Let the poorest among us take what is available or nothing at all?

I graduated from medical school in Mumbai about 17 years back. As with any resident doctor training in a public hospital, I spent 10 years working with patients primarily from underserved and low income backgrounds. The next decade went by in the pharmaceutical industry and I didn’t think much about the underserved sections. Most conversations were in board rooms about BRICS, the emerging economies, the burgeoning middle class and the massive opportunities they offered. Especially in India and China, where the economy was booming and annual healthcare spending growing double digit, we were all focused on the middle classes as the market to focus on.

To put things in perspective, it is estimated that 63 million Indians move below the poverty line every year due to a healthcare shock.Click To Tweet

In 2015, 11.2 million Americans were driven into poverty due to medical expenses. The exact number may vary depending on how one defines poverty, healthcare and shock, but lets not worry about semantics. Millions of underserved people live in dread of impoverishment due to a healthcare event they cannot anticipate.

Over the last 8 years, my work in healthcare technology has given me the privilege of going back to work with the underserved and I feel more equipped to think about their challenges than I did as a resident doctor. I’ve worked on digital platforms for HIV/ AIDS and women’s health and had the opportunity to learn from and work with bright and committed social entrepreneurs in Bangladesh, Africa and India.

The opportunity to use digital and mobile technologies to offer better treatment options to the poor are immense, especially in healthcare, where the need is rapid and the democratic adoption of new technologies provides the tools for doing something disruptive. In most programs I have seen or had the opportunity to be a part of, there are usually two main problems that we‘ve grappled with – the first was to do with the design of the intervention itself. That one’s been relatively easy once you acknowledge that the intervention needs to be user centric, have a value proposition for all ecosystem stakeholders and needs to serve the complexity of the local healthcare ecosystem. Fortunately, having the right partners committed to impact of the intervention paved the way for us to design the right technology intervention for the patients and the doctors.

The second challenge that we grappled with was the business model. The patients/ population we were designing the technology interventions for were typically underserved. They lived in rural areas or were part of one of urban India’s many slum or low income colonies. These patients don’t have access to health insurance and they try and delay healthcare intervention as much as possible. When they do access intervention, they do so on a tap. Spend 30 minutes standing in any pharmacy shop in India and you’ll see patients asking for medicines for fever or body ache (as an example). The pharmacist offers a strip, and after some negotiation, the patient walks away with a few tablets cut from the strip. Whatever it takes to kick the can down the road.

For these patients, many of whom are daily wage earners, accessing healthcare at public healthcare facilities means long wait times, loss of at least a day’s wages and a lack of meaningful communication from their providers. Accessing healthcare at a private facility is expensive with the experience being more variable. There is though, a sense that paying a private doctor allows the patients to ask a few more questions than they could dare to at a public facility. I have found many of these health consumers to be very sophisticated in their decision making. Very often they are willing to pay much more to a private provider so they can get back to work than lose wages from accessing free care at a public hospital.

I am convinced we can only serve the healthcare needs of the underserved using more technology. But someone has to pay for these innovations to go to market! Business model discussions over new interventions for these underserved populations have been particularly challenging ones. Over the last 5 years, I’ve been in countless debates on who should pay for new innovative technology interventions for the underserved populations. The government is an easy answer, but not always the most practical or realistic. Policy makers need data to demonstrate the value of new interventions (rightly so) and may have limited appetite to fund innovations. Besides, how many governments have the money to spend on additional healthcare interventions?

Many of these technology interventions have been funded by philanthropic ventures. This form of social capital has the appetite to and has funded technology led innovations in India, Africa and other developing regions. The assumption is that the social capital funds the innovation and development risk to eventually transition the operating costs to the local government once there is proof of the intervention. There are some examples of this happening but not a whole lot.

I’ve been part of spirited debates with social entrepreneurs that believe the end user, the healthcare consumer should pay for the utilization of services. This is an increasingly touted approach in developing countries like India where the poor already pay for private healthcare services so it’s not a big leap to get them to pay for additional services. The notion is shocking to some – serving healthcare to the underserved must be a responsibility that society must bear. How can we ask the poor in our society to bear the cost of healthcare, especially when the alternative is for them to be driven into poverty?

The social entrepreneurs I work with make equally passionate arguments. They contend that the public spending on healthcare is reaching its limits. The underserved are best treated as consumers that have the right to demand access to best healthcare. Paying some of the cost of the new technology led healthcare solutions elevates them into a position of demanding better quality. There’s no way these patients will be able to make similar demands of a public healthcare service (other than through a long-drawn political process).

I’ve always been fascinated by the discussion on having the poorest amongst us pay for their healthcare. As a entrepreneur, I do recognize the value of paying customers giving feedback on your product/ service. Customers won’t use you and certainly won’t pay for your services if they don’t see value. The market will destroy your value and push the healthcare entrepreneur to improve the quality of the offering or push patients towards alternative options. There’s nothing like feedback from a paying customer to help sharpen your offering. It keeps you on your toes and avoids the complacency that creeps into ventures that don’t have to worry about survival every day.

I also confess to seeing the alternative viewpoint – it seems repugnant that we call on the poorest to pay for healthcare interventions. Some of the programs I have worked on are preventive healthcare programs. The middle and more affluent classes have access to many of these interventions for free (paid for by insurance or the commercial value of their data) but the poor are unable to because they do not constitute an attractive market. Don’t we all bear a moral responsibility to ensure that the poorest don’t end up in abject poverty due to healthcare expenses?

The pragmatist in me (like the many social entrepreneurs I meet) understands there will be limited public money available for additional healthcare interventions so charging the poor for services that actually make a difference is indeed a practical, real way of making our communities healthier. The idealist in me can’t get over the offensive notion of making the poor pay to live!Click To Tweet

I personally continue to vacillate between these two positions. When healthcare technology entrepreneurs think through their business models, I do hope they will be guided by the moral ambivalence I feel. Market linked solutions are more likely to make interventions sustain in the real world. But we can’t risk forgetting how we’d like things to be in an ideal world. That would irrevocably corrupt the soul that should power any healthcare delivery organization.

Dr Aakash Ganju is a healthcare consultant and entrepreneur, focused on increasing transparency, access, and convenience to health providers and consumers. He is the CEO of Mirai Health and lives in Mumbai, India.

A version of this article was published on Tincture.