Forthefirsttimein India,aglobalpharmaceuticalcompanywentbeyondthetraditionalmedicalrepresentativeroutebyaddressingtheunmethealthneedsofruralIndia,therebydramaticallyimprovingaccesstomedicinewhileatthesametimeprovidingopportunitiesto expandbusinessinan innovativeandsociallyresponsibleway.NovartisisthefirstpharmaceuticalmultinationaltouseasocialbusinessmodeltoreachIndia'sruralmarkets.

Forsome800millionmen,womenandchildreninmorethan600,000villagesacrossIndia,theideaofaccessible,affordableandhigh-qualitymedicinesisoftenasremoteastheirruralhomes.Institutionalhealthcarein ruralIndiaislimitedtothegovernmentstructure.Privatehealthcareservicesareindividual-drivenandunstructured.Thegovernmentoffershealthservicesfreeofcostbutover70percentruralpeoplepayforhealthservices.

NovartiscommissionedMARTtounderstandtheheathneeds,behaviourandat-titudetowardsmedicineinruralareas.MARTfoundthattheawarenessofhealth

issueswaspoor,andpeopleaccessedhealthservicesaftertryingvarioushomeremedies.Thedelayintreatmentandtheensuingemergencywereconsiderednatural.Ailmentsrelatedtonutrition,allergiesandinfectionswerenotdifferenti-ated,leadingtothepatientnotapproachingtherelevanthealthserviceprovider.Thisleadstoasignificantwasteofmoneyandnorelieffromailments.Manyofthesepeoplestayedundiagnosedbecausetheyeitherdidnotunderstandtheirsymptoms,orthedoctorsweretoofaraway,or theywereafraidof thecostsinvolvedorofsocialprejudice.Womenandchildrenwereparticularlyvulnerable.

Tuberculosis(TB)wasidentifiedasa keyailmentin ruralareasandthiscasefocusesonTBtreatment.

Problems

Themainprobleminhealthcareforruralpeoplewasrelatedtothe4As,whichisdiscussedbelow..Affordability

- PerceivedorexperiencedcostoftreatmentforTB,if thepatienthastobetakentoanearbytownfortreatment(treatmentperiodisfromsixtoninemonths)isestimatedtobemorethanINR10,000 ingovernmenthealthcentres,againstINR15,000throughprivatetreatment.In governmentcentres,patientshadtogotoprivatediagnosticscentresandbuymedicines.

- Forsimpleinfectionsorskinallergies,thecostofprivatetreatmentwasbetweenINR250-1,000..Availability

- Accessto healthservicesandmedicineshasbeenthemajorproblem.Qualifieddoctors,privateorgovernment,or licenseddrugstoresarenotavailableinvillages.Therefore,thereisthecostoftravellingtotheblocktown,wherethePHC(publichealthcentre)oraprivatedoctorislocated..Awareness

- Patientshavepoordiscerningcapabilitiesand cannotidentifytheappropriatedoctorfortheirailment.

- Theyhavenoideaifthemedicinesprescribedbythedoctorarethesameasthosegivenbythechemist.

- Patientshavenoideaif the"medicines"arepreventive,curativeor formaintenance..Acceptance

- Patientshavetheirownperceptionsaboutailments.Onlythoseailmentsthataffecttheirworkproductivityareattendedto.

- Treatmentofchildrengetspriorityoverthatofadults.

Hence,Novartisfelt theneedfor reliablehealthservicesandmedicinesatareasonablecost.

MART'sStrategic Suggestions.Tocreateawarenessamongthelocalpopulation,establishanetworkof"footsoldiers"recruitedfromvillagestoworkas"healtheducators".Theywouldsupportpatientsforallhealthservicesandfollowuptocompletethetreat-mentprocess..Toimprovetheavailabilityof healthservice,qualifieddoctorsneedto beidentifiedeitherfromamedicalinstitutionorindividualpractitionersintownswithpopulationsgreaterthan50,000(blocktownsorbelow)..Tomakehealthservicesaffordable.Patientswereoftenmis-informedabout

thetotaltreatmentcostandbelievedit to bemuchhigherthantheactualcost,becauseof whichtheyavoidedseekingtreatment.Thiswrongper-ceptionwascorrected,afterwhichpatientsrealizedthatthetreatmentwasaffordable..Tomakehealthserviceacceptable,theprogrammeidentifiedcriticalhealthissuesrelatedtoinfection,nutritionandallergies.TheArogyaprogrammead-dressedtheseidentifiedissues,deliveringgoodresultsandtherebybuildingtrustwithinthecommunity.

The Solution

Toaddressthe healthissuesin ruralIndia,Novartisdesignedan arogya(meaninggoodhealth)programme,thewinnerofthebestlong-termruralmar-ketinginitiative(RMAI2008 SilverAward,WOW 2008 SilverAwardandGoldenPeacockAwards2008),whichofferedpharmaceuticalsolutionsandalsoin-tegratedtheneedtonetworkwithlocaldoctors,educatepotentialcustomers(patients),andlinkpatientstospecializeddoctors.TheNovartisteamaddressedthechallengesbyusinganinnovativedirectapproachtomakevillagersawareof prevalentdiseasesandencouragethemto seektreatment.Bylate2006,theArogyaParivarinitiativewaslaunchedwiththehelpof MARTasa pilotprogrammeinUttarPradeshandMaharashtra.

