A Business Case for Branded Primary Healthcare Services In India

This winter Delhi has been smothered with fog or rather smog. While, I am one of those who enjoy the cold and love my walks in the neighbourhood park, pretty much like almost everyone else in the city I am not immune to the cough, cold and the respiratory track infections that that the damp and the cold brings.

I have been struggling with a bad cough for the last few days and have been wondering that it is perhaps about time I saw a family physician. Unfortunately, we do not have a regular family physician and I am not sure where to go. I also know if the problem worsens and a fever materialises I would go and see a specialist at Max Hospital and with a course of antibiotics I would be fine.

However, this is not the way it is meant to be. For something like this shouldn’t I be going to a neighbourhood clinic and getting the problem fixed before it became bad enough for me to see a specialist at a big hospital? And this brings me to the point that we need good quality and reliable primary healthcare in our neighboourhoods. There is a significant business opportunity here waiting to be tapped.

A Little bit of History

Apollo Hospitals tried setting up Apollo Clinics a few years ago. I was part of the founding team, which went into planning the clinics and the business around them. Apollo however was clear that it was not going to own or fund these clinics. They were supposed to be franchised with Apollo providing medical knowhow, its brand name, some of its doctors and IT support connecting the clinics with the hospitals. Ratan Jalan the than CEO had a vision of opening 200 clinics in 3 years. The clinics were supposed to provide outpatient services, namely consulting with doctors, diagnostic imaging services which included an X-Ray and an Ultrasound basic cardiology diagnostics like an ECG and a Treadmill test and a pathology sample collection centre. We sold some of these franchises and the Apollo Clinics started functioning with the first one commencing operations in Janakpuri in New Delhi. The owners were businessmen running a computer hardware store in Nehru Place and had no prior experience of healthcare. Similarly a few other clinics were also franchised and were set up in Delhi, Kolkata, Bangalore and elsewhere . However, it became apparent early on that Apollo was hardly serious about this business. They were keen on netting more patients for their large hospitals through this network and saw these as no more than referring centres and the support that was promised to the franchise owners  never materialised. The smarter ones quickly realised that in this new business they were pretty much on their own, learnt the ropes of this new business fast and managed to survive. Many did, many shut shop. Apollo was hardly bothered with any of this.

Max Healthcare too experimented with Dr. Max Clinics in New Delhi. Two clinics were set up in South Delhi. Unlike Apollo, Max invested in the clinics and had no desire to franchise. This experiment unfortunately failed mainly because Max in those days was focussed on rolling out its large hospitals and these clinics did not get any management attention. They were just not worth the trouble in the larger scheme of things and were closed down after a few years of experimentation.

The Learnings

While Apollo and Max both tried to set up Primary Healthcare Clinics, they were hardly serious attempts at the business. Apollo did not want to invest and was keen on skimming profits at the cost of the hapless franchisees and Max was just not ready at that point in time for something like this.

Apollo Clinics had a large upfront investment of approx. Rs. 20MN in the venture and since they themselves were not investing, they allowed the costs to go up and with the franchisee not knowing any better, they got away with this. When we crunched the numbers at Max we realised that a fairly decent clinic can be set up for as much as INR 5-7 MN.

The biggest challenge really here was about getting quality doctors (Family Physicians, Paediatricians, Internal Medicine, Obs and Gynae and Cardiologists) to join the clinic. Since the clinic is a very local enterprise one would want to pull in local doctors. However, we discovered at Max that many of them were just not interested as they saw the clinic as serious competition. They were afraid that if they moved to a Dr. Max Clinic and asked their patients to come there, the patients in future might prefer the superior and more professional services of the clinic. We tried hard to convince the local doctors that we sought a win win partnership but it really did not go anywhere.

The solution thus lies in forging a relationship with the local prominent doctors, which safeguards their economic interests. This can be achieved by asking them to invest in the venture. Thus 50% of the ownership of the clinic can reside with the lead consultants in the clinic. Thus let us say a sum of INR 2.5-3.5MN can be invested by the doctors and the balance by the entrepreneur, who sets up the business. A city like Delhi can easily absorb at least 100 such clinics and the model can be scaled up and rolled out across the country.

The clinics can than be established as a chain and can be marketed under a single brand name, 50% owned by an entrepreneur and 50% by local doctors. The clinics can all be connected under an IT backbone and data can be shared seamlessly. This can also open up enormous revenue possibilities from scientific research and allied work. Costs can be driven down by centralised purchasing and efficient supply chain management. Superior and unique customer experiences can be delivered through processes integrations and people training. I personally believe time has come for these clinics to emerge and claim their rightful place under the sun.

Finally, will this mean the McDonaldisation of primary healthcare in India? Well, may be yes, but than don’t we all love the neighbourhood McDonalds.

Pic Courtesy http://theapolloclinic.com/CorMainArticle.asp?Id=3

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The Silly Question of RoI in Healthcare Marketing

The other day I was with Dr. Jadhav who heads the Marketing function at the well known Narayan Hrudayalaya in Bangalore. Dr. Jadhav was keen to use radio for his hospital’s communication needs and I was hoping to persuade him to advertise with Fever 104, the radio station owned by The Hindustan Times, my current employers. Narayan Hrudayalaya, which is a well-known cardiac hospital thanks to the famous Dr. Devi Shetty and his pioneering initiatives, has recently started a Cancer Centre as well as a Multi Speciality hospital and wanted to promote these. The aim of the communication was to tell the citizens of Bangalore about these services available at Narayan Hrudayalaya and to drive ‘footfalls’.

