and scaling it up requires a good understanding of the Indian market.” According to the co-founder of Live Health, healthcare sector has not been able to completely reap the benefits of technology. “Technology has drastically changed sectors like transport and e-commerce. But one cannot say the same about healthcare. Even though we hear about portable scanners and blood testing equipment, many players don’t even have advanced scanners in their labs. There are highly advanced diagnostic devices available in the market. But the question is how many hospitals use those devices?” asks Bhosle.

Bhosle believes that the person who suffers due to the sector’s slow place to catch up with technology is patient.

“We have been hearing about electronic medical records from 2004. However, majority of hospitals still don’t offer e-records. Even if they digitize records, patients are not given access to digital copy of their medical records,” says the co-founder of LiveHealth, which generates intelligent reports.

A fundamental responsibility of a leader of company is also prediction, he notes, adding, “Healthcare lacks centralization. Even the local labs of a pathology lab chain are often not digitally connected. Most of the hospital chains have paper-based reports. Most of the clinicians don’t prefer to use a computer for diagnosis and reporting. That’s exactly the reason we started our journey with diagnostic labs.”

Good Times, Bad Times

According to Bhosle, even though the number of start-ups has increased, most of the entrepreneurs don’t get support of community. He explains, “An entrepreneur really needs to understand that there’s no easy way out or quick solution for the healthcare sector. Most of the time, you are lonely in the eco-system. If you go to a Google play store or even IOS app store, you can find very few health apps. Further, it’s also not centralized. Even a successful player like Practo doesn’t offer online payment for the patient. ”

Boot Strapping

When you expand to other cities, the economies get better and scale get larger. Cash flow is an integral element during this phase, says Bhosle. “We raised our first round of angel funding of USD 3,00,000 from Mplier healthcare ventures and Dr. Pramod Dhembare, founder and MD of Fidelity Life Sciences,” he states.

He also explains that raising funds for healthcare is more complicated than other sectors. His opinion illustrates the healthcare funding paradox.  “Many investors might not have domain knowledge of the sector. Further, investments are more focused towards hospitals and diagnostic chains. It’s hard to find an investor for health tech today. This means, funding can be brutal to entrepreneurs. It always comes with strings attached. It is important to generate sufficient profit and cash flow, so that you don’t have to rely on banks,” explains the alumnus of Pune Institute of Computer Technology.

In the beginning itself, it’s important to create the habit of keeping cash reserves, points out Bhosle, adding, “That allows start-ups to weather storms. In fact, companies like Microsoft always keep a year’s operating expenses in the bank.”

From the early days, LiveHealth had heavily invested in building cutting edge infrastructure to support a business that was growing fast every day.

Business Model- No Simple Miracle

The team started its journey by developing an app for a Suyog Life Care. “We thought it would be useful to provide access to medical records also on the app. Our objective is to disrupt the way patients access medical records in India. Today, we have tied up with more than 176 different players. The start-up works as management information system (MIS) for healthcare providers. We started as an end to end solution for laboratories and then grew to diagnostics and hospitals,” explains Bhosle. “It takes ten hours to get a report from a diagnostic center. But, if they use LiveHealth, they will get the report within six hours. Once a patient decides to do diagnostic tests with a partner of the company, the system does the following: it registers the patient with the provider, generates a unique bar code, tracks the status of the sample and collects directly from the medical instruments in the lab,” he adds.

Today LiveHealth, not just provides a digital medical report, but also an ‘intelligent interpretation’ of the report, which according to Bhosle, is their USP.

“We are a MIS and EMR for providers and a platform for patients. So essentially, it’s an ecosystem of providers, doctors and patients. With every report, there is an interpretation about the test results, including reference ranges for test results. We use colour indicators to highlight what is normal, what is abnormal and what is borderline,” concludes Bhosle.

A Messy Challenge

In India, it’s no joy, if you have to file a complaint against a heap of garbage dump in your neighbourhood. Find out the right officer in the BBMP office is tough because there are no clear guidelines. This was the reality that hit a group of NIT Surathkal students when they wanted to complain about an illegal garbage dumping site in their neighbourhood.

“We could not figure out how to file a complaint about a sanitation issue in our own neighbourhood. And that was frustrating. The question before us was: how can we use technology to solve the garbage issue,” says Anindita Ravikumar, a chemical engineer at Healthizen.

Healthizen app is what they arrived at. You cannot only click a picture, it also has tools that enable you to key in details about the issue and send it to the concerned authorities. It also allows the users to track the status of their complaint.

