Opportunity to create 10 million local female employment and use this as a flywheel to make healthcare universal in India

Suman_Jile · April 18, 2023, 2:44pm

If any of you would like to know the originating story, you can follow this Our Story

But the purpose of this post is to give all of you a sense of the future of Healthcare that we are building for 1.2 billion Bhartiya (excluding the top 10% of India’s population). Also, we want to build this future in a way that could be sustainable for all the stakeholders including the environment. And by posting here, we will get feedback from all of you.

We can understand the problem in four and five points:

India’s healthcare expenditure per capita is INR 5020 extremely lower than USA’s INR 8,76,838 and China’s INR 42,800. This means healthcare is unaffordable to the masses in all three countries - India, the USA, and China (this is true for the rest of the world).
And hence unaffordability of Healthcare is not just India’s problem but a global problem.
USA, China, and the rest of the developed countries solved the unaffordability of healthcare costs and made healthcare universal using the tool - Health Insurance.
95% of the USA and China’s population are insured under Health Insurance. In India, less than 10% of the population is insured under Private Volunteer Health Insurance (PVHI). This is because the available Health insurance is unsuitable, unaffordable, and unattractive for 90% of the population.
Unsuitable because of the uneven distribution of Healthcare supply: here is a picture of the current healthcare supply distribution

The super uneven supply distribution force 90% of India’s population to travel 3 or 4 times up to 1000 km for decent treatment and diagnosis. And travelling costs also have been an obstacle for women to access healthcare.

Unattractive because available Health insurance only covers IPD (Inside Patient Department) expenses but 70% of Healthcare expenditures are on OPD (Out Patient Department). This makes the available Health insurance unattractive and hence zero motivation to pay - cutting present cost for an uncertain future risk is not attractive.
Unaffordable because there is no underlying technology that can measure the health insurance premium based on individual profiles. The current method is one size fits all - adverse risk polling: insurance companies offset their losses of sick people (higher risk) by charging more from healthy people (low risk).

You see, it would be impossible to build or transfer Healthcare infrastructure evenly because it will demand billions of dollars of investment and that will further inflate Healthcare costs.

This leaves us with just one option build a Coordinated and integrated Healthcare infrastructure using available resources and technology. Frankly, just a few years back thinking about solving this problem would have been foolish thoughts. But thanks to multiple forces, today it is possible to solve this problem.

What are those forces:

Health stack: ABDM (Ayushman Bharat Digital Mission)
Partially-trained Health Professionals - ASHA, AW, CHO etc
Technological leapfrog on the AI front - if the current AGI is a child and utilized with moral responsibility has tremendous potential to solve many of our complex problems.

With all these forces and keeping the affordability for consumers in the centres, we have come up with a solution that has real potential to make healthcare universal in India.

We are also extremely excited about the solution’s potential to create 10 million female local jobs that have the potential to create a strong flywheel in making healthcare universal in India.

How?

India has 4 million semi-skilled women health professionals who are, based on their Impact, the spine of India’s primary healthcare, do most of the heavy lifting and have a strong personal connection with the local community - the custodian of hyperlocal trust. And with little effort and the right technology we can convert them into skilled health professionals that can be integrated into a coordinated and integrated healthcare infrastructure. And generate enough work for them so they could employ two more employees and boom - we have 10 million local jobs that would be making healthcare affordable for 1.2 billion Bhartiya. The work on this has already got started!

How much Co2 and travelling costs of consumers it can save?

National Health Profile 2021 released by the Central Bureau of Health Intelligence (CBHI), there were a total of 1.1 crores (11 million) admissions in the year 2019-20 in India, which works out to be an average of approximately 30,000 admissions per day.

Let’s say 80% of such admissions demand 3 or 4 travels - we can settle with 3 travels and an average distance of 100KM
Total Hospital admission by 80% of the population = 1.1*.8 = 88 Lakhs
Number of travel = 88*3 = 264 Lakhs (2.64 Crores)
Total distance travelled per year = 2.64*100 = 264 Cr KM
Let’s consider these buses are run on diesel = 7KM per litre
Fuel require to cover 264 Cr KM = 264/7 = 37. 71 Cr Litre
Let’s consider fuel price INR 100/litre and hence fuel cost = 37.71*100 = 3771 Cr
Co2 release per litre of diesel (There are other gases SoX, Nox etc)= 2.68 KG
Total CO2 release = 37.71 Cr * 2.68 KG = 101.062 Cr KG of CO2

This means we can save 101.062 KG of Co2 emission and INR 3771 Cr of travelling costs per year by building coordinated and integrated healthcare for 1.2 billion Bhartiya. What we all need to understand is that these are from 2019-20, the new numbers would be much higher.

