Chronic Care in India

CHRONIC CARE
SOLVING FOR THE PERVASIVE

CHRONIC DISEASE SCOURGE IN INDIA
Digital health, by many, is still considered a nascent sector. However, in several
ways it has already proven to be a fast-growing, and a valuable space.
Recently, in digital health, Teladoc and Livongo deal created a combined entity
worth $38B, a proof that the space is no longer nascent and has tremendous
future ahead.
Livongo is a health-tech company that provides a set of tools, analytics, and

coaching to manage diabetes. Prior to the acquisition, Livongo was clocking
115% YoY revenue increases, valued at over $11B in the stock market. The
value proposition to customers was a no-brainer. With Livongo, diabetic
patients could get high-quality, real-time tracking and feedback, that would
improve their healthcare outcomes and reduce their medical costs.
Beyond public companies, VC-backed private Digital Health companies have

created enormous value across US, UK, and China.
Chronic Care
Solving for the pervasive chronic disease scourge in India
In India too, lack of access to quality healthcare is a mounting problem. The
overall healthcare spend in India stands at $140B+ annually, growing at
15% CAGR.
Digital penetration in Healthcare in India is still low. At a ~$5B market size,

digital health accounts for <4% of the overall market.
As shown below, across metrics for effective healthcare delivery, India

substantially lags global standards. We believe that technology can play a key
role to bridge the gap, and that the time for Digital Health in India is not
tomorrow but here and now.
$140B
Annual healthcare spending
10% 2.5 3.3

$85
3.9% 0.7 0.6
Healthcare Per Capita Doctor- Hospital Beds
Expenditure Healthcare Patient Ratio (per 1000)
(%GDP) Expenditure (per 1000)
MATURE ECONOMIES INDIA 27% 62% 75%

Source: World Bank, The Hindu, The Mint, Bain
Health Insurance Out of Pocket Private hospitals

Coverage Expenditure (2018) (% of total hospitals)
Chronic Care
Within digital health, solving chronic care challenges using technology can be
a massive opportunity. High stress levels and improper diet are leading to a
marked increase in lifestyle and chronic diseases. WHO predicts ~70% of
deaths in India by 2030 will be due to chronic diseases. Chronic conditions
lead to ~40% of all IPD cases, and ~80% of e-pharmacy sales.
Indian Chronic care market is unique and substantially different from the US
market. Following are the prominent challenges in India:
Willingness to pay
While India has 70M diabetic patients (2.3x of US), they have a very low
willingness-to-pay. To put this in perspective, diabetes devices market in India is
$800M growing at 1.5% CAGR, versus US which is at $9B and growing at 9% CAGR.
Thus, despite being essential products, their adoption is dismally low. This is also
evident in a high ~60% patient drop-off from chronic disease incidence to
treatment. Primary reason is India's out-of-pocket healthcare expense is 62% of
total versus 11% in the US, making it expensive for middle-class India.
Market organization
US is a highly organized market when it comes to healthcare professionals. Through
formal organisations like ADA (American Diabetes Association), or businesses, one
can reach out to 10K+ diabetologists in a capital-efficient manner. In India, there is
a lack of similar platforms, making the process inefficient. Simultaneously, startups
who can crack these partnerships at scale, create as strong moat. Share of
organised players across pharma retail, healthcare delivery, and diagnostics is
<10% in India, v/s ~60% in US and China.
Chronic Care
Wary of the opportunities and challenges, entrepreneurs are taking different
approaches to solving chronic care. To develop and refine our understanding of
the space, we asked the question below on LinkedIn and Twitter:
We received overwhelming response and made a promise to share our

insights and inputs. Sharing below a sample of the responses we received -
Chronic Care
From the responses we received, and the ensuing conversations we had, we
realised the below -
Chronic diseases require a comprehensive approach to treatment and

management that spans across various lifestyle choices such as dietary
habits, exercise, mental wellness, along with tracking and clinical
solutions.
In order to create and capture massive value, a chronic care platform

