Mobile Medical Vans: Overcoming India's Last-Mile Health Care Challenges

There are few skin diseases more debilitating than leprosy. It is characterized by painful sores and lesions all over the body and the infections can lead to the loss of fingers, hands, toes and feet. Eventually, leprosy causes blindness and acute disfigurement. Chandra Babu, 36, from Kasabkheda village in the tribal belt of Orissa in Eastern India, had been suffering from leprosy for four years without knowing what was wrong with him. When he was diagnosed by a Mobile 1000 doctor and told it was easily curable, he flung himself at the doctor's feet with joy and gratitude.

 
"The areas we work in are so poor, people can't afford food and clothes. Health care is an absolute luxury; they choose to ignore illnesses. So we give them a service that is high quality, free of cost and at their doorstep," says Akshay Hudar, CEO of the Wockhardt Foundation's Mobile 1000 initiative.

Mobile 1000 is the flagship program of the Wockhardt Foundation, the corporate social responsibility (CSR) arm of Wockhardt, a leading pharmaceutical company in India. The program, conceptualized and spearheaded by the foundation's CEO and trustee, Huzaifa Khorakiwala, involves the operation of mobile medical vans that travel through remote rural regions in India and provide primary health care services to millions like Chandra Babu. "Since Wockhardt is a health care company, we decided to keep our social work focused around health care as well," notes Khorakiwala. While the foundation has several other social outreach programs -- including initiatives related to water purification and biodegradable toilets -- Mobile 1000 receives more than 80% of the total funds.

The idea for Mobile 1000, so named because Khorakiwala's vision is to have 1,000 vans on the road by 2017, first occurred to him when analyzing research conducted by the National Rural Health Mission (NRHM), a government agency for implementing rural health care. The survey showed that 700 million people live in India's 636,000 villages, but that the locales have only 23,000 primary health care centers among them. Some 66% of rural Indians do not have access to critical medicines and 31% of the rural population travels more than 30 kilometers to seek health care. Additionally, rural health centers, where they exist, are short of trained medical personnel.

According to a PricewaterhouseCoopers (PwC) report, "Emerging mHealth, Paths for Growth," India has only 0.6 doctors per 1,000 people, and the majority of the practitioners are based in urban areas. In addition, Indians cover 75% of their medical expenses from their own pockets, rather than with insurance.

"Even if we put one doctor in a village, he will not have enough work for the entire day because a village has an average population of 1,000," says Khorakiwala. "There are 10 patients a day, who take just over an hour for the doctor to see. So the more efficient way of utilizing the scarce resource [a doctor's time] is to have a mobile van."

According to Mark V. Pauly, a Wharton professor of health care management, "If this initiative works as promised, it obviously will be useful. It surely will not be adequate to bring health care and health outcomes in India up to world standards but it will represent a step in the right direction. The question is whether it actually works."

Making an Impact
It is too early for the Wockhardt Foundation to conduct impact studies, but the project has so far met Khorakiwala's efficiency requirements. Since it began in 2011, the number of vans -- all rented -- has increased from one to 75, and more than a million patients have been treated. "Overall, the program has been impactful," notes Vishal Kapoor, portfolio manager of Dasra, a foundation that helps to fund nonprofits and social businesses.

Kapoor was part of the team that assessed, screened and audited the applications for the Inclusive India awards that recognize substantial contribution to social development. The Wockhardt Foundation won for best social work in the area of primary health. Mobile 1000 was an obvious choice. Says Kapoor: "Mobile 1000 promotes higher quality primary health care as compared to currently available options across villages in India, such as local, self-proclaimed practitioners and alternative home-based therapies. By providing regular and concentrated health-related activities in villages, the program promotes health-seeking behavior."

Rana Mehta, executive director of the health care practice at PwC India, agrees. "Many thought health care delivery would happen through the Internet, but in India we don't see that happening very much because penetration remains a problem and there are cost challenges. In today's context, when millions have no access to health care at all, such initiatives are useful supplements." A typical day in the life of a Mobile 1000 van is carefully planned. A semi-urban area is used as a base location.

The team -- a general physician, a pharmacist and a driver -- starts at 9 a.m. and covers about four villages a day, seeing on average 20-30 patients at each village. The van covers about 25 villages in weekly cycles and reaches 22,500 people a year at US$2.4 per person, a cost that is lower than the NRHM's US$3 per person because the Mobile 1000 program uses generic drugs. The van has on board primary diagnostic equipment and medical supplies that can treat basic illnesses like cough, cold, fever, infection, malaria, dengue, typhoid and hepatitis. For the more complicated illnesses, patients are referred to the nearest hospital.

