We spoke to Dr Asher Hasan, Co-Founder and Executive Chairman of Paskistan HealthTech startup, doctHERs , about his journey between continents — from the UK to Pakistan to the US and then back to Pakistan, from scaling Naya Jeevan to the formation of doctHERs. The company is using digital technology to integrate the public and private healthcare delivery systems, building upon a large, under-utilised supply of qualified female healthcare providers (doctors, pharmacists, therapists and nutritionists) to bring high-quality healthcare to underserved citizens in their homes and places of work.
About His Early Life
Asher grew up in the UK, moved to Pakistan in his teens, studied neurobiology and neuroscience in the US, conducted research at Harvard Medical School and Massachusetts General Hospital and trained in general surgery at Beth Israel before returning to Pakistan where he entered the world of impact entrepreneurship.
Asher lived in the UK during the early years of his life, where healthcare is essentially free at the point of delivery (excluding cosmetic medicine and dentistry). Asher’s parents were from Pakistan and his grandparents from India and he was always fascinated by how his family roots transcended borders. As a child, he visited Pakistan frequently — and this gave him a sense of how privileged he was growing up in the West, and also made him acutely aware of the enormous disparity in both India and Pakistan between rich and poor. He used to wonder: “Why do people accept this?”
He mentions three key ‘trigger’ events that changed his life:
The first was when his father died, while still only in his early 40s. At this point, an 11-year old Asher and his siblings were uprooted and relocated to Karachi, Pakistan, where his maternal grandparents resided.
At his home in Pakistan, a live-in maid was employed who had six children. The children were treated well, and Asher’s mother paid their school fees.
He recalls one young girl in particular who was quite “brilliant and bold.” Asher speculates that she had the attributes and potential to become a future Prime Minister. What she lacked was access and opportunity.
In the 1990s Asher left Pakistan to pursue his higher education in the US. At first, he studied neurobiology and neuroscience at Oberlin College (Ohio). This was followed by several years of cardiovascular research at Harvard Medical School and Massachusetts General Hospital (MGH) and additional training in general surgery from Beth Israel. Asher then transitioned in to the bio-pharmaceutical industry in New York and California over a period of 7 years.
After his first year at university he returned home over a winter break, where was stunned to see that the same bright, bold girl was completely jaded. “She had lost her spark – her spirit.” Asher discovered that her father had suffered a stroke and for want of medical attention, had become paralysed. To make ends meet, the maid had no choice but to put her six kids to work – “all six ended up being either physically or sexually abused,” he said.
This was the second trigger event that transformed Asher, a critical step on his pre-entrepreneurial journey. He says that this event “was a huge wake-up call for me”
The third trigger event was the sudden death of his 60-year old mother, who, Asher believes not coincidentally, suffered a massive, haemorrhagic stroke and died on her way to the hospital.
At that point, Asher was in San Diego in the biotech industry. He says that up until that point, he had been “living the California dream,” but it had been a very self-centred and materially driven life.
Following his mother’s death, Asher felt that he really needed to recalibrate his life. He finished business school at NYU Stern, following which he brought a group of graduate students to India and Pakistan over the summer of 2007 — driven by the purpose to study, understand and analyse the healthcare delivery systems in both countries, especially the increasing role technology was playing in healthcare delivery. The team also researched the health financing role of the private and public sectors.
It became apparent to Asher that the private healthcare systems in both India and Pakistan excluded large swathes of the population – “for each person who benefited from these private-sector financed health systems, there were 20 people affiliated with these mostly corporate executives (such as informal domestic workers and families), who were excluded from the system”
And it was then, back in the summer of 2007 that his journey as an impact entrepreneur first began.
An Inside Look Into His Personal Life
Asher admits he made a lot of ‘rookie’ mistakes — he hopes others can learn from them.
In the early days of his entrepreneurial ventures, Asher says “I was relentless.” But there was a price he paid for that. His lifestyle was unhealthy, and he says he didn’t pay enough attention to close friends creating an ‘antisocial’ distance between him and them. By 2015 he says this crescendoed into severe burnout. “The 24/7 ‘always on’ approach to running a business is not sustainable” he says.