needs to deeply integrate with various stakeholders - hospitals, clinics,
insurance companies, and employers. While being tough to crack, these
partnerships can become a strong moat.
Chronic Care
Case study
of a
comprehensive
and successful
healthcare platform
The Ping-An model
Established in 2015 and having gone public on the Hong Kong Stock Exchange
in 2018, Ping An Good Doctor’s services span health mall, consumer
healthcare, online medical services, and health management and interaction.
With revenues of ~$600M and 60M DAU, Ping An currently has a market cap of
~$15B, achieved in under 5 years.
At the core of Ping-An's healthcare services is a network of partner medical

institutions, hospitals, medical professionals, and pharmacies, which is scaling
exponentially with more partnerships.
Health
Management
Health
Management Health Mall
Outpatient Chronic
Service Care
Health Chronic Outpatient
checkup Fitness
patients visits
market
Express Appointment Chronic
& inpatient illness Weight loss
Drug Delivery
arrangement management
Oral hygiene Diabetes Online

market Patients Consultation
Genetic
Testing
Online Second TCM Step-for-
Consultation option Healthcare reward
services
Medical
Hypertension Offline
tourism
Patients Outpatients
market Health
Headlines
Hospital Telephone Health

Personal Care
Referral consultation Check-up
TCM Market
Wellness
Programs
Beauty Care
Source: Ping An Annual Report
Chronic Care
E-commerce
888 in-house doctors and medical assistants
Hospital network of ~3100 hospitals, including

Insurance Doctors
1000+ Class III Grade A hospitals
Sub-healthy
Contracted with ~2100 external doctors from

Class III Grade A hospitals under “Renowned Doctor”
program
In-
d ho
u Hospitals
te
7500 pharmacy outlets
sis
se
As
me
Beauty
AI
dic
Care
al
team
~1,100 health check-up centers in over 300 cities
I n ter n e t ~500 dental clinics in about 60 cities

Healthy Treatment
Fitness Pharmacies
~70 aesthetic centers in about 30 cities
Commercial insurance coverage by Ping An E Jia Bao

Health Physiotherapy
Check-ups Centers
Note: Class III hospitals are multi-regional hospitals with large capacity that provide multiple regions with high-quality professional medical services, undertake higher
education and scientific research initiatives, which are designated as Class III hospitals by the NHFPC hospital classification system. Date as of December 31, 2017. Source: Ping An Annual Report
Monetization model:
Customer acquisition: Complimentary services such as Health management
plan, health community, and AI triage are low-CAC hooks. PingAn also offers
deep promotions on products in online mall to attract consumer traffic and
engagement.
Specific services such as online consultation, and hospital reservation are

offered on a no-fees-charged basis to consumers. However, PingAn secures
healthy commission from providers. Structure of commissions is ~20% from
online doctor consultancy service and ~20% from providers of online
shopping mall & medical service.
Ping An's success has shown that large scale chronic care platforms can be
built by integrating all stakeholders on a single platform to ensure smooth
delivery of healthcare while ensuring that payments and data collection
happen effectively.
Chronic Care
INFRASTRUCTURE
EFFORTS
The best of technology innovations and
interventions can fail without the support of a
forward-looking public infrastructure. The
Indian Government has realized the importance
of combating chronic diseases and has taken
several initiatives to accelerate the digital
healthcare landscape in India. The two most
notable initiatives are the National Digital Health
Mission and Ayushman Bharat. These initiatives
are aimed at the two-pronged problems of
Approach, i.e. lack of structured data to
undertake long-term initiatives, and
Affordability i.e. ability to pay for chronic care
treatment.
National Digital Health Mission
The stated vision of the National Digital Health Mission is -
To create a national digital health

ecosystem that supports universal
health coverage in an efficient,
accessible, inclusive, affordable,
timely and safe manner, that
provides a wide-range of data,
information and infrastructure
services, duly leveraging open,
interoperable, standards based
digital systems, and ensures the
security, confidentiality and privacy
of health-related personal
information.
The implementation of NDHM is expected to significantly improve the

