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Sylvana Quader Sinha: The Healthcare Challenge, Evolution of Praava Health, and Deliberate Organization

In her third appearance on Future Startup Interview, Praava Health Founder and CEO Sylvana Quader Sinha joined Ruhul Kader to talk about all things healthcare in Bangladesh, Praava Health, the future of digital healthcare services, and organization building. They discuss Bangladesh’s healthcare system, the state of private investment in healthcare, what are the fundamental challenges of healthcare in Bangladesh, her lessons in building healthcare services in Bangladesh, Praava Health’s current state of operation, priorities, strategic direction, Praava’s expanding universe of digital healthcare services, how Praava has built a healthcare brand that people trust, Praava’s challenges, profitability, moats, and short-term plans, the prospects and future of digital healthcare services, innovations in the healthcare space, Bangladesh’s healthcare policy and building a humane healthcare system, her lessons in being intentional about creating your organizational culture, he favorite business book, why young people should prioritize learning and much more. 

Mohammad Ruhul Kader

Thank you so much for taking the time to speak with me again. I'm super excited to talk to you after a long time.

Sylvana Quader Sinha

Great, good to see you.

Understanding Bangladesh’s healthcare system 

Ruhul Kader 

The first question is about the healthcare industry in Bangladesh. You have been building a healthcare company with a vision to deliver high-quality healthcare services in the country for almost eight years now. Quality healthcare remains a challenge in Bangladesh. There is an insufficiency of healthcare professionals, and it is expensive for many people. People have many complaints about the poor quality of healthcare in the country. Where do these challenges come from? How can we solve these challenges in our healthcare system in the country?

Sylvana Q Sinha

The challenges are tremendous. I think every country in the world faces challenges when it comes to delivering healthcare to their communities. That reality was starkly on display during the pandemic, when very few countries were able to serve their communities as well as they deserve. Even those that managed to contain COVID-19 are still facing criticism for their approaches.

It's important to put this into context because I think in Bangladesh we sometimes tend to feel that our problems are bigger and more profound than anyone else's. But the challenges of healthcare exist all over the world.

What's very interesting is that in the last 20-30 years, we've seen the rise of a really strong and robust middle class in Bangladesh. Poverty levels have reduced dramatically in the last couple of generations. And as you have an increasingly middle-class population in a country that is now deemed a lower middle-income country, the challenges evolve.

The challenge changes in a number of ways. First, we are no longer facing the burden of infectious diseases, which was traditionally the biggest threat to mortality in this country. Now, non-communicable diseases (NCDs) are posing a greater threat. Some of the leading causes of mortality in the country are diabetes, heart disease, lung disease, cancer, and chronic kidney disease.

On the supply side, we are seeing a reduced dependence on aid. There is less aid flowing into the country because of economic growth.

The health sector itself has been growing at a compound annual growth rate (CAGR) of more than 10% for the past 10-15 years. It is projected that the per capita healthcare spending will be 5x by the end of 2040. So, health spending is increasing, aid dependency is decreasing, and the government is not increasing investment in healthcare in terms of its annual budget, even at the rate of inflation. This creates excess demand and also an opportunity for the private sector to make more investments. I would say that's a massive opportunity. We all need to invest in expanding our services and scope and reach, not only in the cities but beyond. That requires investment.

As startups operating in this space, we are hungry for more options for investment to help us scale our businesses. And that remains a challenge - venture capital has not come in any meaningful way to Bangladesh’s health sector. At different levels, that's a challenge across emerging markets globally.

During and after the pandemic, we have seen a lot of investment in healthcare, but the vast majority of this investment has been in the United States. This is despite a lot of rhetoric about how integrated the world is, which this pandemic made us realize, and how we need to invest in building resilience in healthcare systems. However, we do not really see these investments happening at the level that I would like to see them happening, not just in Bangladesh, but I would say across emerging markets.

Another trend that I'll highlight is the role of venture capital in healthcare. Healthcare is hard. The "move fast and break things" approach of traditional venture capital doesn't work in healthcare. Healthcare takes a longer time. It involves earning patient trust, which happens one patient at a time. It also involves earning the trust of communities, which takes a long time to earn. This concept of moving fast and breaking things doesn't work in healthcare. If you break things in healthcare, people die. So you need to move at a reasonable pace. And venture capital is not always prepared for that.

