Learnings from Building a Healthcare Startup in India

Shashikant Kore interviews me about my previous startup.

(From 2008 to 2011, a doctor friend of mine, Amit Paranjape, and I ran BharatHealth, a healthcare startup, which failed. In conversations about startups, I would often mention learnings from this experience. For a long time, Shashikant kept asking me to write an article about it, and when I kept putting it off, we finally decided to do it as an email interview.)

Please provide your academic and professional background before starting up.

I am currently a co-founder and CTO at ReliScore.com, a startup focused on helping companies filter job candidates based on evaluation of actual job-related skills. I advise a couple of fintech companies and a Govt of India initiative for startups.

In the past I’ve worked for large companies, and small; I’ve worked in India and in the US; I’ve seen a successful exit, and I’ve seen a dotcom failure; I’ve done product development, and I’ve done research; I’ve written consumer software, and I’ve written enterprise software; and I’ve been a developer, I’ve been an architect, and I’ve been a manager (but hated it).

I’ve done my BTech in Computer Sciences from IIT-Bombay and a PhD in Databases from the University of Wisconsin, USA. I am an inventor on 18 US patents, 2 European patents, and 1 Japanese patent. I’m interested in a number of areas of computer science, including: highly scalable systems; distributed and fault-tolerant software systems; text search, information retrieval, and analysis of unstructured information.

You took a sabbatical after leaving Veritas/Symantec. What were your plans for this period?

I had gotten bored of my big-company job, and I was lucky financially to not have to worry for a few years. So my plan was to just work on things that I found interesting.

As a result, I spent a couple of years doing a bunch of things: I worked on my Hindi song lyrics website . I helped Meeta (@meetalks) set up her movie reviews site. I started https://punetech.com because I felt that the tech community in Pune needed a forum like that. I consulted for a few friends’ companies.

How did you come up with the idea for BharatHealth? Who were your co-founders at BharatHealth?

The doctor friend came up with the idea. He felt that a web-based system to capture all the health records and interactions between a patient and a doctor could revolutionize how healthcare is conducted, especially in case of chronic problems where the care requires lots of little tweaking over the long term. (Note – chronic diseases are defined broadly as conditions that last 1 year or more and require ongoing medical attention.)

He approached Amit Paranjape and me and both of us liked the idea. That’s how BharatHealth was born.

Who were the target customers of BharatHealth? What problems did BharatHealth solve for those customers?

It’s easier to explain with an example. Let’s focus on diabetes patients as that was one of the first verticals we targeted.

Our initial target customers were doctors providing long-term diabetes care. The idea was that the doctors would offer BharatHealth to each of their patients. In the beginning, the patient’s basic history, the doctor’s current diagnosis, and medication protocol would be uploaded to the system.

After this, on an ongoing basis, the patient would keep uploading blood sugar readings into the system as recommended by the doctor. The doctor would check this on a regular basis and if any problems were noticed, they would recommend adjustments to the medication.

Similarly, if the patient had any non-emergency questions, they could just ask it in the system itself. The doctor would check the system a few times a day and answer any questions. This was much better than the patient having to come to the clinic and wasting a few hours, or calling up the doctor on the phone. More importantly, the doctor would be able to see the full history of the patient right in front of them along with the question so the answer would be quicker and more accurate.

We felt this was a win-win scenario.

What were your initial hypotheses for BharatHealth? 

We felt that this would:

  • Improve patient outcomes because of better availability of patient history, symptoms, medication
  • Decrease the amount of time spent by the patient waiting in waiting rooms
  • Increase the throughput of the doctor because the system would allow answering a question in 30 seconds, whereas the same question on the phone or in person would end up with at least 5 minutes if not more.
  • Patients would be happy to pay the doctor for the use of this system
  • Doctors would be happy to pay us a cut out of #4
  • Once a system like this was up and running, we would be able to monetize it in various other ways

What did the early version of the solution look like? How long did it take to get the first version in the hands of the customers?

This was at a time (2009-10) when touch phones hadn’t yet become common in India. Hence the system was a web-based system. We expected that all doctors and most patients would access it from laptops or desktop computers, while a small fraction of the patients would use smartphones to enter their test results and questions.

We built the system using Python+Django. It took a couple of months to get the first version to the customers.

How did you reach out to the early customers for BharatHealth?

Quite early we decided that this would be a B2B2C solution. We focused on getting doctors as our customers, and the doctors would ask their patients to join the system. In other words, we would never be selling to the patients directly.