efficiency, effectiveness, and transparency of health service delivery overall.
Patients will be able to securely store and access their medical records (such
as prescriptions, diagnostic reports and discharge summaries), and share
them with health care providers to ensure appropriate treatment and
follow-up. They will also have access to more accurate information on health
facilities and service providers.
Further, they will have the option to access health services remotely through
tele-consultation and e-pharmacy. NDHM will empower individuals with
accurate information to enable informed decision making and increase
accountability of healthcare provider.
Chronic Care
Ayushman Bharat
Ayushman Bharat - The National Health Protection Mission (AB-NHPM) is the
largest health plan of the Indian government.
Modi government
Rs. 5 lakh Around approves world’s
Insurance cover 11 crore largest and most
per family per year, poor and vulnerable
comprehensive healthcare
irrespective of families to benefit
family size scheme
Beneficiaries
AYUSHMAN
Benefits of the
scheme are portable
can avail benefits
in all empanelled
BHARAT
across the country* public and private National Health
hospitals Protection Mission
* Benefits can be availed anywhere in India
Source: Ayushman Bharath | Read more: http://bit.ly/AB-NHPM
The aim of this programme is to provide a service to create a healthy, capable

and content New India. It has two large goals:
GOAL 1
To create a network of health and wellness infrastructure

across the nation to deliver comprehensive primary healthcare
services.
GOAL 2
To provide health insurance cover to at least 40% of India's

population which is deprived of secondary and tertiary care
services.
Chronic Care
Swasth
Building on the framework given by the NDHM and the vision of Ayushman
Bharat, the startup ecosystem came together to co-create Swasth. Swasth is a
non-profit initiative with the vision of creating the digital backbone for health
care delivery in India. It was created with the following features in mind:
Wider Reach for Doctors/ Providers: Access to standardized

health records for accurate diagnosis and treatment.
Patient Benefits: Single platform for managing health records,

avail healthcare services and seek payer support.
Interoperability: Open source software license.
Data Security & Fraud Prevention: Fool-proof verification of

users, doctors & providers to reduce quackery.
Unified Ecosystem: Seamless interconnection of patients,

doctors, diagnostic labs, pharmacy chains, hospitals,
insurance providers and other stakeholders.
How does Swasth plan to do this?
Source: Swasth Presentation
Chronic Care
Swasth is building a comprehensive home care solution which has a spectrum
of services across the patient journey:
Teleconsultation platform: High quality doctors available over audio/video in

<30 min, speaking 14 Indian languages.
Pharmacy & Diagnostics integration: Pharmacy network with 95% pin-code
coverage.
Remote Monitoring: High quality service offered at subsidized price.
Hospital Integration: Single point-of-contact for hospitalization exigencies.
Source: Swasth Presentation
Chronic Care
investments
in digital health
Over the last 6 years, India has seen c. $3B invested in the Digital Health
opportunity, across 600+ promising startups. Leading up to 2020, the funding
raised by Indian startups, grew 4.7x over a period of 3 years. This highlights
the strong and growing promise of the sector to entrepreneurs and investors
alike. Despite early disruption in deal-making with the ongoing pandemic,
HealthTech startups raised $269M by Jul-20.
HealthTech Funding Trend (India)
$975M
$629M
$402M $461M
$361M
$209M
$269M
2015 2016 2017 2018 2019 2020*
122 181 172 153 118 40
$FUNDING #ROUNDS
Source: Tracxn HealthTech report [Jul-20]
Globally, HealthTech startups have raised north of $78B, driven primarily by

startups building in US (69% contribution), China (7%) and India (4%) markets.
HealthTech Funding Trend (Global)

$18.1B
1.9k
1.8k
1.7k 1.7k
1.5k
$12.4B $11.6B
$11.0B
$9.4B
890
2015 2016 2017 2018 2019 2020*
Source: Tracxn HealthTech report [Aug-20] $FUNDING #ROUNDS
Chronic Care
India's chronic
care platform
For digital platforms, chronic conditions are far more suitable than acute
conditions due to the higher customer life value. We believe that the biggest
companies coming in the space will create digital-first ecosystem that spans
across an individual’s journey in a single chronic disease. The platforms can
have a sticky product hook to acquire users and then leverage partnerships to
deliver other value-added services.
What would the characteristics of successful

chronic care companies be?
• Holistic ecosystem approach: Platform will have to integrate various
stakeholders in the healthcare journey of the consumer, acting as a one-stop
platform, counselling on lifestyle aspects, offering information, and as an EMR
center.
DOCTORS/CLINICS
MEDICAL DEVICES & PHARMACY