ArogyaParivarfollowsadecentralizedmodelwherethefieldforceisinautono-mouscells(250cellsin2011),eachcoveringa radiusofapproximately35kmor 20 miles.Eachcellismanagedbya supervisor,assistedbya fewhealtheducatorswhocollaboratewithlocalhealthprofessionals,pharmacychainsandNGOstoaddressthewhole"patientflow",includingeducation,diagnosis,treat-ment,delivery,andavailabilityandaccessibilityofmedicines.

Akeydifferentiatorisofferingpatientsintegratedsolutionstohealthproblemsratherthanmainlysellingproductstohealthprofessionals.Productsselectedfortheinitiativearesimpletouseandpackagesarereducedinsizetokeepout-of-pocketcostslow.Theinitiativeaimstobuilda sustainable,profitablebusinessthatimprovesaccessto healthcareamongtheunderservedmillionsin ruralIndiabycreatingawareness,enhancinglocalavailability,anddesigningappeal-

1'"ir

ingandaffordablehealthsolutions.Thissocialbusinessapproachrepresentsamixofcorporatecitizenshipandcreativeentrepreneurship.

AnArogyabrandwascreatedfor theuniquehealthservicesofferedbythecompany.Theumbrellabrandhelpedto overcomebrand-relatedissuesandbecameeasyrecallfor the illiterateandsemi-literatevillagers.TheArogyaParivarbrandissupportedbyconsistentgraphicsofleaflets,banners,educationprogrammes,uniformsfor healtheducatorsanddecorationsfor bicycles.Allcollateralisdesignedkeepinginmindthenatureoftheaudience,particularlyintermsof literacyandcomprehensionlevels.Effortismadeto focusonspecificdisease/sonrespectiveWorldDiseaseDaysthroughactivedoctorparticipation.

Tocreateawarenessamongthelocalpopulation,Novartisestablishedanetwork'of "HealthEducators'(HE)recruitedfromvillagestoprovidepatientswithsup-portandfollowuptocompletethetreatmentprocess.TheHEwasprovidedwithbrandedT-shirts,capsandbags.Novartisusedbrandedaudiovisualvans,com-munitymeetingsandadvisoryleafletstocommunicatethebenefitstotheruralmasses.The"HE"movesfromvillagetovillageona permanentjoumeyplan(PJP).Theyconductgroupmeetings,identifypatientsindifferenthouseholds,educatethefamilyandconvincethemof the needfor treatment.Theyalsoensurethatpatientshavetheirsupportwhentheydecidetovisitthedoctor.It isalsoimportantthatthemedicineisconsumedasprescribed.One-on-onecom-municationisnecessarytoconvincethepatientandtheirfamily.Aninformedpatientismorepositivelyorientedtowardscompletingthetreatment(thereisatendencytodiscontinuetreatmentassoonasthepatientfeelssomerelieO.TheHEservestwoblocksand30activepatientsandispaidINR1,500permonth(commissionof10percentfromsaleofmedicines),andnewproductsarebeingaddedbyNovartistosupplementincome.TheNovartisexpenseoncommunica-tionandpromotioniscompensatedthroughthemarginfromincreasedsalesoftheirmedicine.

Theinitiativeis structuredasa "socialbusiness'andisa perfectopportunityto expandthereachofhealthcareto thosepeoplewhofalloutof thecurrentsystemsimplybecausetheydonotliveinurbanorsemi-urbanIndia.

ArogyaParivarbuildsona "bottom-of-the-pyramid"businessapproachmeanttosellproductsandservicesto low-incomepopulationsinemergingcountries.

ArogyaParivaristargetedatallagegroups,especiallywomenandchildren.Thetargetwasselectedonthebasisof publisheddataandmarketresearch.Thispopulationwaseffectivelydisfranchisedfromtherighttoqualityhealth.

ArogyaParivarusesa uniquebusinessmodel,combiningtechniquesusedbypharmaceuticalandconsumergoodscompanies.Its fundamentalinnovationrestsonapplyingamarketingmixbasedonthe4As-awareness,acceptability,affordabilityandavailability-adaptedto low-incomemarkets.

ThecommunicationtoolsusedfortheArogyaParivararedetailedinTable1.Thecommunicationstrategyincluded:

- One-on-oneinteractionatthecommunitylevel(SHGs)- Brandedvanusingaudiovisualsonthevarioushealthissuesandtheneed

toseektreatment- BrandedT-shirts,caps,brandedbicycles,handbills,flip charts,patient

cards.

Impact

Thecurrentreachoftheprojecttothose50millionpeople,or250ruralcells,wherea cellisanareaof 25-30sq.km,including80-100villageseach,isindicativeofthemodel'ssuccesstodate.