This is especially true when we look at the journey of venture capital into emerging markets. For example, we've seen a number of big players come to Bangladesh in the last few years, such as Tiger Global and Sequoia Capital. It's great to see them getting acquainted with and seeing the opportunity in our market. However, they're not investing in healthcare. And that's true across all emerging and frontier markets. The journey of venture capital into emerging markets does not start with healthcare. It starts with fintech and e-commerce.

The state of private investment in healthcare 

Ruhul Kader

Why do you think that is the case in terms of venture capital or general investment not happening in the healthcare sector? One reason you mentioned is that healthcare doesn’t work like software companies. You can’t really move fast and build things, which is something VCs would like to see. That probably is one of the reasons, but are there any other reasons?

Sylvana Q Sinha

I don't think they're making a conscious choice not to invest in emerging markets. Well, sometimes they are. For example, we have heard from large established VCs that they might invest in a business like ours in other markets, but not yet in Bangladesh, because they're new to the market. When the venture capital community enters a new market, they generally start with more asset-light businesses. Businesses like fintech, e-commerce, and ride-sharing don't need the infrastructure that healthcare inevitably needs.

Ruhul Kader

I think Bangladesh is in a precarious position in terms of attracting global investment. The country is caught between Southeast Asia, India, and the MENA region. Few funds have a specific mandate to invest in the country. This is the challenge the country faces. However, if you want to change the situation where investors are taking the healthcare sector seriously, what can be done to change that?

Sylvana Q Sinha

I think it is changing. I mean, just the fact that these venture capitalists are entering our market is a big thing. I have been working in this business for more than eight years now, and I moved to Bangladesh for the first time in my life to start this company. I have seen the shift in the market and the reactions when I meet with investors and say, "I'm marketing the Bangladesh opportunity." So it is definitely changing. It is just about education. A lot of the feedback I get when I visit Singapore, for example, or even London, is not that people think bad things about Bangladesh as an investment opportunity. It is more that they just don't understand it. So I feel like part of my personal responsibility, like all of us as founders operating in this space, is to educate people on the opportunity. And I think that is happening slowly but surely. Entrepreneurs like Kamal Quadir, the founder of bKash, are pioneers. Their success will hopefully lead to more success in this market.

On understanding the challenges of healthcare in Bangladesh 

Ruhul Kader

Going back to the challenges of healthcare in the country, many people complain that the quality of healthcare in Bangladesh is not up to the mark. This has given rise to a trend where people seek healthcare in neighboring countries like India and other markets. What do you think about this complaint? If it is true, then how can we address those challenges?

Sylvana Q Sinha

I do think that it's true. There is a gap in terms of access to quality healthcare in this country. And again, that's not something that's specific to Bangladesh. Across low- and middle-income countries, the leading cause of mortality is lack of access to quality healthcare, not just lack of access alone.

In terms of what can be done, I would implore the government to take a more proactive role in regulating facilities that are not providing quality care. Particularly, I think we see this issue in the field of diagnostics, where there are many labs that are not implementing the most ethical practices when they're drawing patient samples. Some of them are not even running the samples before offering results to patients. I think the government can do more there. They have done a lot, but I think they can do even more to regulate those types of cases and practices.

But I think that, again, we need more investment. It's hard. We need to invest in quality care, quality facilities, quality machines, and in training our people. It's not just the machines; you have to train the technicians, you have to train every person who interacts with a patient, particularly the medical and clinical professionals in the protocols for how healthcare is delivered. All of these things require investment. So we certainly need more investment to improve the quality of care in this country. There is no doubt in my mind that this is an issue. 

At the time that we entered the market, there were four international standard labs for a country of 170 million people. Now there are six, including Praava Health. This is still far too few.

On a per capita basis, India has 55 times the number of international standard labs as Bangladesh. And India doesn't have enough either. So the need is tremendous. The absence of reliable quality diagnostic testing is a big reason why a lot of patients feel they're suffering from misdiagnosis. In many cases, to be honest with you, they end up blaming the doctor for that. It's not necessarily the doctor's fault. If they cannot rely on the quality of the test, then there's no other option.

Ruhul Kader

That's an interesting observation. Another question people ask about healthcare is that it is very urban-centric. If you look at the distribution of doctors and hospitals, quality doctors and quality hospitals are mostly concentrated in some of the major metropolitan areas in the country. People who live in villages and remote places need to travel to Dhaka or Chittagong if they want to access good quality healthcare. Why is that the case? How can the country decentralize quality healthcare and ensure that everyone has access to similar quality care across the country?

Sylvana Q Sinha

Again, I think it goes back to standards and regulations. I think it is necessary to standardize care. Unfortunately, the private sector cannot achieve these things alone.

