A nation of over 200 million citizens, Pakistan is a major player in South Asia, with a large population to care for. Like many countries around the world, it is struggling to address the shortage of doctors and prevalence of chronic diseases while ensuring access to affordable medicine. But where there are challenges, there is also room for innovation. Today, we are seeing entrepreneurs and medical teams come up with a new way to tackle some of Pakistani healthcare’s trickiest problems.
“There’s such an unmet need, because we’re a huge population. We’re the fifth largest population of the world, and imagine if 75% of that population is not being able to access basic health services. We still have some of the world’s great endemics, we still have polio, we’re still struggling with tuberculosis,” Dr Sara Saeed Khurram, public health specialist, tells MobiHealthNews. “I think this is a difficult time, but I think this is also the right time to introduce the right kind of services to the market, because if people can adapt to it, then it can bring a huge opportunity to scale.”
Pakistan is one of a few countries that has failed to eradicate polio. A widespread vaccination campaign is now in place following a resurgence, from 12 cases in 2018 to 144 in 2019, according to figures from the World Health Organization.
“This disparity in access [to] and quality [of care], though reflecting in our poor scores on various health and mortality related rankings, presents an opportunity for healthcare startups to solve real healthcare problems – and leapfrog the development of our healthcare system,” says Rafeh Ahmed, lead of an early-stage startup incubator at Aga Khan University, a renowned academic institution.
From the people that we spoke to, we heard that the digital health space in the country is fairly nascent, with businesses starting in the appointment-booking space and evolving as they get traction.
But there is one innovator that has taken on an ambitious task.
“When I was growing up, my father had three children, and he already planned that he was going to have two sons and one daughter,” says Dr Saeed. “He had a plan that my elder brother is going to become an engineer, the second one is going to become a banker, and I am going to become a doctor.”
All three children went on to do just that. “The reason that he wanted me to be a doctor is because it’s a very interesting thing in Pakistan that the majority of middle-class parents will have money to educate their [daughters and] they want them to become doctors.
“And they want them to become doctors, not because they will become doctors and save humanity, or because there is a lot of demand in the country, but because it gives a very high social stature to a woman in Pakistan. It makes them noble and respected. When their social stature is raised, it helps them get a better hand in marriage.”
This is known as the 'doctor bride' phenomenon in Pakistan. Despite having over 200 million people, Dr Saeed says Pakistan has only around 170,000 doctors, out of which 60%-70% are female.
“We’re clearly in a majority,” she explains. “But between graduation and formal practice, the amount of female doctors that come back to the workforce is only 23%. So we essentially are missing [out] on a great majority of female doctors who are not being able to cross the bridge between graduation to practice, and a lot of times this is because of the doctor bride phenomenon.
“Because, by the time they graduate, they get married and then their in-laws or their husbands do not allow them to come back to work full time – or even if they do, they have children, and it becomes really difficult for them to choose between their career and family.”
In the 2020 Global Gender Gap Index, which benchmarked 153 countries, looking at the extent of gender-based gaps in the areas of economic participation and opportunity, educational attainment, health and survival, and political empowerment, Pakistan ranked third to last.
Figures from the report indicate that only 25% of women participate in the labour force, compared to 85% of men. Furthermore, only 5% of senior and leadership roles are held by women. The gap remains wide in the political arena as well, with only three women part of a 25-member cabinet as of January 2019.
“We have one doctor for 1,200 people, and those doctors are also placed disproportionately in urban cities or urban places where there are more facilities,” Dr Saeed says.
She is speaking from experience. After getting her medical degree, she got married and had her first daughter. As a new mom, she was forced to move to another city because of her husband's job.
“I fell into postpartum depression because I was at home with the newborn in a new city and I didn’t know what to do with my life anymore because I couldn’t work, I couldn’t get out of the house, I couldn’t leave my daughter anywhere, and I just felt that my entire life has finished and my 16 to 17 years of education had just gone to waste.”
That is when she decided to start doing video consultations in a clinic that she previously used to work at, and came up with the idea of setting up Sehat Kahani.
“We connect female doctors to patients who need healthcare using telemedicine. We have a service line for low-income populations, so we classify populations two ways. There’s a low-income population who earns less than two dollars a day, and does not have access to smartphones or technology themselves.”
In these communities, Sehat Kahani has created telemedicine clinics in partnership with nurses, where it provides the training needed for them to use the technology. Patients can consult a doctor through digital means, and they can also view lab results, or be referred to a tertiary healthcare system if they cannot be seen through the clinic, among other things.
“All of these services are paid, and we charge between 50 to 500 rupees (up to around $3 USD) for a range of our services, and we give an incentive to the nurse, around 30% incentive.”
These clinics, Dr Saeed explains, are based on a revenue structure that means they need to see around 300 patients a month to break even.
“That normally happens when the clinic crosses the 12-month mark. So all the funding that we need is to run a clinic, launch a clinic and run it for the first year, and from the second year the clinic tends to get sustainable on its own.”
In the past four years, Sehat Kahani launched 26 clinics in three of Pakistan’s four provinces, which have seen over 123,000 patients to date.
Its second service line focuses on an app offering similar services, with which the startup is pursuing a B2B model.
“We are now giving it to [companies that] have a large employer or consumer base who do not have health coverage, and we are providing them outpatient health coverage through the app, and also we are integrating our app into other applications as an SDK solution.”
Although the app was only launched towards the end of 2019, Sehat Kahani is already said to be working with six companies, with around 10,000 people using the tool so far.