The app has received funding from the government of Karnataka. “Our inability to file a complaint was in fact affecting the quality of life in our city,” explains Ravikumar, an NIT Surathkal graduate. It didn’t take long for the young techies to build a solution to the garbage problem of Bangalore.

Working the Ropes

The team approached the problem at a micro-level. And that meant, involving government and community. The team also successfully persuaded government authorities to be part of the app. “We spent our summer holidays to develop the app. One of our interesting interactions was with Dr. Sadhana, Executive Director, KSHSRC. This was one of our initial pitches and we didn’t know how to explain. But she liked our idea,”  says Ravikumar.

Healthizen is an initiative of the government today and the team points out that it is the USP of the app. The app was officially launched in October 2014 and also got the attention of the Union and State Ministers.

Growth Hacking- not in Healthcare

According to the team, it doesn’t require expensive education or large funds to build an app for healthcare sector.”Creating tools has been democratized as anyone can learn to build an app and that’s driving start-up frenzy in the country. The emphasis of entrepreneurs needs to be on sustainable growth rather than quick growth,”  she says.

Currently, the healthizen team consists of seven people. So, far the app has amassed nearly 750 downloads. “We don’t expect every Bangalorean to use the app from today. But in time, you might be able to file a complaint and get response from authorities,” says Ravikumar.

One of the major challenges for the team is to get budgets for publicity, she says. “It is also not easy to work with authorities. “The enthusiasm of senior leaders often doesn’t percolate to the lower levels. This often creates problems for these initiatives,” concludes Ravikumar.

Hidden Challenges

In a country of millions, there are no dearths of contrary views.

“In India, public health is not considered as a problem that can be solved creatively,” explains V. Shakti, a start-up mentor.

“Even though entrepreneurs come up with solutions, they often have a dismal future because they are not supported by digital awareness campaign. Even app developers often don’t take an effort to upgrade it.  Further, there is no public service cloud to upload the information. We need a sustained campaign to bring awareness about these apps. You need sustained back end support for these apps. There is complete lack of back end support for these services which often run on CSR budgets of company. Kerala government launched a women safety app with UST global, and no one even talks about this app today. Similarly, i-ball launched a mobile phone with a panic button. However, it doesn’t take in to consideration how network of an area works. There are internet dark spots which exist in many rural and urban areas. It’s so obvious that if somebody wants to harm someone, the first thing that they will do is to switch off the mobile phone,”  explains Shakti.

Models dominating today’s healthcare market

Aparajita Agrawal, Director, Sankalp Forum, seconds his view. “It’s true that most start-ups look only at part of the problem. Many young start-ups are app-based and focused on tech-enabled delivery. They are more nimble and have better chances of survival.”

Managing various process and compliances is one of the biggest challenges for start-ups in healthcare. “We often find start-ups focusing on one part of the value chain. Two-thirds of start-ups are in to making existing brick and mortar models more efficient. Whichever study you take, you often find leading entrepreneurs struggling to crack the long gestation period of the sector. Players like Biosense, has not been able to launch more than one or two devices in the market.”

What Start-ups should Know

If you look at the last two decades, what hasn’t changed in Indian healthcare sector is how entrepreneurs don’t give importance to business models,” says Agrawal. “Indian entrepreneurs usually don’t focus on the whole spectrum of issues, because the cost is very high for healthcare. Successful players address part of the issue and provide disruptive innovations that can bring down the cost of a healthcare service. Start-ups are attaching themselves to reasonably working public healthcare delivery model, as they have better chances of survival. We have seen even big players like SRL diagnostics follow this route,” notes Agrawal, adding, “They started offering diagnostic services at Primary Health Centres for minimal profits in markets like Rajasthan. While short listing for new markets, it’s advisable to look at low income population.”

Simply put, for lot of early stage enterprises, expansion is linked to the kind of partnerships or alliances that they can find. “Scaling up is more opportunistic than strategic in Indian healthcare sector. Most of the time, a healthcare player enters a new market as they have found a new partner. Sometimes companies get funding based on conditions that they will operate in a specific market. It’s easier to scale up after a business model is perfected by the healthcare enterprise,” explains Agrawal.

Entrepreneurs need more Business Connections

Agarwal warns that the most important factor that most start-ups need to focus is to maintain a balance between growth and profitability.

