Building a Health Startup in the middle of a Pandemic

Innovation in the time of COVID-19

First hand narrative from a Physician Entrepreneur

At the end of 2019, something strange had been released from a mega-metropolis in the heart of China.

It started with a mild fever.

Then a cough

Some body aches

Altered consciousness

And then the trail of bodies appeared on the streets and the corridors

Public health facilities around the world quickly became overwhelmed, too many patients to too few medical professionals. Entire families were infected and suffering at the same time. Fear of a mystery illness turned civil communities into sheer mobs, obsessed with buying up truckloads of toiletries, sanitizers, canned foods and other needs for an impending quarantine.

And that quarantine did come.

COVID-19 Invasion

First it was self-exile, then it was government mandated.

First a street was cordoned off.

Then a village, a town, a city….and then an entire country.

If you are feeling a sense of dread and despair under your skin. I am with you. It is only human nature to be fully immersed with thoughts of self preservation. Schools have closed, businesses going bankrupt and major public events being cancelled.

Except hospitals, their staff and resources working overtime to the point of collapse.

Doctors, nurses, epidemiologists and worried policy-makers throwing out their carefully designed procedures and manuals.

This was not the first global biological catastrophe.

Mankind had experienced plagues of epic proportions.

We experienced the Black Plague, AIDs, SARS, MERS, Ebola and now the world-conquering COVID-19.

I will not overburden you with statistics, horror stories, tales of decimated cities and apocalyptic predictions from fake news. There is enough negativity in all of our social channels (online and offline).

It is in this darkness that the seeds of innovation take root.

From the epicenter of this pandemic, the combined entrepreneurial ecosystem of China has banded together to work day and night at various curative methods and preventive health campaigns, such as recombinant gene technology for experimental vaccines and even drones spraying disinfectant on entire buildings and infrastructures.

Healthcare startups have been pivotal in creating novel inventions, graciously supported by much needed public funds, in supporting the entire health sector of various countries. IoT devices have been instrumental in rolling out point-of-care diagnostic tests and Big Data analytic software with cutting edge AI-mainframes assisted in health informatics, to guide resources deployment.

In this article I will briefly highlight the potential watershed moment in healthcare innovation in the private sector of Dhaka. Now more than ever, the people of Bangladesh need to know the industry transformation that is required to run an efficient health system, or atleast one that can survive this pandemic…

Key chapters to be discussed:

  1. What is a Pandemic?

  2. Covid latest updates

  3. Effect on business

  4. Opportunity for healthcare innovation

  5. Supply-demand consideration

  6. Positioning doctors back into patient-centered care

  7. mHealth for the masses

  8. Optimising private care to relieve overburdened public health resources

What is a pandemic?

In hushed overtones, WHO had declared that the world is in the cusp of a pandemic - a global phenomena of a rapid, fatal and highly contagious infection that is spreading in intensity at unprecedented speed. Stereotypically such spread would be expected in developing countries with underdeveloped or under financed health systems, but when death tolls from advanced economies force entire nations to figuratively and literally shut down everything, then healthcare professionals need to change their thinking.

More than 119 countries, in all continents, are under actual lockdown.

This is different.

This is a pandemic.

Crossing all ages, populations, socioeconomic identities and geographic borders. World leaders themselves are now infected and under self-quarantine. Such ferocious infectivity has overwhelmed, and in many cases decimated healthcare facilities in developed countries.

COVID-19: Latest updates

At the time of publishing this article, the following real time updates on the coronavirus global impact can be viewed in the official WHO sources.

Infection trends of Coronavirus

-Massive number of deaths reported in Italy. Healthcare professionals forced to make difficult decision of letting moribound patients to be ‘left to die’

-Outbreak in Iran may cause complete civil breakdown under pressure from US embargo

-Many nations and economic bodies are highly advised to begin pandemic response fund to prepare for rising financial pressures

-Most affected countries have shut down academic institutions and banned major public events

-US Hospitals capacity is under scrutiny and stress testing for potential increases in incidence, despite travel ban from Europe and elsewhere.

