‘India is merely a geographical expression. It is no more a single country than the equator’- Winston Churchill
Had I read this quote five months ago, I would have not understood what it meant. But after living, traveling and working in India for exactly that long, I can say that Winston Churchill was exactly right. In India, like in any other large country as the US or Mexico, I expected to find some regional differences in people’s tastes for food or music, their accent, dress code, etc. In my mind, these differences give countries their character and do not have major consequences for business other than the opportunity to bring in some variety to the portfolio of products or services. In India, however, regional differences go FAR beyond the ones I just described. For this reason many authors to talk not about one country but “the many Indias”.
For an enterprise trying to do business across the Indian territory, it is critical to be aware of all the nuances of “the many Indias”. Allow me to illustrate what I mean by this using AyurVAID: Hospitals, the organization I am working in, as an example.
AyurVAID: Hospitals is a local business with the mission of providing high quality, affordable Ayurveda (India’s traditional system of medicine) treatment for chronic illnesses across all socio-economic segments and across India (and some day abroad). In line with this vision, AyurVAID: Hospitals opened six small to medium sized hospitals in three neighboring states: two hospitals in Kerala, three in Karnataka and one in Maharastra. The hospitals are located in urban areas and three of them in the big cities of Mumbai and Bangalore.
At first glance AyurVAID: Hospitals’ strategy of expansion seems very straightforward, but in practice things are let’s say a bit more….complicated. Here is how:
Language– At each location, all sign boards and advertising material have to be translated into at least 2 different languages (English + local language) and 4 in the case of Mumbai (high immigrant population). Our doctors need to speak 2 to 3 languages to communicate with patients, English to communicate with the management and international partners, and Malayalam, the language of Kerala, to speak with the staff.
Human resources– The roots of the Ayurveda system of medicine can be traced back to the state of Kerala. Although today Ayurvedic Medical Colleges train doctors across the country, training institutions for therapists are still highly concentrated in Kerala. Hence, hiring locally becomes a difficult task and most of the therapists have to be relocated from Kerala to other states. Then again, most people in Kerala have a strong affinity for their state and prefer not to leave it.
Systems of medicine– Whereas in other parts of the world, Allopathic or “Western Medicine” is the norm, in India, patients have many other well established options to consider like Ayurveda, Homeopathy, Allopathy and Unani. In competing with these different options, public awareness about Ayurveda is a big challenge. If we take allopathic medicine as an example, most people today know what to expect when they go to a doctor, to a hospital or understand if someone says they need a “dialysis”. On the other hand, Ayurveda means a variety of things to different people, particularly as the distance from Kerala increases. To test this last point, I decided to interview people in the streets and hotels of Kerala (to get some out of state opinions) and asked them one simple question….Observe.
All of these factors make the business at AyurVAID: Hospitals challenging and exciting! One success factor as we continue to grow and do business in “the many Indias” will be to strike the right balance between standardization and customization of our services.
This month I want to share with you not about the investment that I am working in but about myself and my personal experience in the first few months of the Fellowship.
Before flying to India I was part of many conversations in which the common theme was that in order to really make a positive social impact in the lives of the poor we need to slow down… Extend time lines, think in terms of processes not tasks, take into account the infrastructural limitations of the countries when designing a business plan, etc. All of these conversations, plus the many hours in the classrooms at LSE discussing the failures of development efforts in the last few decades, helped me prepare to transition to a work environment that would require a large quantity of patience. Patience with the external circumstances that would shape the way I worked. What I did not foresee was that I would need even a larger quantity of patience with myself and the impact that my personal transition would have on the work I was ready to do.
Find out why by watching my video.
The entrepreneurs at AyurVAID: Hospitals are testing a business model that promises to overcome the scale up challenge of delivering medical care to the masses based on Ayurveda, a system of traditional medicine. According to RV Raman, Head of Marketing at AyurVAID: Hospitals, there are about 18,962 Ayurveda companies registered in India today. Most of these companies focus on offering ayurvedic products (from medicines to toothpaste!) and spa related services, however no one has been able to come up with a successful, scalable model to deliver health services. (Ironic considering that Ayurveda is a system of medicine that has been around for more than 3,000 years!) In this video Rajiv Vasudevan, CEO of AyurVAID: Hospitals, explains some of the challenges inherent to the Ayurveda “industry” and some of the strategies the team has developed to overcome these obstacles.