She adds, “Entrepreneurs are constantly under pressure to expand many bet big on PPP. Most state governments are experimenting with PPP model in one way or another. The nature of public healthcare is so complex one player cannot solve all the issues today. The government is looking at private partners to bring better accountability and better efficiency in the system. However, the government usually prefers strategic tie-ups with non-profit organizations. It is usually up to these organizations, whether they want to bring more players in to it. However, one of the challenges associated with PPP is that payment cycles are often delayed. The model is inherently scalable because the government has reach. But smaller entrepreneurs, who don’t have bandwidth or deep pockets, often, find it hard to take these cash flow shocks. You normally find larger players coming in to these partnerships rather than smaller players. Smaller players often don’t find traction in a PPP model.”

There is lot of scope in terms of policies related to PPP model. The government still follows tendering processes. Many players consider government as a risky client, as they often don’t provide tax breaks or capital for their partners. If there was a tax-break for private players, more number of smaller players would enter in to PPP.”

According to Agrawal scope for insurance is huge. She explains, “The problem with insurance is that awareness is really low in India. It is a complicated product for majority of the population. For the low income population, it’s about cutting down their today’s income for an eventuality that may or may not happen. Most of the time, there is a mental block about insurance. It’s more about tax breaks for middle and higher income groups. However, there are companies that are working on insurance products to vulnerable sections of the population.”

She elaborates: “The overall start-up activity in the healthcare space has definitely gone up. Many would-be-entrepreneurs think that if they conquer 0.5 percent of the market, they are set. Many new investors are also entering the market, because they think nimble business models can be acquired by existing elephants in the market. Even if two out of ten start-ups do well, it’s a good number. That’s the reason why you see a lot of start-ups with a shelf life of one or two years, who want to be acquired by a bigger player. Today, there is a larger and innovative variety of capital available in the market, other than merely PE and VC investors. Many enterprises prefer generating smaller quantum of money from different types of sources. Many angel investors, philanthropic associations often don’t mind the long gestation period. It’s not like any start-up can raise money. But for the better performing start-ups, it’s possible to raise money from bank loans or philanthropic grants, before they go to PEVC.”

She also adds that majority of the current start-ups would die in the next ten years. The total number of start-ups will increase and after few years it might decline. As more money goes in to supporting start-ups and more products come up for the sector, it’s definitely going to be good for the healthcare industry.

What Public Health models can Teach us about Scaling up in Healthcare?

Experts attribute the complex journey of a healthcare company to the fragmented market.

“It’s not a myth that you can’t scale up in public health. It depends on whether you are able to resource scale up adequately. If you do it in bits and pieces, then it’s going to be a problem. There needs to be political will to make it a routine process of how a healthcare program operates. After scaling up in several regions, they have now found problems in certain states. Resourcing and monitoring growth to find out where the gaps are coming up is extremely important. It should be a continuous process of learning rather than setting something up and move on to a new project. To stick with a programme over a substantial period of time and constantly monitor the experience, correct problems and keep it as an ongoing project is extremely important,” says Shreelata Rao Seshadri, Professor, MA Development Program, Azim Premji University.

She elaborates: “There are many successful small healthcare interventions which have worked quite well in India. Problems usually arise when they try to scale it up at a national level. The first challenge is to scale up a programme in the same intensity. It can be quite expensive to take all elements of a particular model and scale it up at national level. It is also hard to replicate the closeness of the organization with the community. For example, when Integrated Child Development Scheme (ICDS) started out, it was a fairly contained programme, as the Tamil Nadu Integrated Nutrition programme. It worked very well at that scale. But when it was converted to a national programme, there were so many problem areas like training. It required two field workers to implement the programme. But hiring workers was expensive at the national level. They started out with one person. So, the authorities had to make all sorts of compromises to scale it up. Compromises have to be made due to lack of resources or lack of capacity, that alters the entire programme and the result is not the same.”

And as she explains: “Let’s say there are small interventions focusing on maternal and child health, where there is a regular monitoring and interaction at the micro level. If the same programme gets converted in to Reproductive or Child Health programme, it’s simply not possible. Then, you can’t expect the same results.”

Surviving the End of Funding

Seshadri, believes that funding for healthcare is cyclical. “For a while, there was lot of funding for HIV AIDS programmes. There was global emphasis to halt the spread of HIV. There was funding come from multiple sources like The World Bank, The Gate Foundation, and Bill Clinton Foundation. Everybody was trying to halt and reverse HIV AIDS. At that time, there was a huge proliferation of government initiatives and NGO initiatives.  For more than a decade, these funds were forthcoming and people were doing lot of work in the field. Now there is a shift and the feeling is that HIV has received a lot of funding. The programme currently focuses on treatment more than community awareness. With that shift, there has been change in the pattern as well as level of funding. These kinds of changes in the availability of funding could be due to local changes of priorities or even global changes of priorities. A lot of NGOs talks about similar trends. They get funding for one or two years for a specific project. After that there’s no assurance of funding and they have to constantly look around for a project that’s going to be funded and try to organise themselves to take advantage of that. It is a question of survival for them. Many NGOs work from project to project. Innovations in health sector often become shaky because of the funding issue,” says Seshadri, who has previously worked with Center for Global Health Research.

