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 Rajasthan

Mom & Home

Pop Stores Remedies
Self Medication

Ayurvedic
Traditional
Ayurvedic +
Healers
Allopathic

Nurses
Quacks Jholachaap
Doctors
Private
Bengali Practitioners
Compounde
rs
Attempted Solutions
• Bring doctors in vans at specific times
Mobile • Reached sustainability but not scalable
Medics • Lack of doctors willing to take the van ride
• Patients couldn’t time their illness

• Part of Piramal Healthcare

Telemedicine • Use video conferencing to connect with rural patients
Initiative • Pilot lasted six months and failed
• Technical Issues coupled with lack infrastructure

• Systematic community transformation initiative

Andhra • Health centers along + water & education initiatives
• Trained local leaders to take over administration late
Pradesh • Health hotline, mobile van service, telemedicine service (video
Project conferencing)
• Most OPEX handled by Govt.

• Disha by Philips:- Sent out vans but used telecommunication with

Other hospitals for diagnosis
Projects • World Health Partners:- Franchise model connected with
telemedicine center for diagnosis asistance
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

Referrals Diagnosis Doctor’s Approval Mumbai Call Center

Mobile
PSS Medical Kit
Villages Phones
Advantages of Competing Services

Parameter Quack Pvt. Clinic e-Swasthya

Treatment of time Immediate Delayed Immediate

Practitioner Doctor +
Unknown Doctor
Qualification CDSS
Treatment Quality Questionable High High
Pharmacy
Medicine Quality Low High
Dependent
Patient Care None Low High

Loss of time Minimal High Minimal

Loss 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 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 1/10th 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 realities
Average number of patients grew – But slowly (5 – 10 yrs expected )

Stay in business or exit ?

 Force Field Analysis
Current State:- Desired State:-
Average of 1 patient/day Average of atleast 3 patients/day
Driving Forces Restraining Forces
Lack of Awareness
Additional Family Income
Bad Mouthing by Competitors
Status
Cultural & Social Obstacles
Exists a need for such service
Reputational Consequences

Transformative Opportunity (Veil)

Excess free Time
Trophies/Awards Entitlement to Salary

Referral Discounts Skepticism to Outsiders

Thank You!