Note: This is inevitable that the Healthcare expenditure per capita is going to rise and in that case, scale is one of the tools that will make healthcare affordable for 1.2 billion Bhartiya. For example, an INR 2 Lakhs of IPD health insurance is possible for a premium under INR 200 provided the number of risk polls is 10 Cr (100 million). And this amount would be affordable for every single Indian.

Note 2: There is tremendous power in standardization and scaling a product among 90% of the Bhartiya. Here is one example: In the 5 years 10 Cr+ (100 million+) consumers have enrolled for term insurance for a claim amount of just INR 2 Lakhs.

Growth-Graphe

And we understand those channels that can be utilized to scale the Jile Health solution.

I would love to hear feedback from all of you and answer your queries!

Suman_Jile · April 19, 2023, 2:17pm

I found one video talking about ASHA’s job function and deep trust in the community. With this strong trust, there is no need for insurance agents who charges additional commissions.

Pai · April 20, 2023, 3:04am

Hi Suman,

I was checking your website and could not understand how the model works exactly. Could you elaborate?

The semi-skilled health professionals, what are the additional things they would they be helping with and who will be employing them for this? If you can elaborate on this as well, please?

Suman_Jile · April 20, 2023, 6:44am

Hi Pai, Definitely

I actually pitched to the other Rainmatter team and assumed it to be understood, apologies. Also, I will be detailed but will try to keep some information invisible.

Before we understand the model, we all need to understand ABHA (Ayushman Bharat Health Account), which has also been termed as Health id. This is one of the public goods under Health Stack - ABDM (Ayushman Bharat Digital Mission).

ABHA (14 digits code) is Module 1 of ABDM (there are M2, M3, HCX etc) an interoperable health protocol that keeps digital records of all your health documents - Prescriptions, Lab reports, Treatment summary, EMR (Electronic Medical Records) etc.

One example: Let’s say, you visited Dr Lal Pathlabs and conducted a lab test since Dr Lal Pathlabs is already on the ABDM, your lab report will automatically get attached to your ABHA id.

Now for you to access your Lab reports there is an end-user app built by companies like us that you can call Personal Health Record (PHR) App.

Let’s call Dr Lal Pathlabs Health Facilities (HF) and for HF there is module 2 (M2) - LMIS (Lab Management Information System)

Now let’s say you would like to visit your family doctor (Health Professionals), after a few months, for them there is module 3 (M3) called Health Information User (HIU), since ABHA is also a consent-based protocol, you can directly give access of your Lab reports and other health documents to your family doctor through your PHR application. Your family doctor can make data-driven decisions based on your past/present health documents.

You see for a nation such as ours where 95% of the entire healthcare is offline availability of this protocol at zero cost is more revolutionary than UPI - and hence we call ABHA UPI of Healthcare.

Even while reading this, can you stress your mind and try recalling your past health records - physical and digital? Most probably, you won’t even remember. And unavailability of health records creates the following problems

Inflates healthcare delivery costs
Create subjectivity among the stakeholders
Risk of Fraud
Increases the healthcare delivery time
Demands multiple physical presences (again inflates healthcare delivery costs)

We will take one example from the above problem statements:

How 3 or 4 visits to a diagnosis can be reduced to just one?

All health diagnoses follow fixed checklists however just one of them demands a physical presence if the right data points are shared with Health Facilities (HF) and Health Professionals (HP).

You see if out of all the checklists only the Physical examination demand physical presence provided the right data points are available to HF and HP. This was impossible before ABHA but now it is possible thanks to ABHA. And if we divide this into 4 parts this is how the model shall look like

Suman_Jile · April 20, 2023, 6:48am

Sure, First things first, ASHA are the lowest churn of volunteer health workers less than 5% (the power of local employment. Here is the complete demography of ASHA.