SUPPLIES
WELLNESS
HOSPITALS
INSURANCE
DIAGNOSTIC LABS
DRUG DISCOVERY
Source: Kalaari Research
Chronic Care
• Building global products from onset: India is a low ARPU market. Thus,
startups need to think about scaling globally from Day one. There is an
increasing incidence of lifestyle diseases in MENA, SEA regions that can be
capitalized on given similar characteristics with the Indian market.
• Monetization strategy: To start off, startups need to choose chronic care

diseases offering high AOV and CLTV such as cancer, kidney diseases, or
diabetes. Healthcare delivery via providers has high value accretion. Over time,
platform has to evolve to solve multiple chronic care diseases as they cannot
be evaluated in isolation. 89% diabetic patients have atleast 2 co-morbid
conditions such as hypertension, obesity, kidney, or cardiovascular diseases.
Having multiple providers on the platform can help improve customer
stickiness and retention.
• Insurance linkage: Only ~40% Indians are currently insured, and <10%
have private insurance. At sufficient scale and data access, startups can
explore insurance linkage. While most healthtech players are sub-scale for
insurer's interests today, we expect that to change over the coming years.
• Integrate health and wellness: The nature of chronic diseases requires a

comprehensive approach to treatment and management that spans across
various lifestyle choices such as dietary habits, exercise, mental wellness, and
tracking along with clinical solutions. Health and wellness are not distinct
categories. Sometime, startups focus on either health through diagnostics, or
wellness through lifestyle interventions. Former provides a higher AOV, while
latter helps create higher engagement. At the intersection of both, is where
models like Livongo thrive and succeed.
Chronic Care
Healthcare
startups
referred on
social media
Within the comments on social media, we saw entrepreneurs share about their
start-ups, and learnings from the journey. On the other hand, there were also
happy customers of health-tech startups that shared some interesting
companies. We captured the details of these startups and benchmarked them
on three parameters.
Problem:
The key problem the startups are solving within healthcare. Some companies
are tackling several healthcare-related issues (Horizontal - Healthcare), some
are focused on the segment of chronic diseases (Horizontal - Chronic), while
the remaining are laser-focused on a particular chronic care or healthcare
problem (such as Diabetes).
Business Model:
Business models are either facing hospitals/clinics & corporates (B2B) or end
consumers. Within consumer-facing solutions, some startups are focused on
curative healthcare (Care delivery) including diagnostics and consultations,
some are focused on preventative healthcare (Lifestyle), while a few models are
doubling down on trackers (Hardware). A small set of solutions span across
these three categories (Full stack).
Offerings:
These are the set of offerings to the end consumer.
The list of companies is by no means exhaustive. These are companies

suggested to us on our social media channels.
What follows is a snapshot of the companies -
Chronic Care
REFERRED STARTUP PROBLEM BUSINESS MODEL OFFERINGS
Curefit Horizontal - Healthcare Full-stack

https://www.cure.fit/
Fitness + Mindfulness + Consultations

Call Health Horizontal - Healthcare Care delivery Consultation + Diagnostics + Pharma

https://www.callhealth.com/
https://www.portea.com/
Portea Horizontal - Healthcare Care delivery Healthcare services at home

https://careme.health/
CareMe Health Horizontal - Healthcare Care delivery Consultation + Pharma

https://icardin.com/
iCardin Horizontal - Healthcare Care delivery Teleconsultations

https://www.jiyyo.com/
Jiyyo Horizontal - Healthcare Phygital Care Delivery e-Clinics with Teleconsults for Rural areas
https://www.fitterfly.com/
Fitterfly Horizontal - Healthcare B2B Content + Tracking

https://cura.tech/
Cura.tech Horizontal - Healthcare

https://cura.tech/
B2B SaaS
https://cura.tech/
https://cura.tech/
https://cura.tech/
https://cura.tech/
https://cura.tech/
https://cura.tech/
Tracking/Analytics + Consultation +
Horizontal - Chronic
https://www.phablecare.com/
Phable Full-stack
Lifestyle Coaching
https://www.wellthytherapeutics.com/
Horizontal - Chronic Full-stack Content + Tracking/Analytics +

Wellthy
Consultations
https://livealtlife.com/
Horizontal - Chronic Food delivery + Fitness + Consultations +

Livealtlife Full-stack
Diagnostics
https://www.rhealth.in/
Horizontal - Chronic Diagnostics + Consultation + Pharma +

