After losing his father in 2016, Jeetendra Lalwani was distraught. "He was in the last stages of life," he recalls. "As a bed-ridden patient, he required an ambulance even for the most basic check-ups. Especially in a do-or-die situation, the ambulance service would quote an unreasonable price or arrive over 30 minutes late." Owing to this, he says that he constantly felt like he was at the mercy of a broken system.

The last straw for Lalwani was when his father had an untimely heart attack, which eventually took his life. "In that critical hour, the confused ambulance driver reached the hospital instead of my home," he explains. Lalwani isn't alone in his grief; many others in India have lost loved ones because they couldn't get help on time.

Out of sheer bewilderment and to understand why such an essential service was still a tall order to fulfil in 21st-century India, Lalwani connected with ambulance owners operating in the healthcare ecosystem in Mumbai.

"Thanks to competing apps in the food sector, you can now get groceries within 10 minutes in India, then why not an ambulance," he wondered.

Out of entrepreneurial curiosity, he tried to learn the pain points in this clearly always-in-demand product's industry. His research informed his decision to co-found Dial4242, an app-based ambulance service that currently serves around 15+ cities in India. It was not an eureka moment or a business idea to make billions of dollars. His personal tragedy spurred him on his entrepreneurial journey, he maintains.

Ripe for the Taking

“The healthcare sector in India is rife with endemic issues, offering plenty of scope for innovative solutions. Common customer complaints include slow response time, inefficient and disorganised service delivery, and errors caused by coordination and data gaps between stakeholders. It's an environment with huge potential for game-changing solutions,” opines Prabhdeep Singh, founder of StanPlus, a Hyderabad-based ambulance service.

"However, there are limitations too, like with any sector. Emergency care does not present a scenario like bot-driven cab-hailing services, such as Uber and Ola, where people just download the app and start booking cabs right, left and centre," quips Lalwani. "People want human interaction. Many are senior citizens who are not tech-savvy," he adds.

The challenge is to effectively use the existing ambulances. And that is what Dial4242 is trying to solve with an aggregation tech-driven model. Lalwani explains that his organisation's emergency response times range between 10-25 minutes. "Basic ambulances take 10 minutes. Cardiac and COVID ambulances that have to be sanitised, have PPE kits, etc., take up to 25 minutes. The challenge in India is not that we need more ambulances," he adds.

Nilesh Mahambre and Jeetendra Lalwani, co-founders of Dial4242 ambulance services

Lalwani says a persistent challenge, as simple as it sounds, is people not having the ambulance service number saved on their phones. "Everybody remembers 911 because of movies and TV shows. But nobody has talked about ambulance services in India, and nobody knows how to contact a government helpline, never mind a private helpline. And there are so many government helplines: 108, 102, 112. When you need help, precious time goes into figuring out the appropriate number amidst a crisis. If you call a government helpline, you can get an ambulance for specific reasons only; you cannot call it for a non-emergency reason, such as for a dialysis patient or a patient needing transport from the hospital to home. That's where we are trying to change things," he explains.

Like Dial4242's Lalwani, Ravjot Singh Arora, co-founder of Medulance, too lost a loved one due to the unavailability of timely assistance. "A reduction of just one minute in response time can save lakhs of lives every year," Arora observes. Launched in 2017, Arora claims his motivation for Medulance was to "make getting an ambulance as easy as booking a cab."

Having said that, he also admits that, unlike a cab, in an Indian setting, providing an ambulance in 10 minutes is not completely feasible at present. "In such cases, Medulance focuses on first providing emergency care," he adds. Medulance asserts that it answers calls in less than 30 seconds, offers first aid communication in less than 2 minutes, and a doctor consultation in less than 5 minutes, in case of an extreme emergency. "While all this is underway, an ambulance is dispatched in less than 3 minutes from the moment the call is received," the founder explains.

Piece of the Puzzle

But a fast delivery model must also process information effectively, cautions Dr. Gowri Kulkarni, Head of Medical Operations at MediBuddy, a digital healthcare platform. "The key is to implement a fast system without sacrificing information integrity," she emphasises, adding, "Building a triage system that focuses on patients requiring emergency care will save more lives and help more patients. Our nation suffers from a skewed ratio between doctors, nurses and patients.”