But one would be mistaken to think that it’s all been smooth sailing; it took time until the efforts started getting traction.
“Initially, it was very difficult to get patients into the clinic,” Dr Saeed explains. “But I think that a few things that we did in the clinic really worked for us. We hired a female mobiliser in the clinic who did a lot of health education and promotion and a lot of door-to-door mobilisation to get patients in. We hired nurses. We started working with nurses who had minimum eight to 10 years of experience in that same community, so they started championing our work, and they started getting patients in.”
Once they saw the value of the services provided, the company grew organically. “When we started, the average [number of] patients was like 50, 60 a month. And we used to worry a lot about how on earth we are going to make this more sustainable. And now the average footfall is around 320 patients a month.”
But, even now, there are still hurdles in the way. “People are just starting to realise even the use of mobile apps for transport, for food delivery, for general day-to-day chores, for banking apps, so digitisation in Pakistan is a very new field,” Dr Saeed says.
Bringing real-time monitoring and connectivity
According to the latest Diabetes Atlas, estimates indicate that 463 million people aged 20-79 were living with diabetes globally in 2019. China, India and the U.S. were the three countries with the largest numbers, followed by Pakistan. By 2045, however, it is estimated that the numbers in Pakistan will exceed those of the U.S.
Faisal Masood, founder of Medworks, has developed a mobile application that, combined with a glucose meter, aims to help make it easier for people with diabetes to manage their condition.
“What’s happening with the mobile application is sort of combining IoT with the device. It’s a smart way to make a glucose meter that plugs into the smartphone, and that's how people can get their glucose readings into their app and then subsequently link with the healthcare provider,” he tells MobiHealthNews. “Real-time monitoring and connectivity is the real benefit.”
Prior to Medworks, Masood worked on a child health project at a nonprofit institution in Pakistan. “That’s where the seed was planted,” he says. “With my masters at LSE [London School of Economics], I sort of continued with policy, public policy, with a focus on healthcare, so that was very good in terms of combining the policy world with the technology world. And then I think that this product, with this company I’ve been able to do that, which has been very exciting.”
The startup has over 2,000 users at this stage, having launched their offering last year. “There’s a B2C model where we’re selling the product direct-to-consumers. At the same time, we’re also targeting some B2B opportunities, speaking to healthcare institutions or public health agencies, it’s a B2B2C model, where we actually work with institutions that then equip their patients – people involved in their programme – with the device and their application, and use their diabetes educators or healthcare providers to monitor their patients’ data.”
With one of the organisations, they are augmenting the platform to add new functionalities. “We’ve discussed some of those features with [a] potential partner that could implement it, and they get a lot of patients from rural parts of the country, so people that come and, you know, pay a lot for a ticket and then do not come again for another eight to 10 months. So there’s no way for the doctor to know what’s going on in this duration, how is the follow-up, whether the patient’s doing well or not so well. Follow-up remains a big issue.
“So those are the kind of populations that would really benefit from a solution like ours, where they’re constantly connected with the healthcare provider, and there’s two-way healthcare communication happening. And they don’t have to come in for every small thing. They can have their prescriptions managed as necessary.”
"Pent-up demand" to consume services in new ways
But these are not the only issues; access to medicines in the country, according to a WHO report, is very poor, with two-thirds of the people lacking access to the essentials. The market is also rife with counterfeit products.
Entrepreneur Furquan Kidwai came face to face with that reality when his mother was diagnosed with diabetes. He returned to Pakistan after studying and working in investment banking for 17 years in London. When he could not find medication for his mom, he came up with the idea to create virtual pharmacy Dawaai.
“In the early days, the idea was to set up something like Boots across Pakistan, and go for the chain model,” he tells MobiHealthNews.
That didn’t prove to be feasible, so the team decided to pivot and turn to technology, now with a web-based, telephone and app platform in place, and around three million unique users, according to the founder.
However, the dangers of online pharmacies are well-known. Kidwai cautions that they take a “holier-than-thou” approach, with a zero-tolerance policy for no prescriptions, and steps taken to tackle counterfeiting, starting with procuring medicines directly from manufacturers or their distributors and working with large pharmaceuticals.
But, in a manner similar to Sehat Kahani's experience, it took a while until business started to take off.
“Effectively, initially the biggest challenge was acquiring customers, right, how to acquire customers, how to actually get to customers,” he explains. “Then we kind of stumbled upon the realisation that when you walk into Boots or CVS, and when you’re buying medicine, the pharmacist actually guides you how to take medicines, when to take, when not to take, what to do. That wasn’t happening here. So, we effectively hired a team of pharmacists and doctors to write the content for every single medicine.”
That was a significant turning point, and with business growing, they started to open more warehouses, doing same-day deliveries in around 16 or 17 cities. “That obviously started a huge influx of people, coming in ordering from us,” he says.
That also brought new challenges, which they still see today, in having the operational capabilities to be able to deliver and cater to that growth. And despite their progress, Kidwai agrees that there’s more to be done on the part of all stakeholders to help innovators bring their solutions to market.
“It’s very, very new, right? [the digital health space there], and if we are the only player of significant size, I think that’s a problem because either we have captured much of the market, which isn’t the case, we are hardly at 1%, and that’s too small a segment to do. But I think there’s a pent-up demand for that, primarily driven by the fact that consumer behaviour is changing.”
And healthcare is known to be a tough place to be in.
“Having done it for a long time, you know, the sort of nitty gritty, and sort of the difficulties you face, it’s a perseverance game more than anything else,” he warns.