Another mistake Asher admits to is quitting his day job too soon. The challenge of knowing when to commit 100 per cent to your business is one that haunts all entrepreneurs. Asher calls it a chicken and egg problem, especially for entrepreneurs focused on working in developing markets. An investor won’t commit unless the founder is 100 per cent involved, but how does that founder survive and thrive? In the case of Asher, he says he made that jump too soon. “We launched in 2009, but didn’t achieve profitability until 2016.” During this bootstrapping phase he had to live off savings, which he says put his family under tremendous, financial pressure.
A third mistake, he says, is that, in retrospect, Pakistan may not have been the ideal location to launch his impact venture. It would have been a great location to replicate the model in and he believes he should have chosen one of the BRICS: in particular China or India into which investors were pumping money in 2007-08 prior to the crash of 2009. He says that Pakistan was (wrongly) perceived as a high risk, frontier market; and raising impact capital in such a market still is “really hard.” The institutional investors who do invest in Pakistan, he says are typically more interested in industrial investing such as into a sugar mill.
He believes that today, Singapore is emerging as a HealthTech hub – “a natural convergence point, blending the best minds in the East and West.” On a similar note, he considers Hong Kong and Dubai as other viable hubs for a HealthTech startup. “But if you want to be the next Mark Zuckerberg or Apple, then Silicon Valley” is obviously the ‘go-to-unicorn’ place to be.
He says: “I should have entered a market where it was much easier to raise money and then replicate in Pakistan.”
Finally, Asher says, be very careful of who you choose as a partner – it’s like a marriage – so you need to ‘date’ and ensure alignment before you ‘get married’. Asher says that he was not philosophically aligned with his early founding members at Naya Jeevan – he had a higher much risk threshold but they “continued to work together for several years longer than we should have because we were values-driven and mission-aligned”. “My advice,” he says, “when finding partners is to make sure you are aligned.”
And Today
Today, Asher takes greater care of his mental health. He participates in an 18- month programme called the Wellbeing Project, which a global initiative co-created by Ashoka, Esalen, Impact Hub, Porticus, the Skoll Foundation and Synergos, “It’s especially designed to catalyse a culture & practice of inner wellbeing for all changemakers.”
He says that he now engages in mindfulness meditation exercises first thing in the morning and last thing at night. He says the “Wellbeing Project, has taken a more holistic approach to ‘nourishing myself.” He also practices yoga and ensures he has a minimum 45-minute jog or fast walk each day which really helps him to ‘clarify my thinking’.
“My message,” he says “is to exercise regularly, sleep well, eat lots of veggies, and avoid meat as well as meatheads. Spend your precious time with people who will elevate your spirit and feed your soul. Avoid those who suck the living daylights out of you” He says that as this practice of wellbeing becomes second nature, his food preferences and diet has been transformed “The thought of a Big Mac makes me nauseous now.”
He says that he is also spending more time with his family, “but still not as much as I would like or my wife would like. She’s still complaining that I don’t give her enough attention. I honestly don’t know how she has endured the last 10 years with me” Asher quips, “She’s definitely made of titanium” he claims.
Immediately after his morning meditation and prior to his night meditation, he reads. Where does he find the time? “You have to make it happen.” He likens time to a vacuum, if you don’t pre-schedule a slot for reading, something urgent but not important is guaranteed to fill it. Focus on what’s important”
So what are these books he reads second from first thing and second from last? He recommends “Scaling Up: How a Few Companies Make It… and Why the Rest Don’t,” by Verne Harnish. “In Search of excellence“ by Robert H. Waterman Jr. and Tom Peters, and “Good to Great: Why Some Companies Make the Leap…and Others Don’t”, by James C. Collins. He is also a fan of behavioural economics book Nudge, by Richard H. Thaler and Cass R. Sunstein, and anything by Malcolm Gladwell.
Books can inspire, but so do people. And Asher says his greatest inspiration is his eight-year-old daughter, Dia Miral. “She’s a true force of nature.” Looking beyond his family for role models, Asher gravitates towards social justice leaders such as Nelson Mandela, Gandhi, Martin Luther King and Mother Teresa” They fought against injustice and tyranny in a way that was so dignified and impactful. They also remind me to stay humble.”
