Covid-19 pandemic bares untapped home healthcare services in India

The shortage is magnified in clinicians, nurses and doctors focused on general and internal medicine, said Vishal Bali Founder, Nightingale

In Delhi’s Greater Kailash, as her twin sister’s condition worsened on several fronts, in Alka Sahni’s mind, panic began to set in. What if her sister passed away without treatment ? Worse, what if she suffered ? What if there was something happening due to the virus in her body that was not visible on the outside ? After she worked herself up, Sahni put her sister in their car and started driving to the closest hospital to admit her before she took a turn for the worse. 

In Bengaluru, Professor Neelkanth Vaidya drove around the city for almost three hours before deciding to drive to the outskirts to a hospital where he felt his wife who was COVID positive would be treated. The 51 year old had a cough, mild fever and a few other symptoms but the fear of the worst had set in Vaidya’s mind. He was unwilling to take a chance.

As it happened neither Alka’s sister nor the Professor’s wife needed hospitalisation. Both were checked and sent home by the hospital staff as they could well be treated at home. This is what Vishal Bali, founder of Nightingale and former CEO of Wockhardt, says is the “big mindset issue”. In the minds of the consumers in India, hospitals are the destination of care. “This is partly why the situation is as bad as it is currently with the pandemic'', he argues. While hospitals are flooded with patients who need hospital care, they are also dealing with a flood of patients who can be managed at home but who arrive in panic, only to be sent back. In India’s second catastrophic wave of the pandemic - currently ongoing - stories abound of people rushing to hospital even when they don’t require it. Home healthcare, Bali says, could be the next big thing for India and could take the pressure off the hospital system if regulations and mindsets permit. 

Healthcare expert, IIT Kharagpur and Harvard Business School alumni Ratan Jalan, who runs Medium Healthcare Consulting, is convinced there is a “phenomenal opportunity” for home healthcare to augment and buttress India’s hospital and healthcare delivery for those who “do it right”. He feels that the sector has in some sense given itself a bad name even before full take-off as some players have been focussed on only the numbers game. 

Home healthcare remains a niche, small segment in India even today but in 2014, after Vishal Bali relocated back to India from Singapore, it was virtually non existent. Bali wanted to do something innovative that would have an impact in Indian healthcare and something that went beyond hospitals, diagnostics and all other tried and tested models - all the “been there, done that” stuff he’d been involved in through his career. .
 

That’s when he hit upon the idea of home healthcare, a segment that had grown in many countries but remained non-existent in India. A company called Medwell Ventures was set up at the time to look at various innovative models for augmenting healthcare services in India with Nightingale as the brand for the home healthcare segment. 

Bali had the requisite experience and credentials to plunge in. After he joined Wockhardt hospitals as a trainee straight out of business school, Bali rose to the position of CEO and managing director by the time the company reached its 19th hospital in India and he’d spent two decades of his working life setting them up. When Wockhardt was sold to Fortis - one of the biggest healthcare deals of the day - post 2009, he became group CEO of the Wockhardt and Fortis combine. He then moved to set up Fortis Healthcare International, based in Singapore, which acquired many healthcare companies in ten different countries cutting across many verticals : 180-185  primary healthcare sites in Hong Kong, the largest hospital provider group in Vietnam, a cancer hospital and a diagnostics facility in Singapore, a dentistry practice in Australia, among others. 

In addition to his entrepreneurial hat, Bali, now 53,  who had spent his career in corporate health wore a second hat in 2014. The San Francisco headquartered private equity firm TPG Capital with over US $ 70 billion in assets under management pulled him into its Indian single entity specialty platform strategy and even as he started work on Nightingale, he continued to be involved with their journey that led to many new innovative Indian brands coming into to provide better healthcare services to patients who could afford it. These included MotherHood Maternity, NOVA IVF, American Oncology Institute which grew from one to 14 hospitals in a four year frame, among others. 

Nightingale offers a range of services starting from family physicians, short and long term nursing care, post hospitalisation care, physiotherapy, stroke rehabilitation, respiratory care, bedside caregivers and attendants, intensive care at home, lab tests and speech therapy. It  focuses on patients with chronic diseases and supporting patients managing these diseases like COPD, arthritis, neuro strokes which require a multi disciplinary team of doctors, nurses, physiotherapists and speech therapists. It offers nursing services for oncology patients at home, managing their peripherally inserted central catheter (PICC) lines, chemo port flushing and so on. 

In terms of pricing, the comparison between hospitalisation and home healthcare can be done with specific medical conditions. For instance for a patient who has had a neuro stroke, one day cost of hospitalisation for recovery in the hospital could be in the region of Rs 6000-8000 or more based on hospital room and number of physio sessions. In comparison, Nightingales one month cost of a post stroke rehabilitation at home will be in the region of 35000 -40000. The company has raised US $ 25-26 million so far. It also acquired a company in South Africa that ran home healthcare facilities for the retired residential communities. Although Nightingale was a pioneer of sorts, competitors like Healthcare At Home and Portea Medical Services have come up since.

Nightingale has three other co-founders all of whom wear other hats and is run by a professional management but Bali says in the early days, it consumed all of them as many of the “enablers” to run a home healthcare company were “missing” in the country back then. 

Two or three of the main stumbling blocks in the growth of the segment has been the fact that home healthcare in India is still not covered by insurance. “Hospitalisation is almost a requirement for insurance reimbursement and this has been one of the biggest deterrents for growth of the sector” explains Bali. COVID has further highlighted the need for home care in the home setting. Bali says that if the segment had the width, breadth and depth by now, it could have taken the load off the country’s hospital network to a large extent in this crisis. Nightingale is currently managing around 22,000 families in Bengaluru, Hyderabad, Chennai and Mumbai that are COVID positive but are being treated at home. “This could be replicated all over the country”, he adds. Although it had plans to expand into ten cities, the acute shortage of trained and skilled manpower has been a hindrance.

From a regulatory point of view, IRDA has to recognise home health care as a way to provide health services just the way it accepts hospitalisation and insurance companies have to launch innovative products for outside hospital care. Some of the more progessive private insurance companies like  ICICI Lombard have come up with more innovative products - for instance it has created a new product for cancer coverage - but a majority of the public sector companies don’t have any new or innovative products for health coverage outside the hospital. “This is one of the biggest impediments that the industry faces”, he says. 

Third, the company has faced trouble with finding doctors in particular. “The company was conceptualised on the thinking that the country has had a great tradition of family medicine and we would provide the entire ecosystem needed by the family physician to provide the care the patient needed at home”, he explains. The family doctor who was generally qualified and able but not a specialist in any field, who generally lived nearby and treated the entire family. As things have evolved, these generalists or those who specialise in internal  medicine have been harder and harder to come by as most MBBS tend to specialise in a particular area be it surgery or paediatrics. “In general, India has failed to create enough talent but the shortage is even more magnified in clinicians, nurses and doctors focussed on general and internal medicine”, he argues.

Manpower is the biggest block even to Jalan’s mind.  “There is a commoditization that has gripped the home care segment  and many have been reduced to supplying nurses or some minimal staff at home to assist patients”, he feels. He thinks the more the successful ones will be those who invest and create their own cadre of  manpower - a bit like the Taj group in hospitality. He argues that players have not tended to think “long term” and since quality is not easily demonstrable, they have tended to focus heavily on quantity.

Most however agree that home healthcare can act as a good “backup mechanism” to India’s shaky healthcare edifice and can become a critical part of the delivery system based on the premise that not all patients require hospitalisation but they do all need good, competent care. The pandemic may end up teaching  policy makers this broader lesson albeit at a very high price. 

(Some names have been changed to protect identities.)