Entrepreneurship -
The CEO and Founder of Praava Health on Reimagining Care in an Emerging Market - Sun and Planets Spirituality AYINRIN
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Author:His Magnificence the Crown, Kabiesi Ebo Afin! Oloja Elejio Oba Olofin Pele Joshua Obasa De Medici Osangangan Broadaylight.
Summary.
Although the author’s grandfather founded the oldest pharmaceutical company in Bangladesh, she never expected to follow in his footsteps. Raised in Roanoke, Virginia, she studied international development and law before working first as a corporate lawyer and then in the Obama administration. But when her mother fell seriously ill during a family wedding in Bangladesh—and Sinha discovered how difficult it was to get access to quality health care in that country even for well-off, well-connected families—she found a new mission. She developed a business plan for a state-of-the-art, full-service primary-care facility in Dhaka, Bangladesh’s capital city, and moved there—where she’d never lived before—to launch it. She focused on hiring a great team and building a culture around the distinctive service they would offer. Five years later, Praava Health has served 600,000 patients, is nearly cash-flow positive, and continues to grow.
My obsession with health care in Bangladesh started with my mother’s appendicitis.
It
was 2011, and I had come from my home in New York City to Dhaka,
Bangladesh’s capital city, to attend a cousin’s wedding. When my mom
complained of a debilitating pain in her side, my family rushed her to
the hospital. However, the care she received—and the care we witnessed
other patients getting (or not)—was awful. We had to chase doctors to
get them to examine her, and even then none gave us straight answers.
Scans and tests took ages, nursing was downright lackadaisical, and most
terrifying, her surgery was delayed and then botched. Eventually, after
her condition worsened, we took her to Bangkok, where doctors ordered a
second surgery. A year later she needed a third, in Virginia, owing to
complications from the original procedure.
Even
as I pursued my career in law and foreign policy back in the United
States, the experience stuck with me. After visiting a top Bangladeshi
hospital, in one of the world’s fastest-growing economies, we had to
leave the country to get quality care. Why?
I
soon realized that this was not just a problem but an opportunity: to
build a new and better system of health care for Bangladesh that would
be grounded in international best practices, patient-centric, and
affordable. I threw myself into learning about the industry and the
country, which, as a Bangladeshi born and raised in America, I’d visited
but never lived in. In 2015 I drew up a business plan and began to
court investors, jump through regulatory hoops, hire a founding team,
and work to outline a clear mission, a set of values, and a corporate
culture. In 2018 we opened our first state-of-the-art medical center in
Dhaka. We called the company Praava Health—combining the words pran (“life”) and aava (“beam”) to suggest the beam of life.
Today
more than 600,000 patients trust Praava Health for their care, making
it larger than most U.S. health care systems. We are a household name in
one of the world’s megacities. Through our “click-and-brick” platform,
we guarantee 15-minute appointments in a country where 48 seconds is the
average for a consultation. Our Net Promoter Score is consistently over
80, higher than that of most Fortune
500 companies. We are nearly cash-flow positive on a corporate basis,
and MBA students and health care practitioners around the world study
our business model. We owe this success to all the members of the Praava
team, who bring our vision to life and earn the trust of our community,
one patient at a time.
Foundations
I’m
not the first entrepreneur in my family. In 1954, when Bangladesh was
still East Pakistan, my paternal grandfather, Hamidur Rahman Sinha,
founded a pharmaceutical company that is now the country’s oldest and
one of its most successful. Like me, he wasn’t a scientist or a doctor
or a pharmacist, but he had a vision. At the time, 80% of the drugs on
the regional market were counterfeit. He built a business that
manufactured quality medicines, constantly warning, “If we ever cheat
the consumer, it will be the end of us.” He died when I was 16; I have
often wished he were still around to advise me.
His
son, my father, grew up in what is now Bangladesh but came to the
United States in 1964 as a scholarship student. He expected to study
chemistry and then return home to help run the family business. However,
after the war for Bangladeshi independence broke out, he decided to
stay in America and become a professor. On a visit back to Bangladesh he
met my mother, and they soon married. They settled in Roanoke,
Virginia, where my brother, sister, and I spent our childhood.
Occasionally our family traveled to Bangladesh when we were young, and
those visits sparked my interest in economic development.
Health
care was a big part of our lives from early on, because my brother was
quite sick from birth, needing surgery within hours of his delivery and
then suffering from inexplicable skin issues, asthma, and seizures for
the first years of his life. Doctors didn’t always take my mother’s
concerns seriously, but she finally found a pediatric immunologist at
Johns Hopkins who could help. That was an early lesson in the power of
patient-centered health care—and the perseverance required to find it.