-Rate of infection in China is slowing according to official reports from Chinese President Xi Jinping after the planned closure of makeshift healthcare facilities, famously constructed at breakneck speeds.

-Larger resource investments are needed in integrating data into health informatics, behavioral economics and medical anthropology as a whole.

COVID-19: Effect on Business

Pandemic associated recession is a relatively new term coined way before the 2003 SARS outbreak that had adversely affected the major South Asian economic powerhouses. There is much similarity in correlating disease behaviour, market speculation and one would hope, gradual and sustained economic recovery to pre-pandemic activity i.e. a return to positive consumer confidence.

Effect of COVID-19 on Global Economy

An expected fall in Global GDP is evident with the rapid closure of economic activity. Factories are closed, supply chains disrupted, high value consumption has decreased and more importantly - since the world’s factories i.e. China is the origin and major sufferer of the COVID outbreak, every business that directly relied on mass manufacturing of essential products is more deeply affected. It has been estimated that almost $5 Trillion dollars was erased from the global market so far, including a sizeable share value of many startup unicorns (especially Amazon).

Pandemics have a great polarising effect on businesses. There are losers, and there are winners. But it is not always that simple.

There are worldwide reports of panic buying masks, sterilization solutions, toilet paper and even doomsday insurance schemes. Naturally entrepreneurs who can leverage their position in the market as sole providers of such commodities are noticing a significant increase in orders. Basic level reports would indicate an excellent Q2 projection of sales.

However the stark reality of fulfilling those mass orders is the difficult part. One cannot simply assume that any ecommerce (or even shady f-commerce) business has the capacity to fulfill each and every sale, especially if they are bulk purchases. Don’t forget where most of these consumer products are manufactured - that’s right the economic powerhouses located in the coronavirus epicentre. Many companies around the world are shutting down because upstream lines of credit are being exhausted - orders are not able to be transported (since there is nobody there) and a shockingly high number of workers are ill (or worse).

Quite expectedly there are some panic-induced speculations, with racist undertones, where Chinese imports may be infected by covid-19 viruses enroute to their destination. The virus itself is not that viable outside of biological surfaces, but due to its high mutation rate, it is not unforseen that a stronger strain may even survive as fomite (non-biological surfaces) infections.

SME and startups are particularly vulnerable to even short term disruptions in their supply chains, and of course their already lean management - imagine the chaos if core decision making cofounders are ill and out of the picture. Truly adaptive and robust teams may be of significant advantage in these turbulent times.

As mentioned before, the Chinese government has been even more pro-entrepreneurial in their/our hour of need. Leniency in regulations and proactive funding support allowed novel innovations to atleast decrease the rate of infections in mainland China. Other South Asian economies have also been keen in public-private-partnerships for such public health initiatives, with many successes in containment in their affected populations.

Ironically European economies with larger budgets and evidence-based policies (Europe bore the brunt of world-changing epidemics in this century) were slow to enact such drastic measures - possible leading to the strangely high number of fatalities in their populations. However Scandinavian countries have now enacted total country-wide shutdown and strict enforcement of social distancing.

So what will happen to their economies?

Do they have enough contingency funds to support the future economic recovery of their startup ecosystem?

Nobody knows, since the storm is just starting.

And what of the rapidly expanding yet fragile economy of Bangladesh?

Entrepreneurs, startups and established enterprises have enjoyed the unusual GDP growth since the past few years - especially the RMG sector. Will COVID-19 be the wrench that dismantles and deletes the decades of its socioeconomic gains?

Nobody knows, since the storm is just starting.

There are unconfirmed reports of suspect cases from returning expatriates from hard hit countries like Italy, who have been targeted by primitive diagnostic resources at the point of entry - with mandatory observation and quarantine for tell-tale signs of coronavirus infection. The Health Ministry assures the public of strict public health enforcement nonetheless.