In essence, Asher reminds us that his personal journey has been one of relearning humility. He has become aware of “what I don’t know” and to be willing to “learn and improve continuously.”
Enterprise Journey
In Pakistan, for individuals who work for a large company, there is good access to healthcare, typically in the form of health insurance. But for each of these corporate employees, there are many others who are formally or informally linked to them, who don’t have access to quality healthcare. These people include informal domestic workers — cooks, maids, drivers etc. In Pakistan, Asher explains that healthcare is still relatively cheap in contrast to the US but the majority of the population in low-resource communities is excluded from convenient access to primary care.
There is an additional issue – health insurance in South Asia is typically catastrophic, i.e. it only covers inpatient hospital care. Outpatient care or OPD as it is more commonly known as in this part of the world ” has so many providers, some qualified some not, that insurers feel very uncomfortable in assuming financial risk due to their inability to regulate or monitor outpatient care.”
There is yet another important cultural issue, women in Pakistan prefer to see female doctors, especially for women’s health issues such as gynaecological care.
Asher identified a gap – a need to meet these needs. His initial impact venture (Naya Jeevan) was first launched in 2007 as a not-for-profit organisation in the US, but Asher soon realised that in order to scale impact to the venture had to be sustainable. Accordingly, Naya Jeevan hybridised by creating a for-profit entity in October 2012 that focused primarily on workers in corporate value chains (e.g. factory workers, distributors, etc)
Gradually Asher began to understand the business case for convincing corporations to finance the healthcare of workers (and their families) linked to the supply chains and value chains of MNCs— e.g., farmers providing dairy inputs into large dairy companies such as Friesland Campina, or retailers selling fast-moving consumer goods (FMCGs) made by a company like Unilever.
Over the past 5 years, Unilever has been tracking the KPIs of the program to evaluate their return on investment. One metric they have focused on is employee attrition, especially among their third-party sales force.
“They were losing $10 million a year in productivity costs from attrition of their salesforce in Pakistan alone.”
Unilever agreed to enrol, not just the worker, but their family, including parents — “in Pakistan, supporting parents is seen as culturally responsible.” For Unilever, this program has impacted their triple bottom line, generating a financial ROI of ~250%.
The consequence of this loyalty-performance program is that the relationship between the distributor sales force and Unilever has been transformed from a transactional relationship to a transformational relationship.
Asher says that the programme is not just helping to build loyalty, but is also developing the markets of the future; while simultaneously “creating tangible financial benefits for the company” in the short term as well.
The evidence from the Unilever experience has accelerated the adoption of variations of this program among other FMCGs such as Shell, Reckitt Benckiser, Friesland Campina and Philips.
The company also built a health insurance model, focused on primary care, which they have scaled significantly. The model emphasises the employment of female doctors. Two-thirds of medical school graduates in Pakistan are women, but only around 30 per cent of qualified female doctors are women. Asher and his team saw an opportunity to reintegrate these women into the healthcare workforce. It was from this idea that doctHERs was born.
The Company Today — doctHERs in 2020
Two factors have underpinned the company’s development in 2020.
The first is COVID-19 related. “It was almost impossible to see a physician for non-COVID-19 related conditions during the initial lockdown period.” This, in turn, increased the importance of home health visits (HHVs), conducted by frontline health workers (FHWs), equipped with tablets, 4G wi-fi connectivity and digital diagnostic tools. They FHWs can, in turn, connect with specialist doctors through technology.
Technology has played a key role in making this integrated digital model feasible – the use of remote digital imaging tools, for example is only feasible due to the ability of doctors to access high-resolution images. Asher refers to how until recently the only option to obtain an MRI , CT scan, or Ultrasound was to visit the hospital. Now, with the progressive miniaturisation of technology, handheld ultrasound devices can be attached to a smartphone.
These technology-enabled developments lower the cost of care.
Asher believes that these digital technologies will leapfrog a lot of infrastructural constraints so that the need for large hospitals in emerging markets will not be so great as in industrialised nations.