After
graduating from Wellesley College, in 1999, I worked as a consultant at
PwC before pursuing a joint graduate degree at Columbia Law School for a
JD and at Harvard Kennedy School for a master’s in international
development. My education solidified my belief that the private sector
is the most sustainable form of development. I spent five years at a New
York law firm, and in 2007 I joined the Obama campaign as an external
foreign-policy adviser. I felt strongly that the people setting U.S.
policy regarding other parts of the world should experience them, so
instead of joining the president’s administration when he won the 2008
election, I moved to Afghanistan with the World Bank, then to Thailand
with the United Nations, then to Qatar with BCG, and finally back to
Afghanistan with the U.S. Institute of Peace. I had some extraordinary
experiences, but I missed the accountability and the pace of the private
sector, so I returned to my legal career in the United States.
After
a few years, however, I found myself longing for more-creative work and
a more direct impact on people’s lives. The experience of my mother’s
appendicitis still haunted me. And because of my connection to
Bangladesh, a country of 170 million, I knew it was making tremendous
progress. Described as a “basket case” by Henry Kissinger when it gained
independence in 1971, it had by the early 2010s become one of the
world’s fastest-growing economies and had reduced the share of citizens
living below the poverty line from 40% in 2005 to less than 30% by 2010,
all while creating a dynamic, growing middle class of 40 million plus
and progressing to “middle income” status according to the World Bank,
leading the World Economic Forum to call it “the next Asian tiger.”
Bangladesh was growing at a faster pace over a longer period of time
than even China. It boasted a GDP per capita higher than India’s and a
GDP of more than $300 billion, putting it on track to be one of the
world’s 30 largest national economies by 2030.
This
was a market that needed quality health care. In August 2014 I decided
to see whether I could build something to tackle that challenge.
Investigating the Problem
I
had a lot to learn about the country, its health care system, the
business and systems of the industry around the world, and
entrepreneurship. At first my research was self-funded. I went on a
global listening tour, meeting Bangladeshi patients and practitioners
and leveraging networks across Asia, the United States, Europe, Latin
America, and beyond to study health care business models. I met anyone
who was willing to teach me something.
Over
the years, I had heard other health-care horror stories from my
Bangladeshi relatives. Once my aunt and her daughter had gone together
to a private Dhaka hospital for routine mammograms, and the clinicians
told my cousin they’d found a concerning spot requiring investigation.
But when she went for a follow-up in Bangkok, her scans were clear, and
she realized that the Bangladeshi mammographers had mixed up her and her
mother’s results. My aunt had breast cancer that demanded a full
mastectomy. Some time later, when the same aunt was cancer-free but
suffering from joint pain, doctors in Dhaka scanned her bones,
determined that they were full of tumors, and prescribed intensive
radiation. But when she sought a second opinion abroad, the true
diagnosis proved to be osteoporosis, requiring a course of treatment
very different from radiation, which would only have made matters worse.
As
I talked with more people in Bangladesh, I found that such stories were
all too common. People consistently told me that they didn’t trust the
health care system. I discovered two primary reasons. First, the quality
of care in both the public and private systems varied greatly, partly
because the government lacked the capacity to regulate it. In fact,
across low- and middle-income countries like Bangladesh, the leading
cause of mortality is not lack of access to care but inadequate care.
Second, demand exceeded supply. As in other emerging markets, health
spending in Bangladesh was growing at an annual compound rate of 10%,
outpacing the economy. With the public system understaffed and
overstretched, private facilities were left to fill the gap, but they
were costly, focused on episodic care, and driven by incentives that
pushed doctors to hospitalize patients and order unnecessary tests and
drugs.
The
opportunity to have an impact was compelling. Access to trustworthy
health care is a human right and something Bangladesh’s citizens
deserved. The financial opportunity was also evident: Across Asia
entrepreneurs in other growing economies with similar supply-demand
imbalances had scaled up thriving systems with two to three times the
market valuations of similar businesses in the United States. I became
increasingly convinced that I could develop a better alternative for
Bangladesh—one that would create more accountability in the system and
challenge all the country’s providers to do better.
Imagining a New Model
By
the spring of 2015 I had a 100-page business plan and a financial model
for a vertically integrated health-care system that would be centered
on high-quality primary care and family medicine—the bedrock for patient
trust—while including secondary and specialist care; outpatient
procedures; in-house, world-class lab and imaging diagnostics; and a
pharmacy that procured only directly from manufacturers. It would be
supported by Bangladesh’s first fully integrated hospital information
system, its first patient app, and tools such as telemedicine and an
e-pharmacy to improve accountability, quality control, efficiency, and
access. The idea was to be the first call and most trusted resource for
any medical issue and to help patients manage their health in a way that
would prevent hospitalizations.