We used our doctor co-founder’s connections to reach out to doctors in Pune, and made the sales the old-fashioned way –  by meeting them, showing a demo, and asking them to join.

What were some of the early marketing channels you used? Did you also have a sales team?

We only did direct sales. We did all the sales ourselves. The idea was that once we had figured out how to do the sales ourselves and streamlined the pitch and process, we could then hire a sales team. However, we never reached that stage.

What was the customer feedback of initial versions? Did any feedback surprise you? How did the initial feedback shape your product roadmap?

I’ll answer this in terms of general “customer reactions”. We ran into these major categories of customers/potential customers:

  1. A small number of doctors quickly understood the pitch and started using the system. They were generally happy how it worked and how it helped them and their patients.
  2. A number of doctors said they liked the idea but they did not think it would work in their situation because of one of these reasons:
    • They felt that a good fraction of their customers were not tech savvy and would not be comfortable using a web-based system
    • They would need to teach their receptionist to use the system, and that would be impossible
    • The system was in the cloud, and they didn’t think the internet was reliable enough
  3. Some of the doctors liked the system, sounded enthusiastic about wanting to use it, but when it came time to start using the system, they never got around to it, because always some higher priority thing came up and operationalizing this system kept being pushed lower on the todo list.

What were some of the hardest challenges in terms of product, marketing, sales and the market itself?

An experienced entrepreneur had told us that our product required behavior change on part of the doctors, and that would be very difficult. We never really appreciated how big of a stumbling block this was. In retrospect, I feel that a number of the problems in points #2 and #3 in the previous answer all stemmed from the fact that behavior change was required and our product did not provide a big enough incentive for driving that behavior change.

Speaking of incentives, based on our initial market validation (with about 5-10 friendly doctors) we felt that the significantly increased patient convenience and potential improvements to medical outcomes would be strong incentives for doctors to use this system. However,  once we moved past our friendly doctors, the impression we got was that in most cases, “Can this system get me new patients” was the more important question on their minds. And since we did not do a B2C play, our answer to that question was No.

Another problem we ran into was that doctors are used to the pharma-medical-representatives style of sales, where there is lots of hard-sell, lots of money flowing around, and royal treatment of doctors, and without that kind of a sales model, we were not very effective at selling into this market.

Another problem with this market (or the way we were selling the product) is that every doctor wanted customizations to the product to incorporate their own workflow into the system. While this is true of the early stages of any B2B product, I felt that this problem was more pronounced in case of doctors, because most of them have high-throughput practices with workflows that have been optimized over the years, and getting them to change those workflows would require too much behavior change. We tried hard to build a very flexible system that could easily incorporate the requested changes via configuration, but in many cases we had to give up on the customer after a number of rounds of changes.

All these reasons that affected our ability to sell to individual doctors were multiplied by N when we tried selling to hospitals. In the former case, we had doctors who didn’t feel they could convince their patients (and receptionists) to use the system. In the latter case, the problem was compounded because we had hospital administrators who had even less confidence in their abilities to convince doctors (who would then have to convince patients).

BharatHealth came up at a time when mobile phones were ubiquitous, but smartphones were just starting out. How big a role phones played in your solution? Would a smartphone have helped in some way?

In this sense, we were too early to the market. A few years later, when touchphones were truly ubiquitous, the resistance to our solution would have been much lower. Without the guarantee of an always-on smartphone with every patient, the (mental) barrier to entry was too high, and as a result the behavior change required was too high.

What were the signals that indicated the product is not working as per your team’s expectations?

While we made quick progress with the initial set of doctors we had talked to, we soon found that expanding past this inner circle was quite difficult. As we approached more doctors, we found that the meetings and demos went quite well (according to our possibly inexperienced judgement), and they sounded positive about the product, but getting them to take the next step was difficult.

In many cases, in spite of positive feedback, we would not be able to get them to set up their account on the system. There was always a plausible reason for it; some emergency that came up, or some other higher priority activity because of which they wouldn’t have time to learn the system. And in the cases where we got them to create an account and learn the system, we found that they wouldn’t actually sign on patients.

As a result, growth just slowed to a crawl.

At what point did your team decide to pause efforts on this product and company?

During a long stretch of low/no growth, Amit and I were involved in some unrelated initiative (part of our PuneTech work), and we hit upon the idea for a different product in a space that we understood much better (hiring for software industry) and we felt it would be easier to sell because we understood the potential customers and their motivations much better (having worked in that industry for 20+ years each). As a result we decided to stop BharatHealth and ReliScore (our current startup) was born.

