Sattar Khan suffered chronic pain in his legs for seven years. He consulted several doctors in his hometown of Kabul, the capital city of Afghanistan, who told him he needed a hip joint surgery but the facility was not available anywhere in the war-torn country.
With time, his mobility got restricted, he lost his job, and he got confined to his home. In January 2017, when Sattar’s cousin Shaukat Khan visited Kabul from England where he had settled with his parents in his childhood, he was extremely worried to see the condition of his childhood playmate. Shaukat had heard good reviews about several Lahore-based orthopedic surgeons from his Pakistani colleagues in London. Unsure how to get in touch with any of those surgeons, Shaukat ran a few Google searches until he landed on the website of Marham (bandage), a Pakistani digital healthcare startup that uses its website and smartphone applications to connect patients with relevant doctors.
Within a few days, Shaukat was speaking on the phone to Asma Omar, a co-founder at Marham, to coordinate logistics for a trip to Lahore where Omar had scheduled an appointment for Sattar with an orthopedic surgeon at National Hospital. Shaukat says the surgery was performed in Lahore and his cousin remained hospitalized for post-op care for a few weeks before the family returned to Kabul. “Sattar has started walking again and plans to resume work soon,” Shaukat says in a video Marham has shared with MIT Technology Review Pakistan.
There is a widespread private healthcare sector in Pakistan comprising hospitals, clinics, and diagnostic centers. Since all of these facilities do not have an online presence, there is no single platform for care seekers to look out for experts ad facilities.
Marham’s website and smartphone applications are filling this gap. The apps serve as a platform where patients can find and consult doctors in private hospitals and clinics at any location across 14 major cities in Pakistan.
“The software allows users to book online appointments as well as to consult doctors online for free. Users can also leave a review for doctors,” says Omer.
She says in the long run these reviews will be used to determine the competency of doctors. Those with favorable reviews only will be made available for care seekers through the smartphone application.
Marham aims to fill in information gaps in the private healthcare sector by providing updated information on different hospitals through its digital platforms. “Our users don’t need to visit individual hospitals to find out about facilities available there. They can access all the updated information through the app and avoid wasting time at hospitals that lack required facilities like emergency care services, ventilators or a burn unit,” Omer says.
The startup was launched in January 2016 and it now operates in different cities of Pakistan including Karachi, Lahore, Peshawar, Islamabad, Rawalpindi, Multan, Faisalabad, Sargodha, Rahim Yar Khan, Sialkot, Bahawalpur, Gujranwala, Kasur, Abbottabad, Swabi, and Charsadda.
Its panel of hospitals has information about 1,500 facilities and over 10,000 doctors.
Omer says that the website of the startup gets approximately 5,000 visitors everyday. Like Shaukat, many of these users are from outside the country. “Sattar was our first user from Afghanistan. We have got several users from among Pakistani diaspora settled in western countries. Most of them cannot afford health insurance in their host countries and find even private consultants here in Pakistan quite affordable,” she said.
“On average, 30 doctors reach out to us everyday to register for our panel,” she says.
Omar says her team has paid specific attention to product design, making sure it is as user friendly as possible. Our app has a comprehensive search engine, an appointment booking mechanism, and a forum for online consultation. But, she adds, product design was the easier part of their work. “The real trouble was in the execution phase. We had to pay special attention to authenticate data provided by doctors and hospitals,” she says.
The end result has been two separate applications, one for patients and the other for doctors and healthcare facilities.
When someone posts a query on the online forum, all relevant doctors are notified through the application, leading to prompt responses.
Every query answered by doctors on the Marham online forum gets compiled and uploaded onto their profile page as well, alongside patient reviews. “This is done to help care seekers make informed choices when booking an appointment,” she says.
Apart from making the procedure for booking appointments hassle free, the online management system introduced by Marham can also enable healthcare providers better manage their accounts.
“This will make payment procedures more transparent,” Omar says.
Though the startup has so far worked with private sector facilities, it has recently received its first public sector client as well. “Our platform is now connecting patients to the only liver transplant facility at Lahore’s Shaikh Zayed Hospital,” she says.
Omar is hopeful that Marham’s model could soon be adopted at public sector facilities that lack online management systems.
“They still follow an archaic system. Patients manually register for a place in the queue and wait for their turn to be seen by the doctor. This creates a haphazard situation. Doctors don’t know how many patients they have to see in a day, and patients are required to wait for hours at a stretch to consult doctors,” Omar says.
Serving the underserved
Another stream of Pakistani health startups are making use of Information and Communication Technologies (ICT) to extend health services to remote areas.
Sehat Kahani’s telemedicine facilities benefit from the expertise of home-based women doctors who can’t work at a hospital or a clinic following completion of their medical education.
Dr Iffat Zafar Aga, the co-founder and the chief development officer at Sehat Kahani, says her research suggests that out of nearly 70,000 women medical graduates , only 9,000 are registered as practitioners with Pakistan Medical and Dental Council, the regulator of the profession.
“Only 13 percent of women medical graduates join the workforce – the rest give in to social or family pressure and never make use of their expertise,” she says.
Sehat Kahani’s telemedicine facilities enable such experts to consult patients from home.
Soon after deciding to open online clinics in underserved areas, Sehat Kahani team realized that setting up clinics from scratch and equipping them with ICT facilities was a costly venture, involving many logistical issues.
Then, Zafar says, the team decided to make use of clinics set up in rural areas by different NGOs and companies. “We reached out to a number of NGOs and companies, and eventually partnered with a company operating 800 clinics across the country,” she adds.
Sehat Kahani upgrades these existing clinics by installing ICT equipment and conducting trainings with nurses and midwives. Eventually, a partially active clinic turns into a telemedicine facility. When a patient visits one of the clinics, he or she is checked by the nurse who then pulls out a form and a laptop and makes the patient directly interact with an online doctor.