Table1 CommunicationTools

Tools

Leaflets

Flipcharts

T-shirtsandcaps

Brandedvans

Brandedbicycles

Patientcards

Communication

Communicationabouttheailmentsandtheirsymptoms

Tocommunicatethemethodsofidentifyingsymptomsforailments,causesofailmentsandnecessarytreatmentprocedures

Toidentifythe"healtheducators"withtheArogyaProgramme

Usecommunicationtocreateahighdecibel

Usedby"healtheducators".Brandrecallfortheaudienceexposedtothehighdecibelbrandpromotion

Foridentifiedpatientstocarryasreferencetotheconcerneddoctor

Peopleacrossfivestateshaveaccessto qualityhealthcarewith thousandsofdoctorsand hundredsof pharmaciesbeingservicedby ArogyaParivar.One

hundredandthirty-eightdistrictsin UP,Maharastra,MP,BiharandRajasthanarecoveredunderthe initiative,and12,000patientshavebeentreatedsofar in

1,000villages.Currently,morethan20 healthprogrammesarerunning,cover-

ingtuberculosis,respiratoryinfections,skinandgynaecologicalinfections,dia-betes,micro-nutrientsduringpregnancyandduringchildhood,intestinalworms,

acidreflux,coughandcold,aswellasallergies.

ArogyaParivarhasbuilta healthynetworkofdoctors,paramedicsandpharma-cists,whosharea similarmissionandsupportthe initiative.It hasalsoestab-

lishedstrongallianceswith pharmacyandhospitalchainsthatserveas a goodcomplementto Novartis.

Thecompetitiveadvantageof ArogyaParivaris that it makeseveryactorwin.Patientsareeducatedandavoidhealthcomplications.Healthprofessionalssee

morepeoplethantheymightotherwise,andarealsotrained.Healtheducatorswhoworkforthecompanyarelocallybased,receiveextensivetraining,andgainadditionalstatuswithintheir communities.As for Novartis,theyare improving

healthcareandchangingthelivesof peoplein need.

A holisticmodel,ArogyaParivarhasensuredthatareasthatwerehithertorela-

tivelyuntouchedby traditionalmedicalrepresentativesare now on the road

map.Theinitiativehassucceededinbringingin additionalrevenue,thusaddingto thebottomlineof thecompany.

I FIG.1 I The Arogya Model

SocialImpact +

Philanthropy Social business

Bottom-lineGrowth

-I-

PR/Damagecontrol

II

II

J~

Performance-drivenCSR

---.----

Sinceits businessmodelis notbasedon puredonations,ArogyaParivarisaneconomicallysustainable"socialbusiness",scalableto morepeopleinIndiaandabroadthataimsto:.Provide health education (hygiene,nutrition, disease awareness)and

improvethequalityof lifefor localpopulations.Improvepublichealthwithouttheneedfor costlygovernmentinterventionorlimited-durationNGOprojects.Createa revenuestreamfor localpersonsassociatedwithArogyaParivar.Increasefootfallat localhealthprovidersandbusinesspartners(encouragingtheirsupportto ruralmarkets).GenerateincomeforNovartisandbuildbrandequitywithanupwardlymobilepopulation.HighlightedbyNovartisin internalandexternalcommunication(inthesamemanneras CSR).FulfilformerPresidentAbdulKalam'svisionof PURA,that is,providingurbanremediesto ruralIndia

Learning.Thepoorarewillingtopayforqualityandeffectivetreatment..Earlier,malepatientswerereluctantto consultANMs(females);however,theArogyaHEismaleandabletogainacceptance,convincepatientsandsupportthem..ChemistsbeganstockingNovartisproductsoncedoctorsbeganprescribingthem..Doctorsaremotivatedduetotheincreaseinincome,andarethereforewill-ingtoparticipateintheprogramme.

. Doctorsareprofessionallysatisfiedthatpatientsnowcompletetreatmentandgetcured.

The Way Forward

TheArogyaprogrammeiscognizantof theimportanceofworkingwithNGOs,especiallyinawarenessprogrammesviacomrnunity-Ievelmeetingsandhealthcamps.In2011,theArogyaprogrammeplannedto forma consortiumof atleast20NGOsinIndiatoprovidetargetedinterventioninthecausesofdiabetes,tuberculosis,diarrhoeaandalsofortheprovisionofcleanwater.

Planshavebeenmadeto replicateandadaptthemodelin othercountriesthroughoutAfricaandAsiaoverthenextfewyears.

Motherandchildnutrition,skinallergyanddiabetesarebeingaddedto thelist

of treatments.Novartisalsoplansto addalliedproductslikesanitarynapkins,waterpurificationproductsandcleandeliverykits to supplementthe incomeoftheHE.Theaccompanyingvideoexplainshowthisprojecthasbeeninitiatedand

implementedin UttarPradesh.

Discussion Questions

1. Whatproblemsof the ruralcommunitywereaddressedthroughthismodel?2. Ust thekeyreasonsfor thesustainabilityof thismodel.

3. Doyouthinkthismodelcanbereplicatedinothercountries?Ifyes,howandin whichcountries?