NETRA EYECARE: A VISION FOR RURAL INDIA

Introduction: The 60-year old Parvathamma was a 'home-alone' woman who does not have any familial
support. She lives in Hosahalli village 16 Kms from Channapatna town. She made her living on income from
her land leased for agriculture. She had been gradually losing her eyesight. When she heard an
announcement that an Eye Screening bus from an eye hospital in Chennapatna was visiting the village, she
decided to get her eyes checked. After the screening tests, Elizabeth, the Optometrist at the Netra mobile eye
camp told Parvathamma that she had developed Cataract in both her eyes. Anil, Manager Outreach Camps,
counselled her at length that she had to get operated to regain her vision. Parvathamma complained about
her knee pain which affected her mobility and that she was alone. She consented when Anil pointed out that
nine more persons from her village had decided to undergo cataract surgery and were going to be
transported to the hospital at Chennapatna in the same bus when it returned to the hospital in the afternoon.
She felt reassured that she could also join the same group after one week for the post-operative check-
up. Parvathamma paid Rs.2000 as advance amount and registered for the surgery. She would pay the
balance after the surgery. Parvathamma rushed home to pack her clothes to join the other patients who
would all be staying two nights at the Netra Super Specialty Hospital at Chennapatna, a town famed for
adorable wooden toys.
Netra hospital in Channapatna (one of the 4 Talukas of Ramanagara District) had completed 3 years of
successful operation by June 2018 and had conducted about 1500 ophthalmic surgeries. Naran. A and his
team had put together the Super specialty hospital, a Vision Center (VC) at Kanakpura, a tele-medicine center
(TMC) at Maddur, and a Mobile Clinic (a modified bus equipped with eye screening facility) as just one cluster
of a larger eye-care model. Once scaled up, Naran believed, this model would overcome the avoidable
blindness problem at the bottom of the socio-economic pyramid (BoP) in rural India. The set-up in
Channapatna had a reach in about 30 of the total 146 villages in the Taluka. Similar clusters were already in
operation in three other districts of Karnataka totalling 6 Hospitals, 2 vision centers (VC), 1 tele-medicine
center (TMC) and 4 Mobile Clinics.

Even though he had reasons to be content with the current financial performance of the Hospitals, Naran
was not really sanguine as he reflected on the impact Netra had made in avoidable blindness space. Netra
had to demonstrate both financial returns as well as high scale of social impact in order to attract further
funding. The key to create higher social impact, he believed, was deeper penetration in remote underserved
villages. Naran had conceived of TMCs, VCs and Mobile Clinics as critical extensions of his eye care service
delivery from the district HQ to the taluq HQ and smaller towns that were very poorly served by a few private
eye clinics. But as he rolled them out Naran faced operational challenges that demanded relook into the
operational model itself.

First, the TMCs received lukewarm response as not many patients were interested in remote consulting.
Second, eventhough VCs received walk-in patients which averaged around 40 per day getting doctors to visit

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the VC even on alternate days was proving to be hard. Even attracting and retaining good optometrists at
the VCs was proving challenging. Third, the mobile clinics seemed to be effective only within a radius of 30-
40 kms from the base hospital and scalability of the mobile clinics was also not simple. Fouth, creating
awareness about eye care and reaching the BoP in villages was complicated by social inhibitions as well as
confounded by the logistic bottlenecks. Naran was concerned whether the patient walk-ins to VCs and TMCs
could be improved or even sustained unless the marketing efforts were stepped up.

All these affected Naran’s ambitious goal of covering all the 1500-1800 villages in a district. Naran also
anticipated that setting up VCs in locations farther away from Bangalore would be even more challenging.
He was uncertain whether his current Vision Centre model would work in the long term. This had a direct
bearing on the optimal utilization of the base hospital surgical capacity of 300 patients per month, the
geographical expansion plan, his valuation commitment to Lok Capital, and eventually Netra’s founding
vision and mission to make a significant impact on AB at the BoP. Looking ahead, Naran felt it was time to
critically evaluate the current model and explore the options. He decided to meet with his founding team.