"By utilising technology during the pandemic, better triage systems were created to help doctors monitor patients online and provide effective, timely care." The system is under pressure, and 10-minute delivery of healthcare is challenging unless technology is involved, Dr. Kulkarni concludes.

"We are not just an ambulance aggregator," StanPlus's Singh explains in this context. He concurs with Dr. Kulkarni's views. "Faster ambulance services are just part of the solution. There are four more core pillars: access, triage, destination selection and vital sharing. We call ourselves a triage, treat and transport company. Access makes it easier for people to reach us."

Triage is the process of quickly assigning priorities to medical requests in order to effectively deploy resources. "This is how we assess the situation and route patients to the nearest hospital while being transparent about the destination. We also insist on vital sharing, so that our medical expert can assist the caller in helping the patient while waiting for ambulances," he adds.

Bridging the Need Gap

Discussing how his startup does things differently, he further explains, "at StanPlus, we seek out ways to make India's emergency response infrastructure faster. We are equipped with the best technologies, backed by a fleet of 200+ ambulances, each kitted out with a hydraulic stretcher, a slide stretcher, oxygen cylinders, and a first aid kit. We kept up with a tenfold spike in demand during the second wave of COVID-19 and are focusing on the 8-minute ambulance paradigm. Our goal is to make 'First minute, last mile' accessible for all,” he concludes.

But this begs the question: Is affordable and accessible emergency care a management issue rather than a medical issue?

"It's about delegation of responsibilities, which makes it a management issue. We've seen it takes hospitals 8-12 minutes to dispatch an ambulance. Their helpline takes 2-3 minutes to assess the situation. When the call is transferred to the emergency room, the same questions are asked again. Then the case is given to the paramedic, who is sent to the scene. Finally, the driver calls the patient asking to be guided through the navigation. At StanPlus, we can run this entire process in 2-3 minutes. Rather than operate their own helpline, hospitals can outsource to us. We manage streamlined services, leaving healthcare providers to focus on their core strengths," says Singh.

Healthcare is a Highly Unpredictable Environment

Talking about how digital technology has dramatically changed customer expectations and behaviour in the sector, Dr. Sunil Chandy, Chief Medical Officer, ITC India, points out, “Let's take Swiggy as a model. Their service is fast. They pick up food from one of the hundreds of restaurants in the city and deliver it by a huge army of couriers. Now, suppose there are only as many restaurants as there are hospitals in the entire city. Will they be able to deliver in ten minutes? Unlikely. Healthcare service offerings are fewer, expertise-driven and sensitive. Creating an equivalence with food or material delivery should therefore be viewed with caution. Likewise, when a person reaches a hospital, he is one among many patients waiting to see the emergency doctor. Unless the care providers are on the spot and ready, a delay is unavoidable even with an app. If they happen to be busy with a preceding trauma emergency, the subsequent patients will just have to wait. The perennial shortage of doctors and nurses in ER will make a 10-minute delivery very difficult,” explains Dr. Chandy.

Source: https://cdn.who.int/media/docs/default-source/emergencies-trauma-care/emergency-infographics-banner_90bd239b-91c3-4aaf-a2bc-19d6635360b7.pdf?sfvrsn=e255c50a_10&download=true

Core of care comes from a select group

The fundamental problem of Indian healthcare is the huge demand-supply mismatch of caregivers and seekers. “An aggregator service provides transport, but not expertise. A patient’s need is quite different from an online order of a McDonald burger or a menu of food delicacies. Healthcare is nuanced with so many variables,” adds Dr. Chandy.

He further elaborates: “Even when a patient, let's say with a broken leg reaches a hospital, how would a 10-minute delivery happen? The patient is in pain and emotional distress. He may not have money and may not know how to fill in the admission advisory. Even if he registers, the doctor has to come for care to commence. The current shortage of doctors would make a 10-minute attendance difficult. That's why hospitals are the most unhappy places.”

