India is in the throes of a diabetes epidemic but one patient refused to be just a statistic and decided to use his experiences to help other diabetics manage their diabetes better. Founder & CEO Ashok Jain’s Lifespan Clinics is just three years old but it is a good start By Viveka Roychowdhury
According to the latest (seventh) edition of the International Diabetes Federation (IDF) Diabetes Atlas, 1 in 11 adults have diabetes (415 million). What is more worrisome is that almost half (46.5 per cent) of adults with diabetes are undiagnosed.
The figures for India are equally, if not more, depressing. The IDF has predicted that by 2030, over 100 million Indians would be diabetic. According to the 2015 country report on India in the seventh IDF Diabetes Atlas, one in every 12 adults in India has diabetes, with 52.1 per cent of the adult population undiagnosed. So India has a higher percentage of undiagnosed diabetics than the world average.
In terms of numbers, diabetes cases in the 20-79 years age group in India are at 69,188,600, of which 36,061,100 are not aware that they have diabetes. Diabetes related expenditure per person is projected to be $94.9 per adult person with diabetes, based on mean diabetes cost ratio of 2.
WWD 2016: Eyes on Diabetes
November 14 is World Diabetes Day (WDD) and this year, the International Diabetes Federation (IDF) has decided to focus on integrating screening for diabetes complications into ongoing care for people living with diabetes. Under the theme, Eyes on Diabetes, IDF is advocating screening for type 2 diabetes to modify its course and reduce the risk of complications as well as screening for diabetes complications as an essential part of managing type 1 and type 2 of diabetes.
With specific importance for low resource countries like India saddled with a huge diabetic disease burden, this WDD will also highlight feasible and cost-effective solutions that exist to help identify people with undiagnosed type 2 diabetes and those at risk of developing it in the future.
IDF’s focus is driven by estimates that globally as many as 193 million people, or close to half of all adults living with diabetes in 2015, are unaware of their disease. Most of these cases are type 2 diabetes. The earlier a person is diagnosed, the earlier treatment can be initiated in order to reduce the risk of harmful and costly complications. A person with type 2 diabetes can live for several years without showing any symptoms, during which time high blood glucose is silently damaging the body.
Diabetes is a leading cause of cardiovascular disease, blindness, kidney failure and lower-limb amputation. Over one third of all people currently living with type 1 and type 2 diabetes will develop some form of damage to their eyes that can lead to blindness. These complications can be prevented or delayed by maintaining blood glucose, blood pressure and cholesterol levels as close to normal as possible. Many complications can be picked up in their early stages through screening, so that treatment can be given to prevent them becoming more serious.
The problem of late diagnosis increases the cost of dealing with the disease, not just in terms of treatment costs but also loss of productivity. India’s dream of reaping its demographic dividend could very soon turn into a nightmare if a sizable section of the nation’s workforce is held back by diabetes related health complications.
Thus the theme for this year’s World Diabetic Day(WDD), Eyes on Diabetics, was chosen by the International Diabetes Federation (IDF) to highlight the importance of screening for diabetes and for its complications. (See Box: WWD 2016: Eyes on Diabetes.)
With specific importance for low resource countries like India saddled with a huge diabetic disease burden, this WDD will also highlight feasible and cost-effective solutions that exist to help identify people with undiagnosed type II diabetes and those at risk of developing it in the future.
Solutions of all sizes
While corporate hospitals and pathology laboratories in India have put all their might behind this cause, management of diabetes requires more than clinical care or a battery of path tests at regular intervals. It calls for sustained personal contact with the patient and caregivers. More importantly, diabetes management needs a change in lifestyle, which is more effective when done by the whole family. Large hospitals do strive to retain the personal touch and follow up but often fail for a variety of reasons, ranging from high attrition rates, distance between hospital and patients” residence, etc.
Which is where initiatives like Ashok Jain’s Lifespan India fit in. With its tagline proclaiming it to be the ‘world’s largest chain of diabetes management clinics,’ this in an initiative which aims to address the accessibility issue.
Jain, a diabetic himself for over two decades, has no clinical background and sees the treatment gaps from a patient’s side. An engineering graduate, who made it big as CEO of the soft drinks business of Cadbury Shweppes, Jain turned entrepreneur after his company was taken over by Coca Cola. A few false starts later, he started Oxygen Healthcare Communications around 2000, an agency advising pharmaceutical companies on advertising strategies. It was around this time that he was diagnosed with diabetes and came to see a business opportunity in the severe lack of disease management options. And thus Lifespan Clinics (Lifespan) took shape as a diabetes management initiative.