Ruhul Kader

The final leg of this set of questions is the cost of healthcare, which has been rising consistently. People talk about out-of-pocket healthcare expenditures. You have rightly pointed out that we have a growing middle class and disposable income has been rising. Those things are true, but at the same time, many people find that when they face a major healthcare challenge, it wipes out their savings and they fall back into poverty. Do you see this as a policy problem? How do you see these kinds of challenges? What are your thoughts on that?

Sylvana Q Sinha

I think it would be wonderful if we had more options for health insurance in this country. As you said, I think the number one reason a family falls back into poverty is a health incident. In the absence of some kind of national insurance scheme, this will be very challenging. However, there is a role that the private sector can also play. There are private insurers like Green Delta and others in this country that are offering health insurance, but it's still less than 1% of the population that has it. This means that it is only serving a very elite population. The care that does exist is often catastrophic care, and the deductibles remain fairly high.

Therefore, I think we need to develop the insurance sector. A lot of this also requires more data, as we need more reliable mortality and morbidity tables. However, I think that these things will come if we develop other areas. It remains challenging to access a permit to become an insurance provider, and I think that's one area that the government could potentially help to make a little bit more accessible. Overall, the sector needs more players to provide more competitive options to the broader population.

Ruhul Kader 

That's an interesting observation. I really wonder why there aren't more insurance schemes in Bangladesh, either through the government or the private sector. The economy has been growing consistently for the last couple of decades, and per capita income has been rising. So what do you think, why hasn't this happened yet?

Sylvana Q Sinha

Yes, it does remain a challenge. However, I don't think Bangladesh is that far behind its peers in terms of the development of the insurance sector. India, for example, has a 10% saturation of insurance, and India is about a generation ahead of Bangladesh in terms of the maturity of the healthcare sector. I believe that we need to go further in that direction.

I think one of the reasons that the sector is not developing is the lack of available data. As we have a changing population, a more middle-class population, we need more data on that population, on their healthcare, health-seeking behavior, and health challenges. We need more data to support the mortality and morbidity tables.

There is also a scarcity of talent. There are only a handful of actuaries in this country, which is another challenge. Actuaries are needed to do this analysis and build the risk models for the insurance companies. That, I think, is another piece of the puzzle.

Again, the situation is changing and evolving. Perhaps, we need to introduce more incentives and more ways to develop talent and have access to that data. Praava, for example, has a large repository of data. We have served more than 500,000 patients to date, and I think we probably have one of the more sophisticated digital solutions for data. We believe that there are opportunities that are emerging from that data size.

On lessons in building healthcare services in Bangladesh

Ruhul Kader

From your journey over the last eight years, what have you learned about healthcare, healthcare solutions, and building healthcare services in Bangladesh?

Sylvana Q Sinha

I think it is important to keep the patient at the heart of any solution that you are trying to offer. That has always been our approach to solving this problem. I am not a doctor, and I actually never worked in healthcare before starting the company. So I always connect to it from the patient's perspective. I think that has defined the way we have tried to approach creating a solution.

Of course, you need doctors at the table, you need science, and you need that perspective to help guide us. But I think that no matter what, we are always trying to create a solution for the user, which is ultimately the patient. And I think that has guided us to build a company that is serving the needs of this country and this community, at this moment in time.

We believe that what has allowed us to grow at the rate that we have been able to is that we have focused on one patient at a time. I truly think that you earn the trust of patients, one person at a time, and trust is also lost that way. We are constantly trying to invest in and retain that trust.

The state and ambition of Praava Health 

Ruhul Kader

Now, I have a couple of questions specifically related to Praava Health. In a 2018 interview with Future Startup, you shared two goals for Praava Health. You said, "I wanted to improve trust in the system and help patients feel that they were being heard and taken seriously. And number two, I wanted to offer quality diagnostic testing so that people didn't have to double, triple, or quadruple check their test results for accuracy, even sometimes traveling abroad in order to do so." Where do you stand today in terms of those ambitions?

Sylvana Q Sinha

Thank you for reminding me of that. I love hearing that actually. I feel that we are doing both. We are trying to restore trust. I can't really say if we have done that, I think that's for the patients to tell us whether we have earned their trust. But our best measure of that is whether they are coming back to us. They come once and they come again, and we're finding that they are doing that. Even during and after the pandemic, when a lot of patients avoided going to the doctor, we still found that we had a relatively higher retention rate. Our net promoter (NPS) score is also consistently 85-90, higher than most Fortune 500 companies, and significantly higher than healthcare companies where 30 is considered a high score.

