Noble Vision

Picture an eye-care facility in a remote rural town in India. Do you imagine it having obsolete equipment, dirty ambience, rickety furniture and an inattentive staff? A visit to Maddur taluka, near Channapatna in Karnataka, can prove you wrong. The city’s per capita income is a mere Rs.46,049 — way below the state average of Rs.126,976. But its 800 sq mt vision centre, managed by Drishti Eye Care, leverages telemedicine technology that is both high-end and impressive.

Well-trained staff, pre-diagnosis tests, image capturing of the eye, a system to push all these data to the cloud and an online interface which presents the data to the doctor who later interacts with the patient via a high-bandwidth skype video call. The Maddur centre offers all these astonishing facilities for a mere consultation fee of Rs.150.

For Kiran Anandampillai, Anjali Joshi and Dr Rajesh Babu B, co-founders of Disha Medical Services, which runs Drishti Eye Care, their mission is to deliver high quality, ethical and affordable eye care in the underserved markets of Karnataka. 

From darkness to light
For a city like Bengaluru, which has a population of 10 million, there are 200 eye hospitals and 900 ophthalmologists. But in most districts of Karnataka with a population of 1-2 million, the numbers shrink to 2-3 eye hospitals and 3-5 ophthalmologists. Development of eye care infrastructure in districts has been dismal compared with those in larger cities, and this has resulted in denial of access to quality eye care for a large section in the lower strata of the economic pyramid. Drishti is looking to cover as many people as possible in the middle and bottom layers of the pyramid with the help of technology. “Even if you are in a remote district, we want to manage the most difficult and complicated cases,” says Anandampillai.

Drishti currently has five hospitals, four eye care centres and four mobile clinics across five districts, including nine talukas, in Karnataka. This includes talukas such as Devanahalli, Channapatna and Kanakapura from Bengaluru rural district, Ramnagar district, Raichur, Chitradurga and Bidar. As of March 2017, Drishti had treated 226,000 patients, performed over 5,600 surgeries and sold about 56,000 glasses. 

Prior to Drishti, when Anadampillai and his wife Anjali quit their over 15 year-long careers as telecom engineers, they didn’t have a clear vision on what they wanted to do. Then 38, all that they knew was that their venture had to make an impact in healthcare and had to be scalable and sustainable. That was when a common friend introduced them to Dr Rajesh Babu who suggested eye care as a field. A visit to Aravind Eye Hospital in Tamil Nadu convinced them further about the gravity of the problems in eye care — a segment that had the elements to meet all the three pre-requisites. “Karnataka didn’t have an LV Prasad or an Aravind. We wanted to do something of that scale in Karnataka,” says Dr Babu. Thus Drishti came into being in 2012 with its first hospital in Devanahalli. With no prior experience in eye care, the first three years were spent learning and it was only in 2015 that the company went for its second hospital in Channapatna. 

Diffrent strokes
Drishti follows a three-pronged strategy to effectively cover a district with a population of 2 million. Anandampillai explains: “Typically, the capital and taluka-level towns together comprise 30% of a district’s population. The remaining 70% live in villages.” To cater to this demographic distribution, a fully equipped eye hospital is put up in the capital as the district’s base hospital. Smaller towns would have vision centres equipped for a comprehensive eye checkup, including evaluation of retina; whereas, a mobile clinic, which is a modified bus, goes around the villages.

Besides, Drishti workers also go door-to-door for eye screenings in villages. Those who require advanced treatments or surgeries are sent to the base hospitals after initial consultation and primary treatment at the vision centres or mobile clinics. For example, a patient with a retina problem requiring laser treatment.

“Even though we are in smaller towns, the infrastructure we provide at hospitals and centres is the same as what you see in Bengaluru,” says Anandampillai. Investments of Rs.1 crore have gone into each hospital, whereas a vision centre cost around Rs.20 lakh. Nearly Rs.60 lakh has been budgeted for equipment alone. 

At present, the company is piloting two models for its vision centres. In the first model a doctor is present at the centre and in the second, a doctor remotely communicates with the patient with the aid of telemedicine technology. The latter is for towns with a typical population of 15,000 to 30,000 where the team feels they will never be able to attract a doctor.

“There are 150 taluka towns in Karnataka where one of these models can be applied since nobody provides good quality eye care in such places,” says Anandampillai. Drishti’s two doctorless models have been around for four months now and, according to Anjali Joshi, co-founder and director, have more takers among follow-up patients. The first time, patients are slightly apprehensive of not having a doctor around. However, it is being managed by introducing them to doctors at camps and later during a Skype interaction.