Keeping Track
The command centre for the entire operation is the Wockhardt Foundation headquarters in Mumbai. Once the van leaves a village, the team sends a report via text message from a mobile phone. "All the records are collected after each visit to each village and stored. That way we know how many villages the van visited, how many patients it checked, their gender and ages, the illnesses, the referrals made and so on," notes Hudar.

Providing quality service obviously comes at a price. The end-to-end operation of each van costs US$50,000 a year. "We operate on a philanthropy model," says Hudar. "We use funds from the corporate social responsibility (CSR) budgets of various companies; we are an implementing agency for them." While the program has private sector donors like Infrastructure Leasing & Financial Services and Welspun, more than 80% of the money to run Mobile 1000 comes from public sector undertakings (PSUs) like Gas Authority and Indian Oil. Khorakiwala expects more with the passage of the Companies Bill that could require spending of 2% of net profit on CSR activities. "PSUs don't have enough reliable causes to spend on," he notes.

But Pauly is not entirely convinced. "The Wockhardt Foundation needs to commit to pay or find another stable source of financing," Pauly says. "They should persuade the government of India or the state governments that this is a good way to spend additional money." The foundation is indeed working on collaborating with several state governments including Kerala, Tamil Nadu and Karnataka. Pauly, however, notes that while this is an initiative worth pursuing, "it is not clear that this is the best way to use those resources or that additional resources will be forthcoming even if this model does work."

Dasra's Kapoor is more optimistic about such partnerships. "The government of India runs its own mobile medical program across rural villages but suffers in part from planning and high quality implementation. [There is] opportunity for the government to partner with private organizations," he says. "In the long term, this will enable scale, sustainability and deeper access to good quality health care. However, if they remain dependent on their own ability to raise funds and implement this program, scale may be difficult to achieve."

Funding Needs
Like most nonprofit initiatives, Mobile 1000's ultimate goal is to become self-sustaining. But, according to Khorakiwala, "Scalability depends on sustainability." He notes that sustainability can come from two sources -- either by making money from the operation or through large grant-based funding. "It cannot happen through private corporate funding because it is usually not more than US$1 million to US$2 million. You need government funding because that [amounts to] much more" than what private firms are willing to give. Eventually, Khorakiwala hopes to make Mobile 1000 sustainable by using the vans as points of retail, selling everyday consumer goods such as soap, shampoo, toothpaste, unfortified biscuits and mosquito nets. "But we will not begin selling until we reach 800 vans because we need mass production of the goods sold to bring down their cost and sell at prices that the poor can afford," he says. "It will require a capital of US$20 million in each state. But we hope to make a profit from that activity and that will sustain the free health care we wish to give."

Mobile 1000's profits will have to be substantial to make an impact on a national level, according to PwC's Mehta. "I think this is a nascent industry in India and getting the correct business model is the biggest key to success. A developing country needs to have its own model. We can't ape anything that might have been done in the West."

But Khorakiwala and Hudar are not daunted by the enormity of their task. They are focusing instead on ironing out the day-to-day operational wrinkles. Control and monitoring of the vans is a big one. One of the challenges is to have a genuine reporting system. "From Mumbai, it is difficult to monitor whether we are receiving accurate information: Has the van truly visited each village it claims to?" Hudar says. "So to counter that, we have fitted each van with a GPS tracking system. But certain villages are quite remote so even that becomes difficult."

Another big challenge is getting doctors to relocate to rural areas and keeping them there. Most want to go back to urban areas after a few months in spite of being paid market salaries. "That's why our single most important criteria when recruiting these doctors is that they should be compassionate and truly believe in the cause," notes Hudar. Those are useful qualities, especially when dealing with the rural mindset.

Generating awareness among the people is Mobile 1000's single largest goal. "Because only when there is awareness will people start taking care of their health and institute preventive measures," Hudar states. He has help there -- telemedicine and mobile health are making headway and are also spreading awareness.

These are promising innovations, but Khorakiwala says that his approach is best. "There are two major problems [with the others]," he notes. "One, physical examination should form the basis of diagnosis. You have to feel the skin to sense its tenderness. And second, it's not easy to get connectivity in all rural areas."

But Mehta of PwC says that one innovation need not compete against the other. "They complement each other. To really have a robust system you need a mix of all of them." On his part, Khorakiwala is thinking big. When the current target of 1,000 vans has been achieved, he says: "We will change the name to Mobile 25,000 and keep going."