Managing Complex Journey

But are there any organizations which had managed to solve this problem? “There are many people like Dr. Abhay Bang in Maharashtra and Dr. Sudarshan in Karnataka, who have stayed with public health and focused on providing basic healthcare services for communities that work in rural areas on a shoestring budget too. We have a strong backbone in the non-profit sector. There are several good examples of people who have worked at the grassroots level,” says Seshadri, who has worked with several international agencies for more than two decades.

She adds: “There are activists like Dr H Sudarshan, who decided to work with tribal communities. He set up Vivekananda Girijana Kalyana Kendra for the integrated development of tribal in Chamarajanagar district of Karnataka. He is also the founder of Karuna Trust which is dedicated to rural development of states in Tamil Nadu and Karnataka. He has developed a very interesting PPP model.

“The government of Karnataka had identified 100 PHCs, where it was very difficult to hire a doctor. They looked for a PPP model to run PHCs in those areas. Dr. Sudarshan has been considered as a pioneer in the PPP model. Dr. Sudarshan took over nearly 40 PHCs in remote rural areas. They have been running quite a few of them and spread that model to Andhra Pradesh and Arunachal Pradesh. The government handed the PHCs to the trust and gave them the same amount of funds allocated for running the PHCs. They gave them choice to keep the government functionaries in the PHC or they can hire their own people.

“Majority of the government officials decided to go to other government institutions. So, they brought in their own teams to run the PHC. Not only were they providing services using the funds provided by the government, they were also able to raise private funding. They not only provided free medicine but also got in to a tie-up with Foundation for Revitalization of Local Health Traditions (FRLHT). They also ran an Ayurveda clinic in PHCs. This is one of the successful PPP models, which has been expanded to other states.”

She also sums up the current focus on insurance policies succinctly, when she says that for several insurance schemes like RSBY, services are provided by the private sector. “The issue is that government agencies don’t have the capacity to write a good contract and manage or monitor it. For example, when government provides free land and tax breaks for private players to set up facilities, the idea is that they are supposed to provide 30 percent of their services for the poorest. Majority of patients don’t even know about it. Private players often find loopholes for not providing such services. Even if you look at the insurance schemes, do we really have a thirty party to monitor whether private hospitals are providing ethical care? For instance, were all the tests and procedures really required? Who is actually monitoring that medical care is not escalated to take advantage of the insurance scheme?” asks the professor.

She also sees it as a sign of the times. “This is the problem with extending partnership to the private sector. The government does not have the capacity to monitor these projects. The number of C-sections is escalating possibly well beyond what’s medically necessary, probably due to the fact of the cost of the procedure is three times that of a normal delivery. But who’s going to look at each case and find out whether the C-section was actually necessary or not? When we don’t have the capacity, we are in a position where it is going to be a disaster very soon.  Everyone is critical of the American model of healthcare.  Despite being one of the most developed countries in the world, the US healthcare system provides the worst health outcome. We don’t have any safe guards in place, yet we provide lot of leeway for private participation,” elaborates the member of the knowledge commission.

PPP models in Digital Health Records

Seshadri is sternly disapproving of the manner in which PPP models are being allocated. One particularly disturbing phenomenon which has become quite a regular feature is the focus on EMR and Ambulance services, she says, adding, “Digitisation of health records is definitely a good idea. The quality of data is definitely something of great concern. Currently, we don’t know whether the data available is garbage or useful information. If you design a digital platform, it’s possible to create checks and balances to ensure the quality of the data over a period of time. Digitisation also has other challenges. For instance, even from the user’s perspective the person needs to be trained. There are other issues like internet, bandwidth etc. It is a very complicated process.

“Technology is very important. Upgrading technology is definitely a critical issue. However, there is an interface between technology and people. First of all, people should have skill set to upload data. The issue is that we collect huge amount of data. But no one really looks at it or uses it for decision-making. It is not just about making data available but also making people aware about its utility.”

Fragmented Solutions

The fact remains that aggressive shift from hospitals to technology is not a healthy model, says Seshadri. “A solution not only needs to look at technology, but also people and how they are going to use it. All these larger questions also need to be incorporated in to the discussion of scaling up,” concludes Seshadri.