Last decade saw significant improvements in technologies like smartphones, wearables and machine learning. You mentioned smartphones would have lowered barriers for adoption. What healthcare problems, that you are familiar with, can now be solved in a better way with new technologies?

Since I moved to a non-healthcare startup, I haven’t really kept close tabs on what all is going on in the healthcare tech space.

The potential for use of smartphones, wearables, and machine learning in healthcare is huge. You pick any aspect of healthcare and it has the potential to be revolutionized by these technologies.

However, the challenge primarily lies in the “behavioral change” that I mentioned earlier. This falls into two categories: preventive healthcare vs acute healthcare.

Preventive healthcare could be applied to everyone, and it could have a huge impact on the world. However, getting people to start using an app and/or providing it with the data it needs is not easy. Most people are quite lazy about taking steps now to prevent future problems, especially if it involves a payment. And if it doesn’t involve payment, then there is always the concern about how the company will use the data and whether privacy will be preserved. As they say it is easier to sell aspirin not vitamins. Because of this the companies most likely to make good progress in this area would be those like Apple, who have: 1. a good brand image, 2. an app or device that is already in people’s pockets, and 3. the data entry is minimal-effort, ideally zero-effort.

For acute healthcare (i.e. solving a problem you have right now, i.e. aspirin instead of vitamins), doctors and other providers have to be in the loop (given the current state of technology and regulations), so this involves handling behavior change and incentives for those players. As is clear from our failure, this is not something I understand well, and I haven’t yet seen a compelling model from someone else.

Since you faced challenges with B2B2C model, which seems to be the primary route to market, what are your thoughts on using the B2C approach?

I think the right kind of B2C approach could succeed, but the focus has to be more on psychology, incentives, distribution, rather than the technology. And would need deep pockets also. We considered pivoting to a B2C model, but we decided that we neither had the expertise nor the budget to pull it off.

You mentioned, you thought about B2C pivot, but didn’t work on it for a variety of reasons. Do you remember what some of those B2C ideas were?

We thought of a lot of ideas, only some of which I remember. For example:

  1. Allow end-users to capture their medical history and reports, and enable easy sharing of this data across patient, doctor, pathologists/labs, family (e.g. NRI children), and for second opinions. 
  2. Same as #1, and get medical insurance companies to offer discounts to patients who show good control over time.
  3. Allow end-users to capture their medical history, and allow them to ask questions to our team of doctors
  4. Same as #3 but have software triggers and/or doctors looking at the data to warn patients of potential problems that they’re ignoring
  5. Same as #3 but allow the patients to suggest which doctors they would like on the system and use that to create pressure on doctors to join.

How long did you work on BharatHealth, from starting work on it, till deciding to stop working on it? I could add it to give some idea of  commitment for new entrepreneurs.

Approximately 3 years.

If a new entrepreneur wants to explore this space again, what advice would you give?

I would say this:

  • Focus on psychology, incentives, distribution, rather than technology. Technology is the least of your challenges. Ask yourself if you can do the first 3 to 6 months of your startup using just WhatsApp and an Excel spreadsheet and you personally handle all the customers. You’ll be surprised at how often this is possible.
  • To be able to do #1, steep yourself in the culture of this domain. Talk to doctors who are not your friends, hospital administrators who are not your friends, and so on.

If your child is unsure of what to do after 12th, consider Liberal Arts

This post is a work in progress, possibly incomplete, and might have some inaccuracies. If you have suggested additions improvements, please leave a comment.

A Liberal Arts degree, which in the west is one of the more common routes to higher education, is relatively new and mostly unknown in India. The defining aspect of most of Indian higher education is the early specialization—students choose a stream (Science, Commerce, Arts) after 10th, and a branch (Computer Engineering, Mechanical, English, Psychology) immediately after 12th. Liberal Arts colleges are springing up in India to fix this.

What is a Liberal Arts degree?

The idea is simple—students get admitted to the college after 12th not only without having to specify which branch they want to specialize in, but also without having to specify the “stream”. In the first year, they can choose to do any courses they find interesting out of a wide variety of courses from all the traditional streams, and more. Only after having spent the year sampling various subjects do they have to declare their specialization. This is their “major” and they spend the remaining 3 years focusing on that. And depending on the major, they can end up with a B.Sc., B.Com., or B.A. degree. In addition to their major, they can also declare 1 or 2 “minors”, which don’t have to be from the same stream. So, for example, a B.A. (Psychology) student could do a minor in Entrepreneurship, or Biology, and a B.Sc. (Computer Science ) student could do a double minor in Economics and Entrepreneurship.