Temporary housing has been set up across the road from my office for construction workers and their families who have come in from rural Maharashtra. I am not talking about temporary apartments with electricity & water access, these are shacks with metal slates used as siding. Water is delivered in the morning for the community and if I come to the office before 8:30am I walk right by them having their morning showers! So I asked a colleague what will happen when their work is done? He responded that although the construction workers and their families would move to the next job, the whole area would soon be re-inhabited by homeless families looking to establish slum housing. First these families will sleep outdoors he said, next they will set up basic, inexpensive siding using burlap sacks, and only once it is clear they will not be kicked out will they invest in more expensive building materials like metal and wood. Eventually the slum lord will come and start to collect “rent” from them to occupy the space and keep municipal and police officials from “noticing” them. After 1-2 years once a community of people becomes established those who can afford to will start re-enforcing their homes with bricks. Like Dharavi, one of the largest slums in Mumbai, this community will operate almost entirely outside of the formal economy.
My next question – why doesn’t the Indian government pay to build low-cost housing and transfer these communities? Well it turns out the government has tried and one of the problems is that families awarded the housing sell it on the market for income and then set-up a slum dwelling elsewhere. According to my colleague the main issue with new housing is that they are not used to formalized systems for rent, electricity, building maintenance, taxes….and revert back to slum lifestyle.
Now please keep in mind this is just one person’s version, and I am sure there are nuances that I have missed, but I do find it fascinating that there can be such complex formalization within a system that operates almost entirely within the informal economy. Below is a picture I snapped yesterday on my walk to the office.
Well we were warned as Fellows that cultural blunders would happen, and I’m sure there will be more to come … Mine involved my first late night at the 1298 Dial for Ambulance office In Mumbai. This time of year it gets dark around 6pm and not many lights were on in the office. Now you must understand that since I have been in India very helpful staff, office boys, shop keepers, drivers etc. have been doing most everything for me, so I recall thinking that I am more than capable of turning on a few extra lights for myself. I get up and walk over to the incredibly complex lighting system that exists in India. For those of you who have not been here each light has its own individual switch and they are usually not marked – creating a myriad of options – my office has 24 switches alone on one main wall. This is to conserve energy I’m sure, which is a good thing, but makes it complicated to simply switch on a light. So I turn a whole row on, just like that – ah the power of not feeling helpless! – and immediately all the office computers go dark and the hum of activity stops. Hmmm this is not good, everyone turns to look at the fool who turned on all the lights at once at the expense of the PCs. Worse yet we have our ambulance call center on-site 24/7 – yikes! Lucky for us there was no emergency call during the 2 mins or so that it took to get power back up and running. We have excellent IT support here thank goodness.
I did learn my lesson however, the simple one is that you can have good lighting or functioning PCs – but not necessarily both in India. And the more important one is that while in Mumbai I need to learn to be patient, to take things one step at a time and to understand consequences before forging ahead. Easier said than done, I think.
I awoke this morning to the terrible news that Mumbai had been bombed yesterday evening. So far 125 are dead and 327 injured. Apparently, one of the terrorists in custody is of Pakistani descent. I hope to goodness that this will not derail the recent talks of partnership between the two countries.
The Acumen Fund team immediately went into action to check on all of the fellows in India along with those of Indian citizenship to see if they and their families were safe. It’s comforting to know that there is such support here and abroad.
Apart from the dreadful news, this day has been like any other. Earlier this week, I tried to contact the US consulate in Karachi to see if they had any Thanksgiving plans open to US citizens, but they did not. While I may celebrate Thanksgiving alone this day, I still have the fresh memories of my family’s Thanksgiving celebration on November 9. I traveled home for a wedding during my final weekend before leaving the states. My sister, brother, and brother-in-law all came home as well for the festivities. We cut-a-rug at the wedding and then enjoyed our last meal together for the next 10 months. I am so blessed to have such an incredibly loving family that supports me and loves me back home!
Joel Montgomery
Acumen Fund Fellows 