We
raised $1.4 million in our first round of funding, at the end of 2015,
and have secured more than $15 million since, all from angel investors.
I began to build a global advisory council to bring lessons learned in
health care and emerging-market entrepreneurship to Bangladesh. This
group now includes Omar Ishrak, MD (Intel, Medtronic); Esther Dyson
(23andMe, Wellville); David Petraeus (retired U.S. Army general, KKR);
Rushika Fernandopulle, MD (Iora Health, One Medical); and Jeremy Lim, MD
(Oliver Wyman, Amili).
I
started recruiting seasoned professionals to Praava before I could even
afford to hire them. Among them were Mahbubur Rahman, a clinical
biochemist with deep experience running world-class labs, who became our
laboratory director, and Zaheed Husain, an eminent cancer immunologist
who had spent 30 years at Beth Israel Hospital and Harvard Medical
School and would set up Bangladesh’s first molecular cancer diagnostics
PCR lab at Praava. Simeen Akhtar, a Bangladeshi physician and an expert
in quality management who had practiced medicine all over the world,
agreed to come out of retirement to be our chief medical officer, while
Sabrina Imam, a software engineer with more than a dozen years of
experience at IBM and recent stints in health tech, signed on as our IT
director. Sawsan Eskander, one of a handful of trained actuaries in
Bangladesh with extensive experience in health insurance, joined as our
chief innovation officer. Kutub Uddin Kamal, a former journalist who had
never previously worked in health care but is now our head of patient
experience, joined because of a passion for changing the system. All
were frustrated with the current state of medicine in Bangladesh and
wanted to be part of making Praava a reality.
Success
would require more than just a business plan, capital, and a team,
however. So in August 2015 I took the biggest leap: permanently
relocating to Dhaka. I was all in.
I
knew the transition would be challenging, because I was neither an
insider nor a total outsider; I was a “third culture kid.” Even today
I’m the only American-born Bangladeshi I know in Dhaka who moved there
for any reason other than marriage. But my vision was so clear that
I wasn’t worried. I surrounded myself with a strong local team and a
global army of supporters to build the bridges we needed.
As
I met with potential investors, prospective hires, and government
officials, they peppered me with understandable questions. What were my
motives? Was I in it for the long haul? Why did I—a 37-year-old
Bangladeshi American—think I could solve this big problem? No one said,
“Who do you think you are?” but some were certainly suspicious and
occasionally ageist, sexist, and anti-foreigner. Still, being
underestimated and flying under the radar allowed me to focus on the
work. To those who were open to it, I patiently explained my vision, my
intentions, and the kind of company I wanted to build, and I won over
everyone I needed to. I’m also grateful to the people who challenged me,
because facing their questions better prepared me for what was ahead.
About
a dozen city and national government agencies would regulate the sort
of health care company we were creating, and we had to build
relationships to ensure that we could secure the numerous permits and
licenses required to operate. The processes were transparent but
tedious. Later we developed a strict code of conduct and
anti-corruption, antibribery, and whistleblowing policies to protect our
team and investors.
Coalescing Around Values and Culture
In
the spring of 2017 I convened Praava’s fledgling team of 20 to define
our organizational purpose, values, and culture. A spirited
brainstorming session produced our vision (“We envision a world-class
health care system that puts patients first”), mission (“We aspire to be
your trusted partner in health”), and core values: service, my Praava,
integrity, listening, and excellence.
SMILE: Praava’s Five Values
For
us, investing in culture is more than a feel-good activity; it is a
business strategy. As we mapped out patient journeys, renovated what
would become our flagship Dhaka clinic, drafted our brand guidelines,
and readied ourselves for patients, we also developed an intensive
hospitality-training program to connect everyone to the patient
experience we were imagining. Every one of our first 65 Praava
employees—from security guards to doctors to software engineers—attended
the first training session, in August 2017. We shared health
experiences and sometimes emotional stories about loved ones who had
died owing to misdiagnosis, personal suffering and pain, and unethical
practices condoned by other management teams.
That
was a powerful reminder of why we were launching Praava. Our job was to
treat people coming into our facilities as we would want to be treated
in the same circumstances. We ended that day with an inspiring video on
empathy. On the second day we watched a TED Talk on patient experience
and then broke into smaller groups to brainstorm how each of us might
bring Praava’s five values to life in our various roles. Then, on the
third day, each group performed skits illustrating both a poor health
care experience and how it could have been improved—a nice way to
encourage creative collaboration and relationship building among
colleagues from different departments. (Six years later I still conduct
these sessions once a quarter as a core part of employee onboarding.)