Businesses in Dhaka have yet to experience the full brunt of the global economic slowdown. Majority of overseas buyers have been affected. Prime manufacturing partners are worse hit. When will the people of Bangladesh feel the pinch?

Food prices, stock values, property rentals, banking transactions are still at pre-pandemic activity, albeit very high since after all Dhaka is the most expensive city to live in anyway (covid or not). Small businesses are naturally enjoying swift consumption due to similar panic-buying as in other countries. Ecommerce related to hygiene products are rapidly depleting their inventory as expected. Public hospitals and medical facilities are ever burdened by the usual stresses of an over-populated metropolis anyway.

The question remains, whether or not the few and scattered health startups in Dhaka have correctly leveraged this unique healthcare capacity building opportunity, besides the typical social media marketing tools about hand washing hygiene and other reshared posts.

In the West, telehealth/telemedicine startups have rapidly scaled up their operations and capacity in response to the massive user demand for remote view consultation - related to a strong advisory for ‘social distancing’. Although such operations do not fully comply with full physical examination as part of a complete healthcare consult, given the situation it is still a viable option for scalable health screening and perhaps triage.

In the Bangladesh context, scaling operations and maintaining economically sustainable processes in quality, is a significant challenge for all types of startups. There are some notable health startups trying their best to provide some measurable value to their stakeholders. Although far from noticeable ‘disruption’, their products and services do indeed provide an option for certain socioeconomic populations.

COVID Pandemic: Opportunity for healthcare innovation

Innovation is often created under the setting of adversity, such as during a sociopolitcal conflict. In times of war and great social scarcity, survivors had no choice but to use their intellect to stretch resources, come up with clever ways to provide the basic human needs and in many cases outwit scavengers.

We can admit that we are in troubling times, on a global scale. Sellers are running out of masks, toilet paper and other pandemic necessities. Hospitals are at over-capacity with very ill patients along with already high patient demands from much worse health issues. And more importantly, in the already existing global shortage of skilled healthcare workers, doctors and nurses are working extra hard to the point of exhaustion, and willingly exposing themselves to COVID-infected patients or maybe coronavirus carriers.

Doctors at the frontline of the COVID-19 Pandemic

Many healthcare workers have suffered and died taking care of the ill. Very few final year medical students are ready to prematurely replace their over-burdened seniors. But the sea of patients keeps on rising, emergency rooms are in absolute chaos. Nobody knows how even advanced healthcare facilities in Europe and elsewhere can handle such drastically high incidences of newly infected persons.

The amazing instance of a hospital being built and ready for sub-acute emergency medical activity in Wuhan had grabbed global news portals, but can it be replicated in other cities and countries? Even under martial law it is unlikely that such a feat would be possible, and most likely too little too late.

The only solution is to move the point of care away from hyper-dense low-resourced settings.

Now more than ever, it is imperative for healthcare innovation to take root and be ready for deployment. Whether it be telemedicine to help educate, guide or even triage the public who may or may not be symptomatic, novel treatments against COVID-19 or even a coronavirus vaccine, mass communication strategies to educate and suppress fake news, or just faster better data analytics processes to optimise resource delivery above all else.

In the Bangladesh context, official numbers of confirmed cases and their public health management are not yet accurately measured. Due to poor health data informatics from point of entry (ie. airport and sea ports) and from the health system facilities in the country, it is difficult to fully assess the full scale of the coronavirus spread. There are news reports several returning expatriates from ‘hot zones’ who have quarantined en masse in makeshift holding facilities, some who are self-contained in their communities and the truly frightening unknown statistic of silent carriers.

And within this systemic deficiencies in SDG-mandated healthcare quality, lies the vast opportunity for entrepreneurs to create impactful innovations; starting from effective mass diagnostic instruments, sterilisation equipments, ecommerce pharmaceutical delivery, COVID test kits, telemedicine apps, data analytics software and quite frankly the opportunities are endless.