I think, certainly, we have built a quality lab. We are one of six international standard labs in this country. We have ISO accreditation, and we are very close to getting accreditation from the College of American Pathology (CAP). I really believe that we need to continue investing in the quality of that lab, something that we do every day. But it's great to be reminded of that.

I think we have always tried to stay true to the original reasons that we came to start this company and what brought us here. In fact, we just had a management retreat, which was a great opportunity for us to reflect on those things that originally brought us here and help us to reconnect with that.

Ruhul Kader

Can you give us an overview of the company today? When we last spoke in 2018, I believe you had one facility in Banani. You were considering expanding to more facilities across the country. You had a lab that could run over 250 tests. I think you were a team of 160 people. How much has the company evolved over this time in terms of the products and services that you offer? 

Sylvana Q Sinha

We still have one flagship center. We also have more than 40 collection points across Dhaka, and even outside of Dhaka, where patients' samples are collected. The samples are then sent to our international lab in Banani for analysis.

We have also rolled out a lot of home services since we spoke. The pandemic played a role in the launch of these services. We already started doing home sample collection in 2019, but that has scaled up dramatically. We have also rolled out telemedicine and e-pharmacy, and a new product called ghorelab which guarantees to anyone within Dhaka that you can have your sample collected within 5 hours of placing a booking, and it will be analyzed in our world-class lab.

We have a new version of the app that will be coming live in the next few months. We are excited to launch it because all of our digital products will be live on that one app. Currently, they are not all on the app, although we have had an app since 2018.

We have served more than 500,000 patients to date. We are still raising funds to scale up the business and have more centers. We want to stay focused in Dhaka over the next three years and then expand to Chittagong and other cities.

Ruhul Kader 

Can you give us some numbers, such as the size of the team, and, if you are comfortable, a bit about the business overview?

Sylvana Q Sinha

We have more than 350 people on our team right now. Most of them are front-facing healthcare workers or lab technicians. We also have a sales force, as well as people at the office who work in tech, product, and medical services administration.

We have an amazing team. We're very lucky to have them, and I'm very proud of them. Those are some of the high-level details. Our flagship center is an 11-story building in Dhaka. The first six floors are all patient-facing, the seventh and eighth floors are the lab, and the upper floors are our corporate office and cafeteria.

On Praava’s expanding digital healthcare services 

Ruhul Kader

You have launched and expanded a number of digital healthcare services over the last few years. As you mentioned, you are about to launch your new app. Could you talk about those initiatives and how they have changed Praava as an organization?

Sylvana Q Sinha

The vision of the business was always to provide high-quality healthcare experiences, both in the clinic and remotely through what I call a click-and-brick model. We always had the vision to roll out telemedicine, but the plan was not to do that until 2021. Of course, when the pandemic hit, we were forced to accelerate our plans. We rolled out telemedicine at the end of March 2020. In fact, we were the first private provider to partner with the government on its 333 COVID hotline. We are proud to have stepped up to do this, and we then started rolling out the product for ourselves and for our own patients. Shortly thereafter, we also rolled out our e-pharmacy in May 2020. This is basically on-demand drug delivery, and we still offer it to this day.

I believe we are one of the largest providers in both telemedicine and e-pharmacy in Bangladesh to date, which mostly means that there is not much competition. I think we need more competition in that space.

What we are excited about in terms of our digital services and how it has affected our model is that standalone digital health providers sometimes face a challenge in retaining patients because most of us interact with healthcare through both virtual and remote services and clinical care. Occasionally, we need to see a doctor, be examined, or have a sonogram or X-ray.

For us, we are able to meet the patient where they need us most. If they are at home and their daughter has a rash, they can do a telemedicine visit to show the rash to the pediatrician. The pediatrician can then either say, "Your child needs such and such treatment. We'll send the medication home for you." Or, "I need to examine her. Please come to our location." This serves as a great triage tool.

Because we have both the infrastructure and the technology, we have the option of doing a telemedicine visit, taking the call that "I need to see this patient," and then inviting them to come to our facility to be examined. We believe that these interactions are really important and have helped us to serve our patients with an end-to-end solution — which also leads to increased retention rates.

Ruhul Kader

If you see digital health services independently, what kind of responses are you seeing? 

Sylvana Q Sinha

We have had incredible feedback from our patients. I think at the height of the pandemic, 50% of our services were remote or virtual. This really allowed us to expand the breadth of these types of services that we were offering. And even to this day, it allows us to do that.