Netra Hospitals : Envisioned as a for-profit Social Enterprise, DISHA Medical Services Pvt. Ltd. was
established in 2011 by a team of three techno-entrepreneurs Anjali, Dr. Rajesh and Naran. Their mission was
“to deliver affordable eye care in underserved markets”, through a network of facilities branded as Netra
Eye Hospitals (Netra). They were seed-funded by Lok Capital , a social impact venture capital fund. The
founders believed that serving the healthcare needs of the 1.2 billion people at the base of the pyramid
demanded viable business solutions, and not just philanthropy. Hence Netra was funded and managed like
a commercial enterprise with the primary social objective of delivering affordable eye care solutions to
address the problem of avoidable blindness. Naran believed that Netra had to achieve speed, scalability and
the sustainability of its business model. Naran summed up the criticality of scale, speed and sustainability:
“Netra model is based on low price and high volume. It is a matter of how much time is required to reach
that volume. We have set of fixed costs, which gives us certain capacity to deliver services. As long as we get
the capacity utilization up, our business model is going to work. It is a question of how quickly we take to
reach that volume level and sustain it”.

The Indian Healthcare Milieu: India ranked among the lowest on public healthcare spending at a dismal
1.3% of the Gross Domestic Product (GDP), a little over a third of china’s spending.The failure of the
government sector led to the rapid rise of the for-profit private sector which came to own about 93% of the
hospitals in the country, 70% of which were concentrated in the cities. But 70% of the Indian population and
78% of those in bottom of the socio-economic pyramid (BoP) lived in rural India, with just about 1% of them

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under any medical insurance coverage. Therefore, healthcare was way beyond the means of most in rural
India. The low purchasing power coupled with poor infrastructure and the absence of institutions for market
formation and efficient operations, rendered rural India totally unattractive for the mainstream private
commercial hospitals. Therefore, the availability, accessibility and affordability of quality healthcare was a
major problem in the rural India, and a humongous challenge for the BoP.

The eye care challenge in the country was more daunting. About half the population needed some kind of
vision correction. The country was home to about 12 million blinds, 80% of whom were classified as
avoidable blindness and hence could be cured. But the majority of the blind belonged to the BoP in rural
India. There was only one ophthalmologist for every 60,000 people in the country and the ratio was worse
in the BoP market. Moreover, the quality and reliability in eye care services demanded expensive diagnostic
and surgical facilities and highly skilled manpower, rendering eye care services costly. In a typical urban
hospital consultation fee was over ₹300, prescription glasses cost around ₹1000 a pair and an eye surgery
over ₹10,000. These affected the availability, accessibility and the affordability of eye care to the BoP
segments. The National Programme for Control of Blindness (NPCB), initiated by the government in 1976,
proved ineffective due to poor execution, infrastructure bottlenecks, poor quality of surgery and inadequate
post-operative care. It was in this bleak scenario, the founding team of Netra sensed profitable opportunities
for delivery of affordable eye care solutions that would have a significant impact on the scourge of avoidable
blindness.

Design of a sustainable eye care model for the BoP market: Realized that extending the urban eye care
model of large hospitals would not be suitable for the rural BoP market the Netra team adopted a hub-and-
spoke model. A mid-size base- hospital at the district headquarters with surgical facilities would serve as the
hub and TMCs and VCs set up within 70 Kms of the base-hospital would serve as the spoke. Hospital would
receive referrals for surgeries from TMC and VC as well as from Mobile clinics conducted within a radius of
30-40 kms from the base hospital.

The rollout started in 2011, with the setting up of the first base hospital at Devanahalli Taluka, the HQ of
Bengaluru Rural district, about 40 kms from Bengaluru city. The hospital had 20 beds and could conduct
about 300 surgeries in a month. The services included Comprehensive Eye Examination, Refractive Error
Services, Cataract Surgery with IOL Implantation, Glaucoma Evaluation, Uveitis and Ocular Immunology,
Diabetic Retinopathy, Childhood Eye Diseases, and Community Eye Care. In order to support the hospital, a
TMC was commissioned at Vijayapura about 12 kms from the hospital and another TMC in Bagepalli, a taluk
hq 60 km away, in the neighboring Chikballapur District. Telemedicine center was manned by a qualified

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optometrist. The optometrist would do the initial screening and upload relevant data and pictures that a
doctor in the Hospital or at any remote location could study. After going through the data and picture the
doctor would advise the patient on the next course of action through a seamless video consulting facility.
The technology was so effective that even a doctor on a family vacation in Goa could advise a patient real-
time. But patient’s acceptance of telemedicine was lukewarm and the TMC had to be closed down.