The basic rules of healthcare entrepreneurship, is the same with any type of startup:

  1. Identify a problem

  2. Assess the key customer base and their characteristics

  3. Leverage your skills

  4. Create a solution, that people will pay for

  5. Develop a functional team to produce it

  6. Fine tune your business model

  7. Scale up operations

Healthcare innovations are the most high demand business concept in the world. In times of turmoil, self preservation can be a strong motivator for impactful available solutions.

Supply-Demand consideration in Frontier Markets

Free markets do not always provide the right environment for inclusive development, let alone solving problems fairly. Just by mere speculation fueled by social media, prices of mundane products which were hardly BDT5 less than a month ago, skyrocketed beyond comprehension. Cheap masks that were the daily attire accessory for urban dwellers (due to the worst Air Quality of Index in the world), have now become as necessary and expensive as a hypothetical vaccine.

Once again this inflated demand with global supply shortage, shows that entrepreneurship now becomes exploitation of the masses. These are not isolated events in Bangladesh only, worldwide blackmarket racketeering has evolved to industrial grade face masks and hazmats - which are core materials reserved for front line medical staff who have to protect themselves and other patients as well, are now in short supply due to rampant panic buying.

As is expected, the coronavirus fear is creating new medical and biotech billionaires around the world, and almost overnight as their share prices rise through the ceiling.

Given the disruption to supply chains, economic slowdown and generalised instability in the banking sector in Bangladesh, the startup ecosystem will face an even harder uphill battle to secure a strong footing to atleast market their innovative solutions. Perhaps even more challenging is the absolute deficiency in credible health startups who need to win the hearts and minds of their stakeholders.

Regardless the tenacity of the growth mindset entrepreneurial drive may be emboldened by the high as usual demand for accessible and affordable healthcare innovation, more so in the midst of the covid outbreak.

The question remains, what health sector deficiency needs to be prioritised for urgent innovation?

What is the most cost-effective solution that the people need now?

Will this healthcare innovation be the right tool for covid 19? And will it be relevant after the outbreak is over?

Positioning doctors back into patient-centered care

We should commend public officials for trying their best to make sense of these difficult times. Most of civilised human history has always been shaped by reacting to the outside world, be it conquest for resources, avenging tribal status or in some instances as the gradual adaptation to globally accepted concepts (eg. climate change resilience, gender equality, child protection). But perhaps from our combined destructive activity and overconsumption - we truly are tasting our own medicine.

The coronavirus outbreak is directly related to mass destruction of habitats, unusual food consumption, corruption and ofcourse affordable global travel. The exact opposite concepts may be needed to at least slow down the infectivity and fatality of covid-19 infections.

Healthcare innovation must bring together cost effective measures, mass digital real-time communication, industry experts and greater transparency of information.

The efforts of young health startups in Bangladesh is a welcoming sight for many patients, many cater to the growing need for appointments with the best doctors in Dhaka, healthcare products, on demand pharmacy services, virtual chat with healthcare professionals and telemedicine as well. Technology truly is a tool for democracy, access to healthcare is not only one of the pillars of the SDG goals and Vision 2020, but a prime value commodity for the masses.

But healthcare is not really a commodity, it is not something that can be defined and packaged into a product nor a service by itself. Healthcare is a means to an end, an end to suffering or an end to illness.

And here lies a crucial point of consideration, as to why most health startups in Bangladesh (and in also in other countries) fail to galvanise the right stakeholders. Healthtech or Medtech industries have not sufficiently cemented a worthy market share due to lack of founder trust, their value proposition (benefit to the user) is not well associated with their business model or quite simply they have not been able to mobilise the combined skills set of healthcare professionals.

This concept is known as having an authority in the market. Startup founders without working experience in the health sector face issues with trust building the primary stakeholders i.e. medical community.

It is hoped that startup founders that wish to incorporate medical professionals into their value stream inspire a particular behaviour change (eg. app-based interaction with patients), also provide a sustainable business model that has a strong economic incentive to provide quality patient-centric healthcare services.