We have been able to reach patients all over the country through our telemedicine products. We also offer corporate hotlines for corporate clients that might have a factory or power plant in a remote location from Dhaka. We have been able to serve those people, and in some cases, they have traveled to Dhaka to meet their doctor and have in-clinic conversations with the doctor they may not have met that way. For us, it has allowed us to serve a broader segment of the population and reach communities that we weren't able to before.

Ruhul Kader

You have a membership service, and I believe you offer three different types of memberships. How is that going?

Sylvana Q Sinha

The membership model is doing well. We find that it has the most uptake among chronic disease sufferers, who really understand the need for ongoing care. The concept of preventive care is still a new one for Bangladesh. So, a lot of people are still not necessarily ready to invest in preventive care, but it's picking up and it's changing. I would say it is evolving over the years.

We have a number of membership products. We have annual subscription plans whereby you pay a flat rate for unlimited access to services. The price point starts at about 350 taka and goes all the way to 3,600 taka. The most expensive plans are for the sufferers of chronic diseases who need more testing on an ongoing basis. We also have unlimited plans and telemedicine visits. Those can be family plans and they range from one month to three months to annual subscriptions as well.

On building the Praava brand 

Ruhul Kader

Praava, as you mentioned, has always tried to build trust in your patients. I think you have been to some extent successful in terms of building a brand, which people see as a quality provider. Although you serve a specific segment, people see it as a trustworthy organization. And also you have as an organization grown significantly, as you mentioned, you have served 500,000 customers over the last couple of years. What are some of the things that have worked in terms of growth and building that brand?

Sylvana Q Sinha

One thing that I have to say is very important is pivoting when you need to pivot. I think that is one thing we did very effectively during the pandemic. We pivoted to roll out virtual products and remote care products. We pivoted to become one of the first private testing providers for COVID tests and were pioneers in coming to patients’ homes for convenient COVID testing. We pivoted to serve our community as we understood the community's needs. I think that's one of the things that really helped us in earning the trust of our community.

The other thing is really trying to communicate with our patients regularly and really trying to understand what their needs are and anticipate what their needs may be. Now that we're finally living in a post-pandemic world, which I think has only happened in the last six months, I think patients are starting to re-engage with healthcare. And so we're really trying to meet them there and figure out their needs. You may not have been to the doctor in a few years. What is it that we can do to serve you best? Even on the marketing side, it's really about listening to patients and trying to understand and anticipate what their needs are and being very adaptive. I think that's important in any industry.

I think that the ability to maintain your agility and to listen and pivot as needed is always critical.

On Praava’s challenges, profitability, moats, and short-term plans 

Ruhul Kader

What are some of the biggest challenges for Praava?

Sylvana Q Sinha

We are trying to raise funds, and it is a very challenging global financial situation now, of course. So that is a challenge that I think every startup that you will chat with is facing. Because we are really eager to scale the business and serve a bigger segment of the population.

Almost every day, we get multiple calls to our call center asking us, "When will you be serving Mirpur? Or when will you be coming to Dhanmondi? And when will you offer this service or that service?" We definitely want to start doing that.

However, we are also very happy with the way that the business is progressing and growing. In the absence of being able to raise funds, we are also comfortable to continue to grow sustainably as the world and our country face certain economic challenges. The good news is that healthcare is relatively recession-proof. So we are not seeing massive shifts in demand for our services, which is great.

Ruhul Kader

In 2019, you mentioned that you wanted to build a profitable business at least in the short run. How are you doing in that regard?  

Sylvana Q Sinha

The unit reached profitability within the first year, actually. So, the unit has been profitable. Of course, we've had ups and downs due to the pandemic, and ups and downs in demand. We faced various challenges, which many of you know about, but we're doing pretty well, I would say.

We've proven the economics of the business. That's why we're not as anxious about raising money. We don't need to raise to survive in the way that many startups may need to.

Ruhul Kader

We briefly talked about the differentiating factors for Praava from other healthcare providers in the country. However, I want to expand on that. Healthcare services remain insufficient, and there is room for many more service providers. Similarly, in Dhaka, you see lots of private clinics and diagnostic centers popping up every day. What are some of the sustainable long-term moats for Praava?