Unlike most patients, Jain decided to accept his disease condition. Rather than hide it, the Lifespan website proudly proclaims that it is ‘Founded by a diabetic.’ This smart positioning strategy may have helped form a bond with potential customers. Likewise, it helps Lifespan stand out from other ventures in this arena.
Three years young
Seated in his office in the first clinic in Worli, Mumbai Jain feels satisfied that in terms of what they have achieved, it (the positioning and strategy) seems to have worked. Relating their achievements, he says,“We’ve treated around 40000 patients over the last three years. Every month, about 4000 patients come to us, which is quite satisfying and something to be proud about. Of the customers who’ve taken our annual plan, 67 per cent have reduced their blood sugar levels. We’ve had testimonials of people who’ve said that it has literally transformed their lives, because their diabetes is under control, they now understand their diabetes better.” But he concedes that in proportion to the problem, the numbers are very small.
Lifespan currently has around 33 clinics, of which six are franchisees. The goal is to expand to 40 clinics by end of this financial year. Given the founder’s mission to help fellow diabetics cope with the disease, this target is dictated solely by finances. Jain indicated he’d like a faster growth rate butwould like to grow organically. Jain has therefore chosen the slow and steady route, preferring to open his own clinics, restricting franchisees to just 25 per cent of the total number.
According to Jain, profits from his communications agency, Oxygen Healthcare Communications, are ploughed into running Lifespan. As a group, they have invested around Rs 20 crore in Lifespan, and are clocking a 40-45 per cent growth over the last financial year.
The strengths of the Lifespan model go much beyond Jain’s own empathy with fellow diabetics. Care management systems have been built into the organisation. For example, he says, everything is automated and is on a cloud. Non-invasive tests have been built into the care model, like the Lifespan RISC test, which in seven minutes, measures 30 cardio-metabolic parameters like insulin resistance, vascular markers like arterial stiffness, etc. and a host of other health indicators.
All these parameters give the doctors and dieticians at Lifespan an indication of the overall health status of an individual. For instance, diabetes often comes with cardiovascular conditions, hypertension, sight issues, etc. With this 360 degree view of an individual’s risk profile, the clinician adds in the patient’s family history so that a personalised treatment strategy can be devised. Lifespan currently has a staff strength of close to around 150 staff (doctors and dieticians) across the country, all offering the same standard of care.
The weak links
Jain says that financing remains the single largest weak link, as expansion and setting up more clinics, adding staff, etc requires finances. His second pain point is finding like minded doctors and staff and then training them to follow the Lifespan model. Explaining his credo, Jain says, “Most doctors don’t think of patients as customers. If they did, they’d ask, why should a customer keep waiting or calling for me? Why can’t I be available all 24 hours, maybe through an email? Why should I overload my patients with so many medicines, some of which they do not require? Just because a new expensive medicine is launched, why should I give it to them? When you start looking at it from a customer service angle, I think that is where we fail.”
The third pain point ensuring that sufficient time is given to each patient. Speaking from personal experience, Jain believes that diabetes is not just a medical disease, it is a behavioral disorder. And that requires a huge amount of consultation and counseling, which needs a lot of time. Doctors just don’t have that kind of time. Therefore Jain’s team needs to train the staff to spend half an hour with every patient, and counsel them on these aspects.
Opportunity to do good
Inspite of these pain points, the business opportunity for Lifespan is only going to increase, given IDF’s figure. Ask Jain how he plans to grow Lifespan, and he turns philisophical, almost spiritual. Äs he puts it, “The opportunity to do good in the country is very, very high. Numbers show that 10 per cent of our population is diabetic but 20 per cent are pre diabetic. Worse, the new numbers say that 33 per cent of India is pre diabetic. According to Assocham figures released recently, 43 per cent in Delhi are pre diabetic. It is the opportunity to do good for one out of three Indians, because that is the incidence of diabetes in our country. I’d not call it a market, but an opportunity to do good.”