Rhealth.in Care delivery
Food/Insurance Advisory
Horizontal - Chronic
http://smit.fit/
Smit Fit Lifestyle Content + Lifestyle Tracking

http://smit.fit/
http://smit.fit/
http://smit.fit/
http://smit.fit/
http://smit.fit/
https://nutripal.in/
Nutripal Horizontal - Chronic Lifestyle Content + Consultations

https://www.heka-solutions.com/
Content + Tracking/Analytics +
Heka Solutions Full-stack
Diabetes
Consultations
https://www.aegleclinic.com/
Diabetes Phygital Care Delivery

Aegle Clinic Clinic + online physiotherapy

https://cureos.in/
Diabetes
https://cureos.in/
CureOS Phygital Care Delivery Network of clinics + consultations

https://cureos.in/
https://cureos.in/
https://cureos.in/
https://cureos.in/
https://cureos.in/
https://cureos.in/
https://twinhealth.com/
Diabetes Network of clinics + Tracking/Analytics +

Twin Phygital Care Delivery
Consultations
https://www.corahealthcare.in/
Cora Healthcare Diabetes Lifestyle Content + Lifestyle Tracking

Diabetes
https://www.breathewellbeing.in/
Breathe Well-being Lifestyle Content + Community + Lifestyle Tracking

https://pcosclubindia.com/
PCOS Club India PCOS Care delivery Consultation + Diagnostics

contd.
Chronic Care
REFERRED STARTUP PROBLEM BUSINESS MODEL OFFERINGS
https://maasika.in/women-health/disorders/pcod_pcos/
Maasika PCOS Content + Consultation + Diagnostic

Phygital Care Delivery

Content + Consultation + Diagnostic +

https://lami.fit/
LamiFit Nutrition Full-stack

https://lami.fit/
https://lami.fit/
https://lami.fit/
Supplements
https://lami.fit/
https://lami.fit/
https://lami.fit/
https://lami.fit/
https://www.23bmi.com/
23BMI Nutrition Lifestyle Content + E-commerce + Diet Plans

http://www.snoozfit.com/
Snoozfit Sleep Management Hardware Sensor

https://www.your-physio.in/
YourPhysio Network of clinics + online physiotherapy

Physiotherapy Phygital Care Delivery

https://endoqure.com/
EndoQure Endocrine Care B2B SaaS

https://www.healthkon.com/
Healthkon Hardware Remote Monitoring device + Tele-OPD

Critical Care
https://purpleribbon.health/
PurpleRibbon.Health Cancer Network of daycare centres

Phygital Care Delivery

Disclaimer - The data in the table is interpreted based on publicly available sources.
If you feel there is a mis-categorization, please write a note at health@kalaari.com, and we will make the necessary correction.
Chronic Care
KALAARI
VIEWPOINT
Chronic care diseases is a large, unaddressed, and growing problem. It is often
attributed to a confluence of Increasing urbanisation, aging population, air
pollution and changing lifestyles. Solving for India's pervasive chronic care
scourge is an imperative. The positive impact is not just limited to better
healthcare for millions of Indians, but goes beyond to strengthening India's
economy. A Bain report estimates, chronic care diseases to cost India $6.2T
between 2015-2030.
The intervention of technology in chronic care is inevitable, due to the following

reasons:
It is an attempt to solve for a massive challenge through a scalable and
capital-efficient model.
The patients need constant vitals monitoring, and a ready access to the
healthcare ecosystem (physicians, pharma) regardless of their offline
access.
With low but growing awareness, there is a need for elements of

gamification to drive irreversible behavior shifts.
There are several approaches that have emerged to solve for either preventive
or curative chronic care challenges. Taking diabetes as a base example, below
is a summary of the approaches, opportunities and challenges faced by
tech-first players:
Solving for ~70M diabetics Solving for ~90M pre-diabetics

Approach 1: Diabetes reversal Approach 1: Lifestyle Intervention
Using only lifestyle (non-pharma) Goal-based gamification for
interventions lifestyle improvements
Opportunity Challenges Opportunity Challenges