The first Vision Center was set up in Chikballapur (district hq) as a spoke for the Devanahalli hospital in 2013.
The center found traction soon with around 40 patients visiting the centre daily. Netra charged a
consultation fees of ₹100 for patients who walked into its hospitals and vision centers, but was waived if the
patient was not able to pay. Naran felt that this model of eye care delivery would be economically
sustainable only if Netra could scale up rapidly to achieve higher volumes.

The first mobile clinic was commissioned in 2013, which operated within a radius of 40-50 kms from the base
hospital at Devanahalli. Mobile Eye Clinic (a modified bus equipped to conduct basic eye check, prescribe
and dispense spectacles) extended Netra's reach into remote villages of the district. Every month around 22
mobile eye camps were conducted covering about 15 villages, and around 150 people attended each camp.
As the team for mobile clinic was sourced from the Hospital staff the reach of the mobile camps was to be
within 40-50 kilometers of the base hospital. About 80% of the surgeries conducted at the hospitals came
through the mobile eye clinic route. The Hub and spoke cluster is exemplified in Exhibit 1

Netra entered Ramanagara District in June 2015 by setting up its second hospital in Channapatna , also a
district hq, located 70 kms south of Bangalore city. In Six months, Netra expanded to Chitradurga District by
setting up its third hospital in the hq about 200 kms from Bengaluru. The first supporting VC for Channapatna
Hospital was set up in March 2016 at Kanakapura- 40 kms from the base hospital and a supporting TMC was
functional in 2017. Naran was in the process of setting up VC ad TMC for the Chitradurga hospital. The
various Netra delivery formats along with resources required and the kind of demand generation initiatives
in the rural market for each format is given in Exhibit-2 and a map indicating Netra’s coverage in rural
Karnataka including Ramanagara and Devanahalli are in Exhibit-3.

Many city-based hospitals, especially in south India, regularly conducted mobile clinics in poor urban
localities as well as villages situated within about 50kms of the hospitals. But Netra model had some basic
differences. Firstly, Netra’s base hospitals were located outside of Bangalore city in Talukas/towns. Hence
the mobile camps of Netra reached many villages beyond the reach of a city-based hospitals. Secondly, VCs
as well as TMCs located in taluka/towns that functioned as spokes of the hospitals were also unique to Netra
model. Hence the Netra model had greater rural penetration compared to any other city-based hospitals.
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Go-to-Market challenges: Netra's Go-to-Market strategy revolved around deep rural penetration through
blanket coverage of each Taluka. Netra had to overcome marketing and logistic challenges such as the social
perception against wearing spectacles especially for the girls, lack of awareness about the importance of
preventive blindness. The Consumer Behavioural Challenges included:

Disease- Distance correlation: Villagers postpone consulting a doctor if they have to travel long
distance. When an illness becomes unbearable, they are willing to travel. Anyone with own
transportation would consult a doctor in the city and would stay loyal to that doctor rather than meet
a doctor in a rural town. Beyond 30 kms of the hospital or vision centre there is little credibility for
Netra brand.
Distance-Cost correlation: To meet a local doctor villager carried Rs.300/-. To meet a Doctor in district
headquarters they carried about Rs. 1000/- or more and to meet a Doctor in the city they carry more
money and also spend on food and accommodation for self and for another person who is familiar with
the city.
Technology acceptance and Brand credibility: Only those patients who were already familiar with
Netra hospital/brand are ready to walk into the tele-medicine centres and consult with the doctor over
the skype. Other patients walk into the facility but would return without consulting doctor over skype.
Also, not all doctors were comfortable with tele-ophthalmology treatment.
Cataract Prominence: 85% surgery cases were for cataract. Mostly elderly people visited the camps. 3-
4 kids visit the mobile camp if it is held on a holiday.
Aesthetics: Even rural patients expect improved procedures and decent looking glasses. The Modi-
procedure7 was not accepted by many villagers because of the “soda-glass” after surgery/ for vision
correction.
Elderly: Old people are left in apathy w.r.t. health matters. Children would own a fancier two-wheeler
but would not spend 3K on his mother’s eye-treatment. As the youngsters don’t care, one-night stay in
hospital after the surgery is mandated for the elderly.
Income and Age information: All women in villages don’t report their age. None reports actual income
class. There is income hierarchy in the village. The well-to-do have a personal doctor in the city and
don’t visit local hospitals.
Peer/hierarchy pressure: Counselling for surgery would be accepted by a patient if it was accepted by
others higher to him in the village hierarchy. E.g. a panchayat member. The camp is held with the
support/permission of the panchayat heads. In other words, the opinion leaders have a strong
influence on the patient behaviour.
Group behaviour: There is fear of travelling alone to hospitals. If patients are formed into groups and
a leader is assigned, there is greater readiness to travel for surgery and for follow-up. If something goes
wrong with the treatment villagers collectively demand money as compensation.
Disinterest in follow-up: There is drastic drop in follow-up post-operative. Only if the patient is
confronted with a post-operative problem, he or she would come for a follow-up.
Felt need: As many old people cannot read or write due to illiteracy, they don’t feel a pressing need for
vision correction. Kids are more forthcoming for counselling.

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A popular cataract treatment project conducted by Dr. Murugappa Channaveerappa Modi in rural India. The treatment was
very successful and he conducted about 500,000 surgeries. However, many patients disliked the thick glasses given after the
treatment for vision correction.

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 Role of Federations: People who are registered as members of a milk-federation or agri-federation first
come to know of the mobile camps and only they are eligible for schemes like Yeshaswini8 insurance
coverage.
Seasonality of demand for treatment: While summer sees high demand for eye-care other seasons
especially festival seasons like Diwali and Dusserah are lean periods. The demand for healthcare is also
low during the sowing seasons.
Besides these behavioral challenges, poor purchasing power, and hard-to-reach locations heightened the
grass-root marketing problems at the BoP. Naran was open to marketing ideas that addressed these
challenges and successfully catered to rural India. He had made all efforts to make the service affordable for
the rural poor. Netra provided free consultation and charged a nominal ₹300 for a pair of spectacles to the
patients attending its mobile eye camps sponsored by donors. Cataract surgeries ranged from ₹ 3800 to
₹25000, depending on the cost and quality of the intraocular lenses. Free cataract surgeries were performed
for poor patients over 60 years old who were not health-insured. The goal was to have a base hospital in
each of the 30 districts of Karnataka by the year 2020. Naran explained about Netra’s pricing policy: “We
want to be an affordable eye-care player. For any service or product, we offer, we have a minimum price. We
don’t offer anything free, but affordable for those who self-select themselves and walk into our Vision Centers
or hospital. The logic is that if a patient self-selects, then he or she was willing to pay….”

Additional Challenges: Door to door awareness creation and screening could be one means of addressing lack
of awareness. But there had to be continuity in interaction to gain credibility in the rural market. The rural
physical infrastructure was so weak that even the basic ancillary services like transportation, electricity and
a clean place for conducting the examination of the patients, or an optical shop, did not exist in most of
these villages. The go-to-market challenge are acute due to the severe shortage of qualified
ophthalmologists and optometrists in the remote geographies.

Another question was how could Netra make the treatment even more affordable? How could the surgeries,
hospital stay, spectacles, medicines, and transportation be made more affordable to the rural patient?