Sylvana Q Sinha

The demand for healthcare is growing, as I mentioned earlier. The compound annual growth rate (CAGR) is 10%, and health spending is expected to grow 5x over the next decade. There is tremendous excess demand in the market. For us, I think the more aggressive growth that we seek is to grow faster than the market as a startup. And I think we are being able to achieve that. And I like to believe we will continue to be able to achieve that by providing an elevated patient experience, a patient experience that is different from anyone you will experience anywhere else. And that means being treated with dignity and respect, getting to spend time with your provider, getting access to providers who are practicing protocolized, international medicine, and being able to trust the quality of the drugs that you buy in our pharmacy. Our pharmacy is one of 600 model pharmacies, which means that you can guarantee that the drugs have been procured from the manufacturer, and you can guarantee that there is an on-site pharmacist at all times.

Our lab, again, as I have mentioned, offers a high standard of quality of care. We are also, I think, the only healthcare provider that is providing both in-clinic services, as well as virtual and remote services, and has its own app as well. We just got on TikTok. I think we are the first healthcare provider to be on TikTok. We always try to be innovative and differentiate ourselves. The world is constantly changing, and it is our responsibility to try to stay as much as possible one step ahead of the game.

Ruhul Kader

What are the plans for the next three-four years, and what is the long-term ambition for the company? 

Sylvana Q Sinha

A lot of it depends on fundraising. But it is our vision that within the next five years, we will have served more than 5 million patients within Dhaka and beyond. That's basically our plan. We would like to expand initially within Dhaka and then move to Chittagong, while in parallel rolling out our remote virtual care services, which we project will be a majority of the services, by the end of 2027.

On the prospects and future of digital healthcare services 

Ruhul Kader

That was the last question about Praava Health. I have a couple of questions about digital health initiatives and digital healthcare services in the country. I wanted to get your opinion on those things. What is your take on overall digital health services in Bangladesh? The kind of response you mentioned that you have been receiving for Praava, that's really encouraging. There are a couple of healthcare companies that are trying to build digital-only healthcare services. Do you think digital healthcare services can become a viable alternative to in-person in-premise services?

Sylvana Q Sinha

I don't think it's an alternative. I think it's a supplement. I think it's an amazing and incredible supplement.

In terms of the landscape, it's exciting to see some of the digital health providers that exist in Bangladesh. However, I think the ecosystem is still quite immature. We're at a very early stage. I would love to see more innovation and more excellent founders emerge. There are incredible people who have been around for a while, whose businesses are starting to reach a different level of scale. And then there are newer players in the market who are doing interesting things.

I think we all need more capital to help us reach the next level. I certainly hope that a lot of these businesses will survive through the next challenging few months and probably the next year in the global financial markets. But I think the opportunity is huge. And I'm very, very excited to see how the next few years pan out.

Ruhul Kader

Telemedicine has been around for a while in the country, but in terms of adoption, if you look at the numbers, do you see telemedicine and similar services going mainstream anytime in the near future?

Sylvana Q Sinha

I actually think that telemedicine is fairly mainstream in the cities and to some extent outside of the cities. The problem is that this country suffers from a huge lack of trust when it comes to healthcare. And so people still prefer to be seen in person. However, telemedicine certainly provides a fantastic opportunity to be able to see a doctor in the absence of being able to travel and if you don't have time to go visit a facility.

The challenge in telemedicine all over the world is that it is hard to differentiate one product from the next. So, if you are starting a telemedicine business, I would make sure there is something really different about the product that helps you stand out. It could be integration with remote care management, integration with remote diagnostics, or other tools. However, I think it is important to understand from a business perspective how you are going to differentiate yourself. But I definitely think telemedicine is here to stay. At what level it is here to stay is still yet to be seen.

Ruhul Kader

There are always discussions around innovation in healthcare. What are some of the exciting trends and innovations you see in the healthcare sector, not only in Bangladesh but across the world, that people should look into?

Sylvana Q Sinha

Well, I actually think we are seeing a rise in models like Praava that are combining technology and infrastructure in a meaningful way, which is very exciting to see. For example, recently One Medical was acquired by Amazon, and Amazon is making a big bet on healthcare. One Medical is an integrated brick-and-click model very similar to Praava's, in terms of the clinics aspect. This is a very exciting trend that we are seeing globally.

Again, it is taking time for this trend to trickle down into emerging and frontier markets. However, I believe that this trend will continue. And so that is a positive thing.

I also think we are seeing some really interesting innovations in terms of the addition of mental health services into primary care in a more mainstream way, which is so important. I was meeting Dr. Ashique Salim, the founder and managing director of the Psychological Health and Wellness Center, which is a Sajida Foundation interest. I was so thrilled to hear from him that when I first moved to Bangladesh seven years ago, there were 200 psychiatrists in the country. Today, there are 600. So the supply side is improving; it has doubled. The fact that more doctors and more medical students are choosing to specialize in psychiatry is a reflection that there is more appreciation for it. And I think there certainly is demand.