Unlike traditional B.A., B.Sc., or B.Com. courses, most Liberal Arts colleges offer students the option of getting a 4-year degree, so they have enough time to explore multiple areas of study through the minors and electives.

Why Liberal Arts?

Liberal Arts degrees have two advantages over more conventional courses. First, if your child is unsure of what they want to do after 12th, then this is a great way to decide, as opposed to picking something that the parents like. Second, lots of people feel that in the fast changing world of the future, where AI is going to automate more and more tasks from traditional jobs, it is dangerous to be too specialized unless you’re one of the best at that. In other words, it’s fine to do a traditional engineering/medical degree from one of the top colleges, but if you can’t get into one of those, then a Liberal Arts degree better prepares you to succeed in an uncertain world. Engineering might be better for the short-term, Liberal Arts might be better for the long-term. One third of the CEOs of the 500 largest companies (Fortune 500) are Liberal Arts graduates.

Dheeraj Sanghi, professor at IIT-Kanpur, ex-dean at IIIT Delhi, director of PEC Chandigarh, JEE almost-topper, and someone who’s been closely studying the higher education system in India, says that if he was a student today and could choose to be in any college/degree in India, he would pick Liberal Arts in Ashoka.

Liberal Arts in India

Pretty much everybody agrees that the best liberal arts college in India is Ashoka (in Sonipat, near Delhi, est. 2014). Top class faculty, most with PhDs from some of the top universities in the world, great infrastructure, and a focus on what makes sense for a modern higher education degree.

The second best is probably FLAME (in Pune, est. 2015), Pune. I get the impression that FLAME seems to be rather strong in business and finance areas, and relatively weaker in the humanities areas (e.g. history), but still it is far better than most other places you could go to get a rounded education.

After Ashoka and FLAME, the choice is probably between Azim Premji University (in Bangalore, est. 2010), SSLA (Pune, est. 2004), and a recent entrant, Krea University (Sricity, near Chennai, est. 2018).

SSLA (Symbiosis School of Liberal Arts) is the oldest Liberal Arts college in India. They have the right vision, and the current director is a great person, but I get the feeling that they have challenges with faculty retention (and I suspect that the quality of faculty isn’t as top-notch as you’ll find in Ashoka, FLAME, Krea, and Azim Premji). And being a part of the sprawling Symbiosis empire comes with its own advantages and disadvantages.

Azim Premji, and Krea both have the potential of becoming at least as good as FLAME, but they are still very new, so there is the risk of teething troubles.

The other new colleges worth checking out might be Jindal (Sonipat, near Delhi), because their law college is quite good, so they might be able to do a good job of the Liberal Arts college, and Auronya (Puducherry), because Indira Parikh (ex dean IIM-Ahmedabad, and founder of FLAME) is involved.

Shiv Nadar University is another college I keep hearing about. They give a lot of flexibility to students in terms of the different electives, courses, and minors the students can take. However, it appears that they don’t have a Liberal Arts program, and students need to enroll in a specific stream/branch. (Someone please correct me if I’m mistaken.)

Here is a list of other colleges with a Liberal Arts or similar program which I haven’t yet evaluated. If you have opinions on any of these, please leave a comment below.

  • PDPU, Gujarat
  • Karnavati, Gandhinagar
  • NMIMS, Jyoti Dalal School of Liberal Arts
  • SRM, Amravati (AP)
  • Rabindra Bharati, Kolkata
  • DY Patil, Pune
  • MIT, Pune
  • Manav Rachna
  • Women only: SLE, Shri Shankarlal Sundarbai Shashun
  • SPPU (Pune University): new 3-year BA (Liberal Arts) program starting from 2019.
  • Normal/Traditional Arts colleges that have a good reputation: Madras Christian College, Christ University Bangalore, LSR (Women), TISS Bombay, St. Stephens Delhi, Loyola Chennai, St. Xaviers Bombay.

What about jobs?

What do students do after a Liberal Arts degree? What kind of jobs do they get?

Frankly, I don’t have an answer to that. Most of the Liberal Arts colleges in India are quite new and there isn’t much data about what the students end up doing afterwards, especially in the long-term (which is where liberal arts is supposed to shine). Many of them (60% for example in the case of Ashoka) end up going for further higher education, usually abroad. Some of the top companies are also recruiting these students from campus. Anecdotally, I know that a lot of these students are doing really interesting work afterwards.