The second factor relates to the probable post-Covid world. Asher expects that as people return to work, they will require convenient, access to quality healthcare. It will be possible to provide this via technology and through telemedicine, employing a skilled nurse who has digital diagnostic equipment on-site, alongside a blood lab and pharmacy — all on-site, at the place of work.
He sees this model scaling up across the ASEAN region, not just Pakistan.
Partnerships
As part of its expansion, doctHERs has entered into partnerships with some very large consumer-goods brands.
One key partnership has been with Levi Strauss with whom doctHERs had been in discussion for some time. However, with the arrival of COVID-19 in the Spring of 2020, things accelerated for doctHERs. Levis is financially supporting the implementation of the doctHERs SMART telemedicine clinic model.
Asher envisions this model being replicated across the ASEAN region, where the textile and garment industries are dominant.
Then there is a second partnership led by Unilever with DFID catalysing it along with the support of Philips, Pfizer and the Punjab government (via its agency, Punjab Population Innovation Fund).
The model involved frontline community workers, equipped with 4G-tablets going door to door, conducting home visits, and also conducting focused groups for educators, in which doctors and nurses operate Q&A with women in rural villages.
These doctors and nurses help navigate and also curate care in conjunction with doctHERs in a way that is highly coordinated. Asher says “one of the biggest challenges in healthcare markets is one of fragmentation of pharmacies, labs, hospitals, private clinics and so many types of providers, including faith healers, spiritual healers, western type allopathic care, homoeopathic, herbalists and all different types of medical providers. Integrating these in a coordinated way is something front line workers can do quite well.”
So, putting all that together, doctHERs is looking at scaling up private and public partnerships with the private sector co-financing, and in return getting access to rural markets.
The frontline healthcare workers also sell goods on behalf of Unilever, making them last-mile retailers who are also health workers.
Asher says he sees that type of model growing “because the private sector is willing to spend money on marketing and advertising for rural market development. They were already doing this in an ad hoc way; now, they are just institutionalising it strategically.
“The government has always had the responsibility of providing good quality healthcare for poorer citizens; now they have a private sector partner that is subsidising that and using technology to help scale and coordinate the prices.”
Last year, the model impacted over a million women, and Asher says doctHERs is on course for two million women impacted in 2020-21.
Impact of COVID-19
Before COVID-19, in Pakistan, specialist providers were resistant to using telemedicine, especially those who were considered to be more ‘old school’ and well established. Asher believes that COVID-19 has created a “consumer led’ transition. Necessity is the mother of invention and traditional consultants have wholeheartedly embraced this mother as they have been losing market share to more tech-savvy consultants, “We have seen a big uptake from senior consultants who have been quite resistant to the use of telemedicine in the past.”
The behavioural change has, in part, been brought about by consumers who want to use technology and partly as they don’t want to go to a clinical hospital and expose themselves to an environment that is very likely to be contaminated.
What Impact Has the Galen Growth HealthTech Cohort Have?
Asher says that the Galen Growth’s HealthTech Cohort has exposed doctHERs to a unique set of stakeholders that is quite different from the impact investors and donors they have encountered in Europe and the US. He says that in Pakistan, most investors have historically come from the US or Europe. “For the first time, we find ourselves looking eastward”
“Galen Growth has exposed us to a different set of investors, stakeholders and partners that we wouldn’t previously have had the opportunity to interact and explore synergies with.”
About the Galen Growth HealthTech Cohort
doctHERs is part of the Galen Growth HealthTech Cohort, the only acceleration programme built to scale digital health startups to be the next generation powering healthcare innovation in the New Normal in Asia. In 2020, Galen Growth is working with 25 HealthTech startups which will benefit from Galen Growth’s long-established and unmatched curated community of investors, corporate leaders and innovation teams and other essential stakeholders through our proven multi-channel tools. For more information, visit Galen Growth’s HealthTech Cohort webpage or read this article on the launch of the Galen Growth HealthTech Cohort.
Read our previous interview with Abhishek Shah, CEO & Co-Founder of Wellthy Therapeutics here.
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