“There are logistical challenges to a 10-minute health delivery on a 4-wheeler ambulance. Unlike cities overseas, our traffic snarls and relatively subdued give-way sense makes ambulance transit difficult. Ambulances often queue behind vehicles that do not give the right of way. Our roads are narrow with roadside parking. Ambulances cannot cross medians like they do overseas. There is an infrastructure challenge to rapid transit. The third issue is the absence of networking. The nearest ambulance should respond with the help of a centralised control room. This is where technology could come in. You must have a single coordinated networking system and one number that is known to all,” he adds.

Chandy points out that India must go for two-wheeler ambulances as a platform for rapid care delivery. “A mobile, well-trained paramedic who carries a portable life pack system and reaches the spot as quickly as possible as a first-responder. Two-wheelers help you reach the spot faster than 4-wheelers. Suppose a cadre of young paramedics with BLS/ACLS training, well-paid, equipped with life-packs are positioned in critical locations like traffic points, malls, busy junctions, and dense residential areas. They are connected with a GPS-enabled call network and rush to the area of need. Their task is to stabilise the patient while an ambulance is on the way. Many hospitals have discontinued their own ambulance networks because of 108-like services. The essential paradigm shift is to move away from transport-driven ambulance care to first-responder care using a better mobility vehicle in our crowded cities,” says Dr. Chandy.

Dr. Chandy also highlights that many ambulances are ill-equipped, without the emergency kit, or a full oxygen cylinder sometimes. “The fourth problem is that paramedics are not trained well enough. For a 10-minute service, we need multitasking, trained and able-bodied paramedics. Paramedics must be considered professional on par with nurses and lifeguards. Dignity of work, salary and pride must be given to these life-saving soldiers. We can learn from the western model of paramedic work. The ambulances must be well-maintained, akin to the service of aircraft. With these changes, a total paradigm shift can be brought about to the ambulance care segment of healthcare,” he concludes.

Makes Business Sense

Many startups say the aggregator model can work successfully as a subscription-driven model. "Suppose I tell you that an ambulance will be available whenever you need it, anytime, for any medical reason, for a year, at the cost of ₹200-300. Even insurance companies don't support this, but we do. We've tied up with insurance companies to provide their policy members access to our services," says Dial 4242's Lalwani.

"We estimate that there are around 2 lakh private ambulances in India. Even if they do an average of ₹3,000 per day, look at the amount of revenue possible. In top cities, ambulances make at least 2-3 trips per day and make ₹8-10 thousand per day. That is the kind of volume available. Currently, many people take their car or a taxi instead of an ambulance. That is another challenge. They think, if I book an Uber XL, an Innova, I will be charged this much, so why to take an ambulance?" Lalwani adds. That is why affordability is a significant challenge in India, and that is what he claims he wants to change with their subscription model. "When we sign up with a corporation or institution, we provide a clause stating that if we don't deliver an ambulance in the defined turnaround time, Dial4242 will foot a penalty," says Lalwani. At present, the startup says it attends to 800-1000 calls per day. It is also working to tie up with health and fitness tracker devices, such as the Apple Watch, which senses when a patient is in a critical condition. "We are also trying to tie up with car manufacturers. So, when an accident happens, and the airbag gets deployed, our ambulance will be sent to the traced GPS location," adds Lalwani.

Public-Private Join Hands

Another formidable challenge is the government's scale and access, which, Medulance's Arora believes is incomparable for private players. To turn this into an advantage, instead, in Delhi, Medulance has worked with the government and reduced the average response time from 22 minutes to less than 10 minutes. "However, to achieve this requires a huge ambulance fleet and backend support, for which the government has to spend enormous amounts. We are in talks with other states for integration of private ambulances," he says.

According to him, all ambulances should function under one umbrella. "The pandemic showed us enough examples where the private sector stepped up and was able to help in dealing with the crisis, which has led to more trust in companies like Medulance. An integrated system will increase accessibility and affordability of services and will bring more transparency," he explains.