The 2020 Coronavirus pandemic needs such human resource centered innovation to help sick people find the right doctor at the right time, and for the right doctor to be available when patients are looking for their high value skills - a sort of on demand healthcare solution for immediate consultation on the phone which can help triage the truly ill patients (depending on their symptoms) to visit the doctor’s practice.

As most epidemiologists have explained in the wake of the covid outbreak, amongst other global health emergencies as well, community management as quickly as possible by skilled professionals in the health system can help mitigate the infectivity potential of a pathogen, long enough for support systems to organise and mount a more effective response.

Right time for healthcare innovation

It is commendable to be patient-centered in healthcare innovations, but entrepreneurs must also remember that healthcare providers are a crucial element as well. You cannot give healthcare without putting healthcare providers in the same value chain as well.

mHealth for the Masses

More and more European countries are imposing strict curfews and total bans on mass congregations and international travel. When thousands of citizens are succumbing to the mysteriously fatal novel covid-19 nobody can second guess the severity of inaction.

Other countries are also implementing their own travel bans and precautionary measures against the coronavirus infection, with continuous social media broadcasting urging the population to maintain self-quarantine, limit social interaction and be hyper vigilant to symptoms in oneself and in close contacts.

With such extreme social isolation, the mobile digital device and media become the sole methods in atleast maintaining some form of normality.

The consumer demand to access quality healthcare is still a top priority, especially here in Bangladesh. Even in the pre-covid times, finding a good doctor was a difficult task for the vast majority of Dhaka citizens. There are no effective options in finding a good doctor, knowing about their skills and most importantly, their social proof i.e. patient/peer recommendations.

Health apps in the time of COVID-19

Many tech-based startups have ventured into mhealth solutions, with varying levels of success and actual impact. Many have created ingenious methods at digital prescriptions, online doctors appointments, various medical blogs and some have bravely ventured into 3D prosthesis.

But going back to the previously mentioned issues about creating impactful solutions with an impact, I personally believe there is still a lack of a solution for a problem that many of us are not seeing. From my perspective, which many of you may or may not agree with, maybe such entrepreneurs are not properly assessing a specific hyper-local issue that seems so simple or even mundane.

I agree that the health sector of Bangladesh needs serious disruption, now more than ever, but the challenge remains in identifying the true bottleneck issue that once fixed would actually lend some credibility to other downstream provider issues.

As a former private practice clinician, I can relate to the daily struggles of any small business or consultancy. That is the issue of sustainable foot traffic i.e. number of leads turning into sales. In private healthcare this notion is best translated as number of patients coming to my chamber who seek high value clinical management which I am adequately trained and certified to give, at an affordable price.

The main thing that private doctors want is more patients. Full stop.

True there have been various startups who have tried lead generation by creating options for patients to book appointments with specialists in Dhaka. There are digital health startups that make it easier to video chat with a specialist via their mobile platform.

But are they innovative? Are they impactful?

In my opinion, in the current setting of the coronavirus pandemic, such health startups did not fully motivate nor optimise the healthcare service capacity of their doctor stakeholders. Without the full leverage of the medical community in such innovative platforms, the high patient demands may remain unanswered simply because the Bangladeshi people want more than a video chat or some appointment system.

Digital solutions only at the hands of patients, guided by innovators with no direct knowledge of the healthcare ecosystem, will end up creating vastly inflated healthcare apps with plenty of features (known in the tech industry as feature-creep).

Healthcare innovation is not a perfect mobile health solution with so many cutting edge features. True innovation like any other concept, is about solving a problem as simply and affordably as possible. True entrepreneurship is about the right product-market fit to make a profit.

So in essence what is needed is to solve the problem of doctors as well. We all know that patients have a lot of demands from the health sector, and rightly so. But from the doctors’ perspective the overarching issue is autonomy and career independance. This is a timeless issue going back to the early history of modern medicine. Doctors want to see enough patients to earn a decent income, and make an impact on the health of the community.