While I discussed the plans with Dr. Jadhav, I could not help but notice his concern about the RoI on his marketing spends. Dr. Jadhav was very clear that if he spent Rs. 100, he needed 3 times the  sum in revenue, which could be directly attributed to this activity. I could easily relate to this because this is exactly the kind of  expectations the management teams had of me, when I headed the Marketing function at Max Healthcare and Artemis Health Institute.

I wish calculating RoI on healthcare spends was this easy. While there are many websites, which help one calculate RoI on marketing spends using complex formulae and spreadsheets involving the lifetime value of a customer, the cost of capital and what have you, I believe quite often the best way forward is a subjective gut feel and patience.

Measuring the success of a healthcare marketing campaign by merely counting the number of queries/walk ins generated in the hospital OPD is a great folly. The hospital business is unlike any other business and one must remember that exciting marketing communication alone will not lead to people walking in to check out the services of the hospital. This can happen for a new restaurant or a movie theatre,  but for someone to visit a hospital he must have a pressing need.

Tactical communication involving discounts, freebies and the like should be handled with care. I am not sure I would prefer to go to hospital for cardiac surgery because there is a discount being offered on the surgery, or I would like to go under the knife at a particular time just because the hospital is offering a deal. Come to think of it, I would be downright suspicious of the hospital if it tries to hustle me into a medical procedure by making a commercial offer.

Marketing spends in a hospital must be looked upon as an investment in the hospital brand and the values it stands for. The customers should be informed about the services of the hospital, the experience and training of its doctors, the robustness of its systems and processes and above all the promise of the experience the hospital hopes to deliver to its customers. It can highlight its ease of access, competitive pricing vis-a-vis other hospitals and superior services.  The hospital must showcase medical excellence, send out stories of success against great odds and constantly remind its customers what it truly stands for. It needs to communicate all or some of these over time before it should even attempt to measure the RoI.

A hospital’s brand equity is built over many years and much as hospital marketers would like to hurry this up, there are just no shortcuts. A hospital must set aside a small sum of money (7% of sales in the first years tapering to 2-3% in later years) year on year to spend on connecting with its patients and the local communities it hopes to serve. It should diligently spend this money informing, educating and reinforcing its brand values.

A few years later, the hospital will find itself buzzing with patients and no one would really be interested in the RoI on marketing spends.

Indian Healthcare 2010

Here is a list of 10 things one would like to see happen in healthcare services arena in India in the New Year.

1. Healthcare Service providers should move faster towards recognising the patient as a customer and focusing on delivering ‘Total Patient Care’. This would include better medical care as well as much superior levels of hospital services. Hospitals need to invest heavily in people and process improvements to achieve the goal of ‘Total Patient Care’.

2. Investment in the hospital brand. Most hospitals in India are chary of investing in the brand and whatever little marketing communication that happens is purely tactical, meant to drive traffic or communicate the commencement of a new service or the addition of another doctor. This must change. Hospitals must find a credible and differentiated positioning in the consumer’s mind and move quickly to occupy it.

3. Develop an information resource pool that allows patients and caregivers to check out the hospital services, compare doctor’s qualifications, training, specialisation and years of experience.

4. Focus on wellness rather than illnesses. Indian hospitals are mostly about sickness and ordinary folks dread visiting hospitals. It would be a lot better if our hospitals also incorporated wellness services and promoted them aggressively. Prevention and community medicine should become critical areas of focus.

5. Develop sustainable and high quality outreach programs by seeking local community participation. I live next doors to Indraprastha Apollo Hospitals in New Delhi and I often wonder, wouldn’t it be great if this hospital ran a community health program in our area. The local community can offer space for the hospital to run and manage a small clinic with a round the clock nursing coverage and doctors (family physicians and specialists) visiting for a couple of hours everyday. Imagine, all major hospitals running maybe 5 such clinics in areas abutting them. The hospitals will not only get more patients, they will earn tremendous goodwill of the local community.

6. Use social media to create patient communities and facilitate constant exchange of thoughts and ideas. Let medical experts join in to provide guidance and keep the community interactions at an even keel. We had tried something like this at Artemis Health Institute in Gurgaon. Unfortunately it fizzled out once I moved on. More hospitals need to remain connected with their patients in a meaningful manner, even when they do not need the hospital. It is an investment in a relationship, which will pay dividends in the long term.

7. Improve Emergency services. I recall calling Apollo Hospitals once to rush an ambulance to my residence to pick up my wife who had accidently hurt herself and was bleeding profusely. I explained that I was at work and was on my way as well. I reached home before the ambulance and brought my wife to the Emergency in my car. The ambulance never reached my place because the Emergency services at the hospital kept calling my wife at our home landline phone to confirm whether she was really hurt!!!

8. Government run hospitals treating the poor are models of sloth, inefficiency and corruption. It would be great if private enterprise forges some kind of a win-win partnership with these hospitals and improves services. I am sure the savings from reducing crippling systemic inefficiencies will itself ensure decent profits for the private healthcare enterprises. The government must take initiatives in inviting a few carefully selected private healthcare organisations to participate in this experiment.

9. Health Insurance must penetrate deeper and wider. The claims processing should become less cumbersome. In this age of instant communication, hospitals and insurance companies manually fax documents, seek patient histories and look for loop holes to wriggle out of paying claims. This must end. Insurance companies and hospitals must connect with each other seamlessly and exchange information that helps patients get better service.

10. Rural and semi urban India must get its due share in the development of healthcare infrastructure. The government must encourage investments in primary and secondary care  in these areas. Unless we have more and more people accessing reasonably good quality healthcare services close to where they live, the India growth story will remain a big sham.

Here is wishing everyone a happy and healthy 2010.

Pic courtesy http://www.muhealth.org