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When launching a clinic, the team recruits two community mobilizers to spread the word about the clinic. The mobilizers go door-to-door and make sure that word gets out to the entire community.
Then a free medical camp is set up in collaboration with pharmaceutical companies and sponsors on the day of the clinic’s launch.
The decision to open a new clinic is based on findings of surveys done to ascertain technology feasibility of the location, the payment potential of the community, and major diseases found in the area.
“We offer our services at a subsidized rate to ensure sustainability of the business model,” Zafar says.
Sehat Kahani has set up nine telemedicine facilities in Sindh, Punjab, and Khyber Pakhtunkhwa. Two of these are dedicated just to psychiatric health issues.
The startup now has a panel of 15 home-based women physicians who have treated more than 30,000 patients over a span of two years. “Our database consists up of 75 to 80 doctors,” Zafar says.
Beyond Service Delivery
Service delivery is not the only area in the healthcare sector where startups are leveraging latest technology to plug gaps and cater to patients’ needs.
The pharmaceutical industry has also attracted startups that are pioneering technology-based solutions for problems like prevalence of counterfeit drugs.
The counterfeit drug market is a global phenomenon and Pakistan is no exception. There are regular reports in the media about government raids on factories producing and marketing spurious drugs. In 2017, health authorities in Punjab unearthed two factories in Sargodha that were marketing counterfeit drugs of famous international brands.
The World Health Organization (WHO) defines a counterfeit medicine as ‘a medicine, which is deliberately and fraudulently mislabelled with respect to identity and/or source. Counterfeiting can apply to both branded and generic products and counterfeit products may include products with the correct ingredients or with the wrong ingredients, without active ingredients, with insufficient active ingredients or with fake packaging’.
An estimate by the WHO suggests that approximately 30 percent of all drugs manufactured in developing countries can be counterfeit.
In Pakistan, a startup named Procheck is tackling this problem using the short message service (SMS) technology of cell phones and the pharmaceuticals’ automated databases.
Launched in 2014, the startup works with pharmaceutical manufacturers to help protect their products by assigning a unique code to every medicine pack (serialization). The unique identification number makes it impossible for counterfeiters to replicate the packaging, thus preventing loss of revenue for manufacturers as well as enabling customers to ascertain a medicine’s authenticity. Customers just have to send the identification code to 8776 via SMS to immediately receive confirmation of the authenticity of the medicine and its expiration date.
In the instance of a counterfeit medicine, the consumer can return it to the retailer and the manufacturer can take action accordingly.
Saim Siddiqui, the chief executive officer of Procheck, says that the startup’s first client saw 30 percent increase in sales after implementation of its programme. “ProCheck has booked orders to protect over 40 million units of medicine,” he says.
The serialization of medicines helps create visibility throughout the supply chain by tracking each product. This is done by aggregating the codes on the medicines and tallying them with shipper cartons at each location in the product supply chain.
“Initially some companies were skeptical about our idea as the pharmaceutical industry is highly regulated,” Siddiqui says. “The more regulated the industry, the slower its products move from one point in the supply chain to the other.” Unlike the banking sector, the pharma industry is quite labor intensive which is why they are wary of the incorporation of technology with their products, he says.
ProCheck is working with four pharmaceutical companies: GetzPharma, Ferozsons Laboratories Limited, Stile Pharmaceuticals, and Nabiqasim Industries.
An e-health passport
Another startup E-novatRX has set up Pakistan’s first e-pharmacy benefit management system – a service popular in western countries but not yet introduced here. The system aggregates private and corporate customers and negotiates on their behalf with healthcare providers and pharmaceuticals for significantly discounted prices of services and drugs.
E-novatRX uses pre-existing technology platforms to provide these services. It has collaborated with the National Database and Registration Authority (Nadra) to leverage technology deployed by the authority to compile and maintain its database of Computerized National Identity Cards (CNICs). For payment processing requirements, the startup has struck a partnership with Telenor enabling it to use the Easypaisa mobile banking platform.
“The idea is to create an e-health passport using a smart chip card that can be used by care seekers to access healthcare services across the country at discounted prices,” says Dr Hassan, a co-founder.
Further explaining the concept behind the startup, he said, “We have identified a large population with unmet needs. Our tech-based platform has a digital financial tool attached to it through which we provide services and benefits to this population segment.”
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By loading essential medical information onto the smart chip embedded with the personalized card and linking it to a cloud-based medical record system, the startup is also building a repository of information that can help streamline the highly fragmented healthcare sector.
For example, its database will hold information such as allergies suffered by a consumer and recent prescriptions. This information can be accessed by authorized healthcare providers and pharmacists in real time.
“This promotes continuity of care. One of the biggest challenges in Pakistan is the fragmentation in the healthcare system,” Dr Hassan said.
If healthcare consumers go to a clinic or a hospital in Pakistan, they may have some medical records or none at all. But, by using E-novatRX e-pharmacy Benefit Management System the medical records can be accessed immediately, helping healthcare providers make informed decisions. Because of the use of Nadra database, the system also allows biometric verification at point of sale. This is useful for insurance companies and other stakeholders who want to verify that the consumer is in fact the person entitled for the services. “For example many corporations give medical allowances to their employees but there is leakage in the system, in terms of fraudulent receipts and inappropriate utilizations.”
Currently, the startup is testing its product in a corporate B2B population — working with Unilever and its value chains. Unilever has approximately 4,500 distributors across the country who have started using the startup’s service.
“We’re also running a hepatitis awareness and treatment campaign with Chughtai Lab, where the distributors can go for a screening. If needed, they can get a highly subsidized treatment plan provided by Ferozsons, a Lahore based pharmaceutical company,” he said.