In
February 2018 we officially opened Praava’s medical center in Dhaka—a
one-stop shop for outpatient health care, with 19 consultation rooms, an
advanced laboratory setup, basic to advanced imaging services, and a
pharmacy. Within a few months our patient app—Bangladesh’s first—was
live. For the most part we got our product-market fit exactly right from
the start. We were offering trustworthy, integrated, tech-enabled
health care that the country hadn’t seen before.
From
day one we asked patients, Did our medical professionals listen to you?
Did they answer your questions? Were they empathetic? Praava managers
and team leaders meet weekly to review all patient feedback. We spend
about five minutes on the positive comments and the rest of an hour on
the ambivalent or negative ones, trying to learn and adapt and improve
our work accordingly. Science is not perfect, and neither are the
doctors and the staff at Praava, but when we make a mistake, we hold
ourselves accountable and try to prevent similar incidents in the
future.
In
the early days we spent very little on marketing. Each patient we
served became an ambassador and a word-of-mouth marketer, and the
patients kept flowing in. In November 2018, in our 10th month of
full-fledged operations, our flagship unit broke even.
However,
with aspirations to build smaller clinics as spokes around Dhaka and
eventually scale up a similar model in cities across the country, we
still had work to do. I knew that staying focused on values and culture
would position us best for expansion. In 2019 we embarked on a formal
initiative to create a culture deck. First we surveyed 30 culture
documents from companies around the world that had frameworks we
admired. Then we talked with employees across all our groups to
understand how their work aligned with our corporate goals and culture
and what they loved about working at Praava. Simultaneously we launched a
companywide survey. All those learnings plus details of our five values
went into the culture deck that we now use alongside the hospitality
training to onboard hires and refresh existing teams.
This
might seem like a lot of energy for a start-up to invest in culture.
But I believe it helps us ensure that all who work at Praava are on the
same page about who we are and, as a result, can be trusted to act in
line with our values no matter what decisions they need to make. That’s
especially important for frontline workers, who constantly face
unpredictable scenarios and personalities.
Our
response to the Covid-19 pandemic was a case in point. Our team rose to
the moment largely thanks to our investments in culture, and I couldn’t
have been prouder. Initially we faced a terrible cash crunch: We
couldn’t pay anyone for two months. But by the end of March 2020 we were
the first private facility to partner with the government on
telemedicine and offer it to our patients, and by May 2020 we had
launched our e-pharmacy. That same month we were entrusted with being
one of the first private providers to process Covid tests, and in June
we received a public grant for a remote-care management tool that
resulted in a two-thirds reduction in hospitalization rates. Like health
care systems everywhere, we were initially stretched thin and had long
wait times for our call center and care. But everyone worked tirelessly
around the clock to serve every patient who needed us.
The Road Ahead
Over
the past few years we have harnessed the goodwill we earned during the
pandemic and continued to grow. We have stayed true to our vision and
values and are excited about the future. Data from the more than half a
million patients we’ve served shows that they are less likely to be
hospitalized than those treated elsewhere. Among our in-house doctors,
we have a 0% attrition rate: Once physicians come to work at Praava,
they don’t leave. Our lab is one of only seven in the country that meet
international standards, and it also processes samples collected from
hospitals and doctors across more than half of Bangladesh’s 64
districts. We have more than 2,000 corporate clients who offer Praava
access to their employees. They include local conglomerates;
multinationals such as Unilever, Mastercard, and Chevron; and
institutions such as the World Bank, the U.S. embassy, and a dozen UN
agencies, and they account for more than 20% of our revenue. We’re
seeking capital for expansion into more areas of Dhaka and then the rest
of the country and beyond. We have seen larger players, such as BRAC
(the Bangladesh Rural Advancement Committee, now known as Building
Resources Across Communities) and private hospitals, start to copy our
model in Dhaka—competition we welcome if it helps more Bangladeshi
patients get access to high-quality health care.
Launching
a start-up in an emerging market is the hardest thing I’ve ever done,
but it’s also undeniably my greatest privilege. In founding Praava, I
was able to leverage my experiences and networks to bring health care to
Bangladesh in a way that I was uniquely committed to. I am proud that
we’ve built a company with rock-solid values, a cohesive culture, and a
dedicated team, and that we never brought in investors who would push us
away from our initial mission and vision. We want Praava to be
available to all of Bangladesh’s 170 million people. We also hope to see
our model deployed in the many other emerging markets where
high-quality health care is desperately needed.
Strangers
frequently approach members of our team in Dhaka to thank us for
building the company. That only fuels our impatience to bring quality
care to more patients. We are just getting started.
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