Irreversibly improving Delivering solution at Personalised life plan Awareness and intent to avoid
lifestyle of patients, avoiding affordable price-point; spanning content, diet, severe-risk diseases;
taking meds and injections resistance from the ecosystem exercise, sleep, supplements monetisation beyond
and tracking e-commerce; tech for true
personalisation
Approach 2: Adherence
Driving complete adherence to
doctor recommendations
Opportunity Challenges
Collaborating with the Figuring means of
ecosystem for monetisation; ensuring platform
comprehensive care retention and engagement
Chronic Care
At the intersection of progressive Government
initiatives, pandemic-induced digitisation, and a
massive underlying market, Digital Health in India
is at a tipping point. We are committed to
collaborate on the future of chronic care and
creating a meaningful impact.
Kalaari values the opportunity to work with

missionary early-stage founders with deep
customer insights and a long-term mindset, as
they build the enduring enterprises of tomorrow.
If you have suggestions of entrepreneurs we

should talk to, we would love to hear from you at
health@kalaari.com.
Chronic Care
Phone: +91 80 6715 9600
Email: info@kalaari.com
Website: kalaari.com
Kalaari Capital, Ground Floor,

Unit-2 Navigator Building, ITPB,
Whitefield Road, Bangalore,
Karnataka - 560 066
twitter.com/kalaari
facebook.com/kalaaricapital
linkedin.com/company/kalaari-capital
medium.com/@kalaari

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CHRONIC CARE

SOLVING FOR THE PERVASIVE

Livongo is a health-tech company that provides a set of tools, analytics, and

Beyond public companies, VC-backed private Digital Health companies have

Digital penetration in Healthcare in India is still low. At a ~$5B market size,

As shown below, across metrics for eﬀective healthcare delivery, India

10% 2.5 3.3

MATURE ECONOMIES INDIA 27% 62% 75%

Health Insurance Out of Pocket Private hospitals

We received overwhelming response and made a promise to share our

Chronic diseases require a comprehensive approach to treatment and

In order to create and capture massive value, a chronic care platform

At the core of Ping-An's healthcare services is a network of partner medical

Oral hygiene Diabetes Online

Hospital Telephone Health

Source: Ping An Annual Report

888 in-house doctors and medical assistants

Hospital network of ~3100 hospitals, including

Contracted with ~2100 external doctors from

I n ter n e t ~500 dental clinics in about 60 cities

Commercial insurance coverage by Ping An E Jia Bao

Speciﬁc services such as online consultation, and hospital reservation are

To create a national digital health

The implementation of NDHM is expected to signiﬁcantly improve the

* Beneﬁts can be availed anywhere in India

Source: Ayushman Bharath | Read more: http://bit.ly/AB-NHPM

The aim of this programme is to provide a service to create a healthy, capable

To create a network of health and wellness infrastructure

To provide health insurance cover to at least 40% of India's

Wider Reach for Doctors/ Providers: Access to standardized

Patient Beneﬁts: Single platform for managing health records,

Interoperability: Open source software license.

Data Security & Fraud Prevention: Fool-proof veriﬁcation of

Uniﬁed Ecosystem: Seamless interconnection of patients,

How does Swasth plan to do this?

Source: Swasth Presentation

Teleconsultation platform: High quality doctors available over audio/video in

Source: Swasth Presentation

HealthTech Funding Trend (India)

Source: Tracxn HealthTech report [Jul-20]

Globally, HealthTech startups have raised north of $78B, driven primarily by

HealthTech Funding Trend (Global)

2015 2016 2017 2018 2019 2020*

Source: Tracxn HealthTech report [Aug-20] $FUNDING #ROUNDS

What would the characteristics of successful

MEDICAL DEVICES & PHARMACY

Source: Kalaari Research

• Monetization strategy: To start oﬀ, startups need to choose chronic care

• Integrate health and wellness: The nature of chronic diseases requires a

The list of companies is by no means exhaustive. These are companies

What follows is a snapshot of the companies -

Cureﬁt Horizontal - Healthcare Full-stack

Fitness + Mindfulness + Consultations

Call Health Horizontal - Healthcare Care delivery Consultation + Diagnostics + Pharma

Portea Horizontal - Healthcare Care delivery Healthcare services at home

CareMe Health Horizontal - Healthcare Care delivery Consultation + Pharma

iCardin Horizontal - Healthcare Care delivery Teleconsultations

Fitterﬂy Horizontal - Healthcare B2B Content + Tracking

Cura.tech Horizontal - Healthcare