A literate woman -Married/Widow/Divorced - and between the age group of 25 to 45 yrs., with effective communication skills, and leadership qualities and be able to reach out to the community

Current responsibilities of ASHA:

Conduct test of NCDs (Non Communicable Diseases)
Counsel women on birth preparedness, the importance of safe delivery, breast-feeding and complementary feeding
Mobilise the community and facilitate them in accessing health and health-related services
Provide primary medical care for minor ailments such as diarrhoea, fevers, and first aid for minor injuries

Current Work arrangements:

ASHAs have a flexible work schedule and their workloads are limited to putting in only about two-three hours per day, on about four days per week (All of them have enough additional hours in a day)

The current Compensation Structure (Average monthly income INR 4500 to 7500):

ASHA is an honorary volunteer (ASHA is not a formal employee under NHA [National Health Authority]) and would not receive any salary or honorarium. Her work would be so tailored that it does not interfere with her normal livelihood. And the compensation is based on performance.

I might not be able to give additional responsibilities on ASHA through Jile Health in detail, a close call would be suitable. However, we are extending that to

All Primary non-prescriptive health activities,
Lab test samples,
Coordination and After Treatment Protocol (ATP) etc.

And again the compensation for these additional responsibilities is based on performance. We would like to make sure ASHAs make a total of INR 10,000/month. And can employ two more.

I would be happy to answer any additional questions!

Suman_Jile · April 22, 2023, 12:35pm

Frankly, at this point, I am surprised by the fact that Healthcare is so complicated - based on our past 6 months of work we find it surprising.

Would you believe, if I told you, most NCDs (Non Communicable Diseases: Chronic Diseases) could be identified just with 7 or 8 Health vitals, in fact, the symptoms and lifestyle of a human can be identified just using one health vital - Heart Rate.

According to National Health Profile 2021, NCDs account for 63% of all mortality in India. The largest Healthcare expenditure is on NCD and India has over 500 million+ Chronic patients. This means $20 billion dollars of preventable Healthcare expenses can simply be eliminated.

Let me tell you Patna’s personal story:

In the month of Jan, I visited a clinic for fever and cold. And this is what I received: a paper. It is called EMR (Electronic Medical Record) in medical terms.

I digitized this. And believe me, the digitized version of this simple paper is nothing but gold for the lifetime of the patient. In this case, it is me.

PS: Please remember, I paid INR 500 in cash - that I regretted later on!

Pai · April 23, 2023, 6:05am

Thanks so much for the detailed response, Suman. Will speak to our team also once and get back to you on this.

Suman_Jile · April 23, 2023, 8:20am

Sure, also come across this essay by a16z on Healthcare: The Biggest Company in the World | Andreessen Horowitz

However, I have a different opinion - The world’s biggest company will be a consumer Healthcare company but that company could also come from India

Pai · May 16, 2023, 5:09pm

Hi Suman,

Just a few more questions, as a product how does this work - was a bit confused. Could you maybe let us know how this will work as a product. And if you have any POC that would also be nice to check out.

Suman_Jile · May 17, 2023, 10:23am

Hi Dinesh,

Yes, most people struggle to understand that because there is no reference to a similar solution. We are creating a demo video - will share that in the next couple of days.

In super compressed language, the way a Debit Card user can use his/her cards across any merchant - online and offline, provided it has a balance :), and get their jobs done. Jile Health customers will be able to use Jile Health Card across all Health Service Providers - Hospitals, Clinics, Labs, Dentists, Doctors etc - for all types of healthcare activities - Medication, IPD, OPD, Day Care, short-term, long-term etc. - Online and Offline, and get their treatment done. The only difference will be - a Debit Card user will have to add money almost every month. In the case of Jile Health, the user will have to pay only one time, in a year.

There will be no waiting period, 48 hours pre-approval request, surprised bill, claim refusal, claim fraud etc

Again, we have used ABDM as the underlying technology in building this solution. Without ABDM, this will be impossible.

The functioning POC is the 2nd stage of building this solution. However, we must start small hence we have released a tool for 700 million PMJAY (Pradhan Mantri Jan Arogya Yojana), a state-sponsored free health insurance. The tool is free for users however, we collect user’s important data points - Pincode, Districts, State, Phone No, PMJAY users or Non-PMJAY users etc.

You can install and test: Jile Health