Going beyond the metros

Nimith Agrawal, CEO, DoctCo, a health-tech startup, envisages making fast, high-quality healthcare available to patients, says, "One such initiative we carried out was Swasthya Ghar Tak which works in Tier-2 & 3 cities to provide patients with last-mile connectivity to specialist hospitals and doctors without requiring them to go to distant metro cities. Over time, quality healthcare can be delivered to all communities."

A promising market, but prepare for a long haul

Given that there are still gaps in the healthcare sector in India, and government initiative alone isn't capable of fully servicing demand, the private sector has a vast untapped market to explore. But one shouldn't be quick to assume that it is an easy space to make inroads into. Pramod Kutty, CEO and co-founder of Connect2MyDoctor, a telehealth platform, offers some sobering advice and points out that change takes time in the healthcare sector, perhaps even longer than it does in other sectors. "New entrants should not come with an expectation that they will see results or change immediately. To have them adopt a new process, even if it is better, takes time. The successful startup will work through the process, be persistent, and adapt. After all, timely healthcare delivery is uniquely critical,” he says.

Is 10-minute model the answer?

Several factors impact the feasibility of 10-minute delivery in the Indian healthcare sector: current infrastructure, availability of personnel, and prevailing attitudes among both patients and providers, according to Gayatri Kamineni, COO, Kamineni Hospitals.

She points out that one potential impact of a fast delivery model on India's health system could be increased pressure on healthcare infrastructure. A fast delivery model would decrease wait times for medical procedures and increase access to medical care. This is especially beneficial for rural and poor populations who often have to travel long distances to receive care, but it is sure to collapse if not managed with the right tools," she says.

Challenges abound

Where there are opportunities, there are challenges too. Kamineni identifies five major ones that ail the model.

Capturing as much information as possible while being concise and clear
Dealing with patients who have multiple questions and want to discuss their entire medical history
Medical history can also pose a challenge when trying to provide care in a short period. It is vital to have all relevant information about a patient to provide the best possible care.
Handling complex or emotional patients
Keeping to schedule, especially when there are unexpected delays

But one shouldn't lose heart; Kamineni outlines some key considerations to help startups navigate the terrain:

Have a clear value proposition. What makes you different from the competition? Why should patients choose you?
Establish trust with patients: Be transparent and honest about your services and always put patient's best interests first.
Prepare for regulatory challenges: Healthcare services are highly regulated, so you'll need to be familiar with relevant laws and regulations.
Operate with professionalism. Patients trust you with their health, so it's crucial to maintain excellence in your operations.

“Healthcare delivery is complex compared to other markets where the 10-minute delivery model is gaining traction. Even today, services in few areas within the healthcare space have the potential to be delivered remotely and effectively. "Services such as urgent care and emergency medicine qualify as need-based and have potential for practical remote application in the Indian healthcare context," says Ravideep Singh, Associate Director, Creative Designer Architects, an interdisciplinary architectural practice that is an established design leader in the healthcare sector.

"A 10-minute delivery model might not be seamlessly applicable to our healthcare space. However, there is much to learn from such models. They vouch for a stipulated delivery time based on enhanced visibility across all steps of the chain. Within healthcare, this can be achieved through two mediums – predictive data and control across verticals, such as technology, human resources, infrastructure, and distribution. Getting this right will involve some trial and effort, but it will ultimately open up avenues for prompt healthcare delivery," he adds.

The third wave of the internet is not about creating the next viral game or social media applications; it's about fixing real-world problems and finding innovative solutions, says author Steve Case in his book The Third Wave, An Entrepreneur's Vision of the Future. With the space primed for innovation, investment and ingenuity, and with many entrepreneurs already competing, it remains to be seen how startups can overcome challenges to build sustainable emergency models in a sector that is ready to explode.

Healthcare entrepreneurship to the rescue: Should all hail the 10-minute delivery model?

Is the healthcare sector ready for speed, or is it too complex an environment for startups. Can quick-service, Zomato-like models become more than a pipedream in this space? Arunima Rajan finds out.