Jain feels ignorance is the biggest threat to tackling diabetes, ranging from self-denial, lack of knowledge about diabetes, etc. He is specifically dismissive about what he terms ‘grandmother’s stories’ linked to diabetes, like the use of traditional karela, methi etc to control/cure diabetes. Most borderline or early stage diabetics comfort themselves saying, “A little diabetes won’t harm me”, not knowing that the disease can impact many other organs and systems of the body. Illustrating patient ignorance levels, he says that though the heart is the single largest organ that gets affected by diabetes, its been shown that people can link the impact of diabetes on eyes and kidneys, but never the heart. As much as 76 per cent of diabetics died of heart problems, he points out.
Jain’s ambition is to reach 2000 clinics, but his ramp up is dictated by how well his other businesses are doing, because that is his primary source of funding. Jain has a strategic relationship with The Times of India Group, whom he refers to as an “advertising VC” who is an equity partner in Lifespan.
But Lifespan does face competition from the local unorganised diagnostics players, to the bigger chains like Thyrocare, Metropolis, SRL etc as well as hospitals groups. For instance, hospital chains have diabetes management initiatives like Apollo Hospitals’ Sugar Clinics, which is a partnership with pharma company Sanofi India. So will a minnow like Jain’s Lifespan survive in such a competitive market, even though the unmet need is too great?
Also, as in any business, Lifespan needs volumes to become sustainable but the founder is hampered by finances to expand the chain. Most diagnostic chains build volume and expand their market by offering discounted package deals.
In a price sensitive market like India, with poor insurance coverage, discounts are a given. A cursory glance at Lifespan’s site reveals similar discounts, For instance, the pre-diabetes proactive plan, for pre-diabetics who are at higher risk due to their weight, is priced at Rs 18875 and available at a discounted price of Rs 8500.
So it seems that though Jain will get a lot of personalsatisfaction from meeting patients’ needs, the business front will be challenging for the next few years at least. Unless he changes his business strategy.
Jain remains confident that he i on the right track, because as he puts it, his model is built around a core of customer satisfaction. Every customer who walks in to Lifespan, gets a feedback call. According to him, 84 per cent of such feedback is positive. Annual packages were started in January this year so its too early to check the renewal rate, but around 40-45 per cent of customer/patients who were on the four month packages have now upgraded to the annual package, which could be one indicator that they see value in Lifespan’s services.
In terms of pricing, he says they have bundled every service possible to make it as value-added to the patient. And he doesn’t see hospitals, diagnostics chains as competition but collaborators because they too are helping diabetics. But he points out that some of such ventures turn out to be recruitment centres for hospitals, whereas Lifespan’s focus is to try to ensure that patients manage their disease so that they do not need to go into a hospital.
Jain says its too early to think of an IPO, and he’s not thinking in terms of too many financial goals right now, but more in terms of expanding to help more patients.
The fast food industry is today seen as the main cause of the current epidemic of lifestyle diseases. So shouldn’t these corporations, like Jain’s previous employer, play a major role in rectifying their mistakes and curbing this epidemic with healthier food choices?
Jain counters this strategy, saying that we need to work on increasing consumer awareness rather than on the corporations. State bans on alcohols and sin taxes on colas, cigarettes etc don’t work long term because if the consumer doesn’t know better, he will ensure that he gets his fix. If leading brands adopt healthier choices, the customer will move to unhealthier smaller brands.“The biggest problem is not the corporations, but educating the consumer. If cola companies, for example, set aside two per cent of their budgets to educate the customer on healthy food choices, then this might help. When his tastes change, they will have to follow and change their offerings.”
So can policy makers crack the whip and make such corporations fall in line? On initiatives by some state governments to impose such taxes like Kerala’s fat tax, he concedes that this approach might help but not in its current avataar, which selectively targets the organised fast food industry and turns the blind eye to unhealthy foods in the unorganised sector is meaningless. Consumption of oily Indian snacks is around 95 per cent, so going after the five per cent will have no impact.
“If you can ban unhealthy foods across the spectrum, and have a mechanism to implement this, it will work. But banning or taxing without education and counseling is meaningless. And the education should be at every level, starting from from schools to work places.”
Jain’s other businesses support this aspect of his beliefs. Oxygen TV, a part of Oxygen Communications, is present in around 6500 doctors’ waiting rooms, beaming in consumer education programmes on diseases. The programmes are supported by advertisements of health foods brands, which are also displayed in Lifespan clinics. It is revenues from such collaborations that are the lifeblood of Lifespan and to some extent de-risk Jain’s business model.
The success of Lifespan and its strategy seems guaranteed, given India’s humungous diabetes burden. But can they scale up fast enough to be sustainable?