I think the demand for it has also grown, even as we see it. We also provide counseling and psychiatry services. We also see that it has become much more accepted and understood that mental health is part of our overall health. That's another really positive trend that I would say.

I will say that there is a lot of talk about the need to invest in pandemic preparedness. And I do think that there is a need for that. However, I think NCDs pose the biggest threat across emerging and frontier markets to our populations. And for that, we do need more investment in primary care, diagnostics, and in the basic tools that you need to detect, manage, and prevent chronic disease. 

On healthcare policy and building a humane healthcare system 

Ruhul Kader

What are some of the changes that you'd be very happy to see in the healthcare sector in Bangladesh?

Sylvana Q Sinha

We would love to see more competition in the market. We would love to see more providers that are investing in quality care and investing in creating better experiences in health care for patients. I think you know, that's a very lofty high-level goal perhaps. But I think that's what I'd love to see. 

Ruhul Kader

Healthcare in many places around the world is a private-public thing. Governments across the world play an important role in healthcare. What are some of the policy changes that you think would make a big difference in our healthcare sector?

Sylvana Q Sinha

I will say two things. First, I think the government can play a leading role in terms of regulation and managing the quality of healthcare services that are provided across the country by both private and public providers. Second, I would say that when it comes to patient privacy, we would love to work with the government on helping to establish standards around patient privacy. So, that's definitely an area where we would look to the government for leadership, but would be thrilled to contribute.

Ruhul Kader

Can you talk about the dynamics of healthcare services, particularly private-sector healthcare services? If we break down the healthcare service from a business perspective, what are some of the cost centers, and where does the money come from? How does that work? As we were talking about, quality healthcare remains expensive for most people. Hospitals that provide quality service are very expensive and out of reach for a significant percentage of the population. Is it possible to offer quality private healthcare services to a large number of people at an affordable price? Can we really bring down the cost of high-quality services to a level where it is accessible to more people?

Sylvana Q Sinha

I certainly think it's possible. I believe we have an affordable solution. However, providing it for the masses has to be at a different price point. It has to be more affordable. I think the government can play a role in subsidizing services. In many cases, they did just that during the pandemic.

The cost center is really the infrastructure cost. There's an upfront investment required in delivering healthcare services, whether it's equipment or space. Every clinic requires at least space. 

There are options, but there need to be more alternative financing mechanisms or deferred payments to incentivize investors and entrepreneurs like me to set up facilities. I think that's one of the areas where the government can also potentially offer leadership. There is a facility called Upass, which gives you a one-year grace period before you have to repay a loan on equipment financing. So there are such options in place. But I think even more types of flexible alternative or blended finance instruments would be beneficial for the market.

However, I think the challenge of providing quality healthcare at scale to the masses is one that every country faces. The countries that have done the best at it are probably the Nordic countries, but their populations are different. They don't have anywhere close to the population density that we face in Bangladesh and across Asia and across most of the world.

There are various other models we can look to for inspiration. However, we also have to figure out what makes sense for our populations at this moment in time. One of the things that makes it challenging is that we have increasingly middle-class lifestyles. Again, a focus on preventive care can also be led and inspired from the top and really at the policy level.

On lessons in organizational culture 

Ruhul Kader

Praava is one of the companies we look up to when it comes to culture discussion. What are some of the important lessons you have learned in terms of building a high-quality organizational culture?

Sylvana Q Sinha

One of the books I read when I was founding the company was called "Patients Come Second". The idea was that employees come first, patients come second, and profits come last. In fact, if you order your priorities that way, you will end up making your patients happier and having higher profitability than your peers. I truly believe that.

So we have always chosen to invest in our employees. That means appreciating them as human beings at a very personal level, and it also means investing in their development as professionals and trying to help them grow and mature as much as they want within our organization and even beyond.

I think we've also been quite thoughtful about culture. We developed a culture deck fairly early on, where we talked to some of the early team members to find out what attracted them to this business, what they believe defines us as people and as a team, and what brought us together to build this dream. We would continuously revisit and check that. Because culture is also a living instrument that evolves and grows over time. We've been through a lot of hard times together as an organization, which helps to solidify you. 

Overall, I think it's something you have to be thoughtful and intentional about. As an entrepreneur, when you invest in your culture, it comes back to you in spades and is really important for the success of the business.