During its early camps, the team had to make do with milk dairies, school rooms and panchayat halls — most of which were dirty and lacked power supply. Drishti’s mobile clinic was an outcome of this uncomfortable experience. The customised bus has an interesting design with its sides converting into benches and a table for seating and registration purposes, respectively. It is equipped with all the required equipment inside and solar panels for power supply. Patients who require glasses or medicines are supplied with the same, whereas those who need to meet the doctor are transported to and from the hospital in the bus. Each bus costs Rs.30 lakh, treats around 150 patients in four hours and covers 15-20 villages in a month. Of the four buses, the chassis and fabrication of three buses are taken care of by 2.5 NVG Essilor, an inclusive business arm of Essilor. Drishti is responsible for the operations and equipment inside the bus. 

“We started our partnership with Drishti with one big bus,” says Milind Jadhav, India head, 2.5 NVG Essilor. “We saw that they were doing good not just on the business front, but also in terms of social impact. The partnership later extended to two more buses and we started promoting our products — high-quality lenses and frames for low economic segments. Now, we are promoting the products through their hospital networks too. Currently, we are taking care of their entire supply and looking at more partnerships with them,” Jadhav says. 

Making economics work
With the aim of serving the backward sections, Drishti makes available consultations, medicines and glasses at affordable pricings of Rs.150, Rs.49 and Rs.300, respectively. While Drishti’s hospitals have sold glasses at an average of Rs.900-1,000, it comes down to Rs.600 in vision centres, further falling to Rs.360 in camps. 

The company also carries out surgeries at starting prices as low as Rs.3,800, though a lot depends on the nature of operations, the technique and type of lens used. Drishti does about 450 procedures a month, where less than 10 people go for high-cost surgeries priced above Rs.40,000; 30% opt for surgeries between Rs.7,000-Rs.15,000; while the remaining 70% choose surgeries that cost up to Rs.6,000.

Casting the net wide
Launched with an initial investment of Rs.50 lakh from the founders, the company later raised funds from Lok Capital in 2012 and Nandan Nilekani last year. The funds were mostly used for expansion plans, while 10% went towards operational expenses. Although a for-profit enterprise, Drishti also runs a grant programme in government schools where students till 10th standard are treated for free through its units.

So, what helps Drishti sustain the business? While the outreach and engagement programmes bring in people, a strong technological platform in the backend crunches numbers to bring a lot of analytics and efficiency. Anandampillai gives a demo of the Online Reporting Visual Module, developed in-house by Drishti. “Even as I speak, across all our units, 298 patients visited, of which 190 were new. In Maddur, we saw five patients. There is separate data for each centre. Last month we had done 389 surgeries, 432 before that, and the average yield per surgery is Rs.7,600.” That’s an exhaustive set of numbers, but it is this module which helps Drishti monitor the system, helping it spread across multiple districts. Being a low-margin business, the founders were clear right from the beginning about the role of technology in scaling up and invested in it right since Drishti’s inception.

Aditya Sharma, director at Lok Capital, explains what differentiates Drishti’s model from most others in larger cities. “Their model is a combination of tradition and innovation (telemedicine). It has been built ground-up, not top-down and superimposed on smaller towns, so the focus is clear.” He points out that the capex is on the lower side and a robust IT architecture right from the start has lowered costs by substituting manpower with technology. The IT infrastructure too has been developed in-house by Drishti’s two-member team, spending around Rs.40 lakh per year that includes salary costs and expenses to host it on Amazon’s cloud offering. 

Unlike corporate hospitals, the 100-member team currently comprises 12 doctors who are not given any targets. However, the biggest challenge for the company is to attract doctors who share the same vision as the rest.

But Sharma feels it’s a surmountable challenge. “Given our reputation, we have been receiving enquiries from doctors who have grown up in small towns and now want to come to Karnataka. We also have offers from doctors who have set up their own centres but don’t want to get into administrative hassles. Quality assessment is very strong and we have a chief medical officer who goes from centre to centre,” he says.

Covering around 8,000 patients and 2,500 glasses a month, Drishti clocked a revenue of Rs.9 crore in FY17 against Rs.4.2 crore last year. It plans to add two more hospitals and two mobile clinics this year. Seven of its nine units are EBITDA-positive. “Even though the units we run today are making some profits, that’s not enough to cover all our corporate costs because we have invested in growth,” says Anandampillai. 

Drishti hopes to be cash-flow positive by FY19, but its vision goes beyond that. The company is also trying its hands at ENT and dermatology and is currently offering these services at its vision centres. Drishti aims to be present across rural Karnataka by 2022 with 25 hospitals, 75 vision centres and 25 mobile clinics. But the team is clear about sticking to Karnataka. “We want to serve the underserved, but to do it right it’s better to go in-depth rather than spread oneself thin,” smiles Joshi.