But it would be safe to say that the answer to the question of “What to do after the degree?” is much less clear for Liberal Arts than for conventional degrees. This is a new frontier, and nobody knows the long-term value, so I would say this is a high-risk-high-reward situation. If your background isn’t privileged enough that you can handle some uncertainty for some years, I wouldn’t recommend this option. (Speaking of privilege, the fees at these colleges tend to be high, for example, approximately ₹10L per year at Ashoka. But most of them also have financial aid programs that can help in case someone can’t afford it.)

Next Steps

If your child is in 10th or 11th std, both Ashoka and FLAME have a short residential summer camp for 10th and 11th std students to get some exposure to what is Liberal Arts, the various subjects, the faculty, and the teaching styles. I would highly recommend it. Let your child experience what world-class teaching looks like. My son, who hated history as a subject until 10th came back a huge fan of history after doing Ashoka’s Young Scholar program, and it is now one of his favorite subjects. And he will be joining Ashoka this August. Details of these summer programs can be found here and here.

If your child is in 12th, and my description above sounds interesting, you should start applying. The application procedures of most of the schools I mentioned above starts in November-December, and continues in multiple rounds until the summer.

Improvements/Corrections welcome

This article is work in progress. If you see any mistakes, or have suggestions on how to improve it, please leave a comment below, or get in touch with me at navin@smriti.com

When thinking about God/Religion/Spirituality “truth,” isn’t important

Recently, I posted this on my Facebook page:

“Does God exist?” is a bad question.

“Do people who believe in God behave better or worse than those who don’t?” is a far more useful question, isn’t it?

This was a relatively shallow take on a much deeper article I’d read a few days earlier. Very quickly, my friends started poking and prodding at it in the comments, which made me realize that I wasn’t going to get away with a shallow take, and I would have to dive deeper to support the point I wanted to make (which was basically my take-away from the article).

The article itself is a bit heavy for me; I don’t have the appropriate Liberal Arts background, and I was unfamiliar with many of the terms used there (hermeneutics, intersubjectivity). But, I think I got the overall gist of the argument, which I’m reproducing here. (Knowledgeable people, if you find places where I’m mistaken, please post corrections in the comments below.)

I see this as a rationalist atheist’s guide to thinking about God/Religion/Spirituality. The basic idea, I think, is this:

Let us assume that science is right and the universe is fully driven by the principles of science, and with enough knowledge of all the universal laws and enough computation power, we could predict the results of all actions and behaviors. However, we don’t know all the universal laws, and even if we did, we certainly don’t, and will not have enough computational power to do the computations.

Human beings are very complex. And human societies are even more complex. In the absence of our ability to perfectly model either of those, what kinds of rules of behavior should a “scientific” or “rational” person formulate? Specifically, if we formulate certain rules of behavior for a person in society, can we predict the effect of those rules across long time-frames—over generations? (Spoiler: No, we can’t.)

Let’s approach this from a different angle.

There’s a survival-of-the-fittest evolution happening at tribal/societal level. Tribes/groups/societies that have certain beliefs and hence follow certain rules of behavior survive and thrive, and those that follow other rules die out. This process has all the key characteristics required for evolution: natural selection, genetic drift, mutation and gene migration due to genetic admixture. Repeat this over long-enough time frames, and you can start thinking along these lines:

Old traditions that have survived long enough have important properties that are key to survival of the society as it exists today

This is true, even if you, as a rationalist thinker do not see the connection. Because, the connection is beyond your computation capabilities.

We can follow up that thought with this one:

Beliefs drive behavior. So, traditional beliefs, even if they’re objectively untrue, even if they’re provably false, have value in terms of the behaviors (rules) they’re driving, which can have important properties that are key to survival of the society as it exists today.

And thus, we reach

If a belief has survived in various different societies for thousands of years, it has value (in as much as it results in society as it exists today), even if the belief is provably false

Does this mean that we should uncritically accept all traditional beliefs and rules? Certainly not. There are things wrong with society as it exists today, which are driven by traditional beliefs and rules. But, these problems cannot be fixed by purely rational thought processes, because purely rational thought processes are not powerful enough to even model the problems, forget fix them.

There are lots of things wrong with lots of traditional beliefs. Also, many of them were responses to situations and problems that just don’t exist today because of modern science, medicine and technology. But I want us to acknowledge that there is a lot right with many of them in ways that are not obvious, and we need to re-view them with this new lens. For example, this thought process has helped me better appreciate the reason for homeopathy’s existence.

Anyway, here’s the original article that inspired this thought process. Good food for thought, if nothing else.