Ruhul Kader

I think it's easier to have some sort of control over your culture in the early days when you are a small team. However, as an organization grows, it should get challenging. What kind of cultural challenges do organizations face when they grow?

Sylvana Q Sinha

The challenge of culture is huge. When you're 12 people sitting in a room at one table together all day, that's one thing. But now we have 350+ colleagues.

I'll tell you what I do. Yes, we've tried to build systems. We have a culture deck, and we have a program for introducing employees to our culture. But I also personally conduct hospitality training every few months for all the people who have joined the company in recent months - from doctors to security guards to engineers. I personally get to meet them, and I personally get to tell them what inspired me to start the company, what drives me and motivates me to be here, and I ask them why they come to work here. Everyone has many options about where they can work, but they chose to come here for a reason. So helping them to connect to that, helping them to understand their role and our broader vision of building patient experience in Bangladesh, is still very important to me. Maybe when we get to 4,000 people, it won't be as easy, but we're still doing it, and I'd like to still do it for as long as I can - because I really personally enjoy it, and think it’s impactful.

There are also systems that you can build. The idea of Praava is really one of empowering every single employee to take accountability and ownership of our challenge of the patient experience. This concept of adaptive leadership that Ron Heifetz teaches at Harvard is that every single person needs to be a leader in whatever their role is in the organization. It could be the security guard or the cook in the kitchen. But everyone has a role to play in this.

There's an anecdote that I always think of. Apparently, when President John F. Kennedy was visiting NASA, there was a gentleman who was the cleaner, and he asked that young man, "What do you do here?" And he said, "I'm helping a man go to the moon." And that's right. If the floor isn't clean, then NASA's mission couldn't be achieved. Every single person plays a role. I think connecting individuals to that is our biggest priority when we're onboarding new employees and when we're keeping them engaged.

On books, what else? 

Ruhul Kader

A few books you would like to recommend to our readers. 

Sylvana Q Sinha

There are many books I would recommend, but the one that I really think founders in Bangladesh should read is “Out-Innovate”. The subtitle is: “How Frontier Market Entrepreneurs Are Changing the Rules of Silicon Valley.”

One mistake that I sometimes think local entrepreneurs make is that they try to adopt the Silicon Valley model of startups, which might only work in Silicon Valley. I think that the book highlights this and that when you're operating a business in a frontier market, you face very different challenges. You walk into a coffee shop on Sand Hill Road in Silicon Valley, and there are 18 developers sitting around. That doesn't happen when I walk into a coffee shop in Dhaka. You don't have the same access to talent, and you don't have the same access to capital.

The argument of the book is that we should stop focusing on building unicorns and instead focus on building camels. The author's point about camels is that they are more sustainable and more resilient. So those of us who are operating in frontier markets should focus on building sustainable, resilient businesses. The concept of growth at any cost may be feasible in a market where there is unlimited access to capital and human capital, but it's less feasible in our markets.

We all have to figure out the economics of our businesses, and that will eventually allow us to stand the test of time. 

Advice for young people 

Ruhul Kader

Advice for young people. 

Sylvana Q Sinha 

I always say, to pursue the opportunities that allow you to grow and learn at the rate that you know you're capable of, no matter what those opportunities might be. That could be starting a company, working in a business, or working for a large company. It could be anything, but that should be your guiding light. Don't just go work for an MNC that pays a lot.

I understand that finances are real, and we have to look at the value of the package. But assuming that is managed, I think you should look for the opportunity that will allow you to grow and learn, and get closer to what you want your life's work to be.

Ruhul Kader

That's excellent advice. I think this is an excellent place to end this conversation. Thank you so very much for doing this interview with us. 

Sylvana Q Sinha

Thank you so much, Ruhul. It's great chatting. 

Originally published on Jul 30, 2023. Rereleased on Jan 29, 2024.

Mohammad Ruhul Kader is a Dhaka-based entrepreneur and writer. He founded Future Startup, a digital publication covering the startup and technology scene in Dhaka with an ambition to transform Bangladesh through entrepreneurship and innovation. He writes about internet business, strategy, technology, and society. He is the author of Rethinking Failure. His writings have been published in almost all major national dailies in Bangladesh including DT, FE, etc. Prior to FS, he worked for a local conglomerate where he helped start a social enterprise. Ruhul is a 2022 winner of Emergent Ventures, a fellowship and grant program from the Mercatus Center at George Mason University. He can be reached at ruhul@futurestartup.com

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