The problem that I had identified back in pre-covid 2018 was the issue of doctors’ career independence and financial freedom. Quite simply, the majority of skilled doctors have a hard time to promote their high value medical skills at the right time in the right way. Due to the fragmented health system and inadequate referral system, their valuable time and resources are not properly optimised to coincide with the time a patient really needs their consultation.

Even way before the Coronavirus epidemic, or SARS or even the endemic Dengue outbreaks, people of Bangladesh were suffering far more from non-communicable chronic diseases such heart disease, diabetes, cancers and ofcourse mental illness.

There is a terrifying shortage of skilled healthcare providers (the lowest ratio of Doctor:Patient ratio in the world according to WHO) and those who do get patients via unprofessional corrupt brokers (dalals) are actually of very poor calibre, improper certification, procure unwarranted diagnostic referrals, have poor communication skills (shortest patient consultation records in the world) and a total systemic lack of healthcare soft skills.

I decided to look deep into this health system problem and try to create a comprehensive yet hyper-simple solution that is compatible and acceptable by the right population base.

Optimising private care to relieve overburdened public health resources

There is a flood of sick and dying in any public health facility. The shortage of human resources is evident from the moment you walk in. One overworked underpaid doctor for every thousand of patients every single day. And this scenario is in spite of any global health emergency that may or may not have reached Bangladesh yet.

The systemic deficiencies in adequate manpower training, mobilisation, motivation or even necessary upskilling is a very real public health threat. Emergency departments and inpatient wards are a perfect petri dish for rampant spread of coronavirus, amongst others. The solution is not easy, nor will it be cheap. A total overhaul or upgrade of a healthcare system will bankrupt a nation if adequate tax revenue or foreign aid is not properly distributed. And who else will keep suffering except the poor and destitute, and the high exposure risk healthcare professionals.

But where will people go for affordable private healthcare services?

There are hundreds of private medical institutions with hundreds of private practice chambers. But in its irony there is a systemic deficiency of skilled and trusted specialists to be present there when patients actually arrive. Even worse, due to Dhaka chronic traffic congestion, even after a doctor’s appointment is secured (in person, by telephone or by ‘dalals’) the patient may arrive late and miss the appointment, or as mostly the case, the doctor has not arrived and every subsequent appointment lags behind. These are core ingredients of an inefficient health system even in the private sector.

Inefficiency in any private sector will disrupt its profitability.

With the growing GDP of Bangladesh and its increasingly affluent middle classes, value for international standard healthcare quality is an emerging unmet need. With this widespread distrust in an inefficient health system, it is no wonder that at least $2 billion dollars per year is ‘exported’ to neighboring healthcare facilities.

It is not enough to simply provide a type of digital marketing tool for a doctor’s professional branding, a solution has to be impactful. Impactful on a global systemic scale. A concept so powerful that it can even cause a proactive behavioural change ie. an upgrade in healthcare soft skills in value-centered professionals

It is with this notion of a paradigm shift that the VIOS network was born. A tech-based solution that is more than just an idea, more than just an app.

Will it mobilise the healthcare community to give real time service of high quality?

Can VIOS assist the already overburdened Health Ministry of Bangladesh?

Will VIOS make an impact?

The VIOS platform and the true potential impact of COVID-19 are both at its early stages. Nobody really knows how effective a tech solution can be for a global coronavirus pandemic. The journey of physician entrepreneurship is a path least taken, the value of healthcare apps is still in its rudimentary phase. But every situation is an opportunity for action, with or without a global coronavirus pandemic.

Be safe.

This article was endorsed by ViOS Ltd, to bring value and connection to our stakeholders. We are always trying to connect with our ever growing ViOS specialist doctors, therapists and other healthcare professionals here in Dhaka. We know the people of Bangladesh deserve top class healthcare services at affordable, trustworthy and convenient means. The team and I are dedicated to serve our constituents with even better products and services in the coming future.

Visit our website and official Facebook page ‘VIOS Healthcare’, to keep up to date on upcoming medical entrepreneurship events and healthcare app updates.

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