Netra sought the partnership of social enterprises and NGOs who were familiar with the rural context and
had complimentary capabilities in order to address the unique behavior of rural BoP consumers. Netra
collaborated with Accredited Social Health Activists (ASHA 9workers) who went door-to-door educating the
villagers about the need for preventive eye-care. These workers knew the local community and hence were
acceptable for the villagers. They conducted initial screening and qualified people for the forthcoming

8
Yeshasvini Scheme: A health insurance scheme introduced by the Government of Karnataka for the Co-operative farmers of
Karnataka that covers about 823 defined surgical procedures to the farmer cooperators and his family members.
9
A trained female community health activist. Selected from the village itself and accountable to it, the ASHA workers
are trained to work as an interface between the community and the public health system.
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mobile eye camps to be held in the village. These workers also follow up on the use of glasses given to the
village school children under sponsored mobile eye camps especially conducted for the schools. The ASHA
workers provided the much-needed continuity for Netra and served as the critical link at the village level.

In a typical month Netra held 22 mobile camps across 15 villages. Naran commented about ASHA: " I am
trying to reach the grassroots. I don't think it would be possible to reach them without the support of
collaborative partners like this". But the challenge remained that the ASHA workers were active only in a
few districts if the state. Getting more buses and equipping them for eye screening was a very expensive
affair. But mobile clinics were important for service delivery.

Netra had to grapple with the challenge of recruitment and training of optometrists for its facilities located
far away from the urban centers. Over and above these there was acute shortage of Ophthalmologists in the
rural districts. Naran managed to get doctors for hospitals which were located in the district headquarters.
But getting doctors for the vision centers was very difficult. Many qualified ophthalmologists migrated to
cities like Bangalore. The vision center in Kanakapura Taluka is manned by a doctor who travelled from
Bangalore but has roots in the Taluka. This not only increased the cost of operations of the Center , but also
raised doubts about the willingness of the doctor to bear the stress and strain of travel for a long time. Naran
had tried, without much success, a small format Vision Centre manned by one optometrist and got convinced
that patients would like to consult with only a doctor. Without a qualified doctor’s availability, opening new
vision centers would not be possible which in turn affects Netra’s reach in the BoP.

As setting up vision centers became tougher Naran looked for general practitioners (GPs) with successful
practice in small towns for tie-up. The GP could refer the ophthalmic cases to Netra hospital and get a fee
for it. Netra provided the screening devices required at the GP’s clinic. However, the general practitioners
did not treat this a priority and Netra did not get much referrals.

An alternative to setting up more vision centers would be to revamp the telemedicine initiative wherever
vision centers were not feasible. But the TMC in Maddur received on about 6-8 walk-in patients a day. One
would have to wait patiently for teleconsulting to become acceptable among more rural patients.

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Exhibit-1: The Hub and Spoke Model

Exhibit-1: Demand generation initiatives in the rural market for each format
Format Facilities Demand activation
1 Base Hospital (located in a *2 to 3 Ophthalmology surgeons. *Facility to *Mobile clinics conducted in rural areas by the
district headquarter) conduct about 20 surgeries/day and post- staff of the hospital. * Accredited Social Work
operative care facilities. Activist (ASHA) workers conducting door-to-
*An outpatient department (OPD) equipped door promotion in the neighborhoods of the
with all diagnostic devices. hospital
*Facility for dispensing spectacles.

2 Vision centres (Provides up to *An ophthalmologist along with 2 optometrists *Accredited Social Work Activist (ASHA)
secondary care at a Taluk in a state-of-the-art clinic facility providing only workers conducting door-to-door promotion in
town) OPD services. rural villages.
*Facility for dispensing spectacles.

3 Tele-ophthalmology centers *2 Optometrists providing remote access to an *Promotional Booths set up in busy shopping
(located in smaller towns of a ophthalmologist. *State-of-the-art clinic facility areas as well as booths held at public places
taluk) equipped with screening devices as well as tele- like parks where elderly come for regular
consulting devices. morning walks.

4 Mobile ophthalmology clinics *2-3 Optometrists in a modified bus. *Drum announcement 2-3 days before the
(operates in villages within 30- *A camp organizer and a driver. camp
40 kms distance from the * Banner put up at a public place in the village
hospital) and leaflets circulated to each family in
advance. S
5 Vision center attached to a *Netra gives screening devices to be used by the GP’s own efforts in his/her locality.
General Practitioner’s clinic doctor.
(located in small towns)

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Exhibit-2 Rural Markets covered by Netra Services highlighted with white circles

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