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Ziqitza Healthcare Limited

Medical professional conducts examination in the back of a Ziqitza ambulette in India

Building the foundation for emergency medical services in India

  • Case Study
  • Healthcare
  • India
  • 2006
lives impacted
of those reached are below the poverty line

Ziqitza Healthcare Limited (ZHL) provides emergency ambulance services across India. Through government partnerships, the company has been able to scale its impact.

The problem

In a medical emergency, providing quality health services within the first hour is critical in preventing deaths. At the start of the 21st century, Indians were not able to call ambulances, even in dire emergencies. In the capital city of New Delhi, less than 2% of trauma patients could access care in the first hour. In Mumbai, injured patients who could access hospital care waited an average of six hours to be seen.

As a direct result, India led the world in accident-related deaths in 2004, with over 1.1 million fatalities. There was a lack of centralized emergency medical services (EMS) infrastructure and a lack of trained ambulance staff.

The problem is exacerbated for people in poverty. Even though a few nonprofits and charitable organizations owned their own ambulances, they did not follow standardized protocols or adhere to quality standards and were usually unable to respond promptly. Life-saving care was outside their reach.

The solution

With more than 2,300 ambulances, Ziqitza Healthcare Limited (ZHL) provides ambulance services across India through partnerships with the government and through fixed fee contracts with hospitals and corporations.

Under the government partnerships, a person who needs emergency care can dial “108” and reach the 24/7 call centers operated by Ziqitza. The center will then deploy the nearest ambulance with trained staff who can provide pre-hospital care for the patient who is taken to the nearest government hospital, free of charge. ZHL is especially focused on reaching pregnant women, as the government of India’s Janani Suraksha Yojana (Maternal Safety Scheme) specifically covers free transportation services for delivering mothers.

Once the patient is brought to the appropriate care center, ZHL provides the government with an invoice and is paid a combination of a flat fee per trip and a per-mile fee to compensate for distance.

The origin

ZHL was founded in 2005 by a group of young professionals who witnessed the disparity between emergency services in India and the U.S.

Shaffi Mather and Ravi Krishna’s mothers had diametrically opposite experiences when they needed urgent medical attention in Kerala and New York City, respectively. While one failed to find an ambulance and ultimately rode to the hospital in the back of a taxi, the other was able to access the services of a trained medical professional who reached her within minutes.

Mather and Krishna partnered with Sweta Mangal, Manish Sancheti, and Naresh Jain to solve the problem together in 2002. Reflecting on the experience, Sweta Mangal stated, “The initial part of building this industry was very joyful. It was new and we were creating something that never existed.”

“One thing we were very clear about is that we didn’t want to build a company which was only in Northern Bombay. The vision was India. The vision was developing countries. It was never small. It was very big.”

Sweta Mangal, Co-Founder

The impact

ZHL’s impact stands out in Acumen’s portfolio for its unduplicated track record on its poverty focus. Their “108” model has dramatically changed healthcare access, offering affordable emergency services where exorbitant private options once dominated. Pregnant women in rural areas now have access to quality care thanks to ZHL’s involvement in government delivery initiatives. Studies also indicate that states who adopted the “108” model in their early years have seen improvements in key health indicators such as institutional deliveries and maternal and infant mortality rates.

Since Acumen’s investment, ZHL now manages more than 2,300 ambulances and has impacted 48 million lives including 13 million pregnant women. ZHL has also set new benchmarks in the training of drivers and paramedics – critical stakeholders in any emergency response system.

The investment

Acumen invested in Ziqitza in 2006 as part of our initial set of equity investments. We were the first institutional investor, and eventually invested a total of $2.6 million. As part of the investment, Acumen took a seat on the board and provided strategic accompaniment throughout the crucial period of Ziqitza’s growth. Acumen’s focus was to provide governance oversight and support the scale of the organization, including ensuring the right talent and partnerships were in place.

The story

When Acumen first invested, Ziqitza used a pay-per-use model, where those living in poverty were provided either free or highly subsidized services, with the subsidy coming from other users. While the cross-subsidy model was successful in demonstrating the potential of high-quality, widely-accessible EMS, its reach was limited. Enforcing the sliding scale/cross-subsidy model was difficult – attempts to do it through a trust-based model or on the type of hospital reached were both fraught with challenges. However, just by providing widespread care, ZHL demonstrated its value proposition and helped build trust with its customers and, eventually, its government partners.

The business took a dramatic turn when they were the first ambulance to respond during the tragic terrorist attack of 26/11 that shook Mumbai and India. Their ambulance was seen live on TV, and the courage of the attendants made state officials take notice, which led to the team securing a contract with the Bihar government. They were able to scale their government partnerships after receiving recognition for significantly improving the quality and reliability of emergency medical services.

Between 2010 and 2014, ZHL started focusing on scale through the “108” government partnership model. Universal access was more inclusive and easier to implement, and states were willing to pay for results. The “108” model enabled Ziqitza to scale its operation beyond Mumbai and Kerala to other states and develop the operational efficiency that was critical for this model to work. The company demonstrated to the government that partnering with private companies can open up access to quality emergency services which were previously unavailable.

In states where ZHL launched its operations, a population that had previously been without emergency healthcare was now able to access ambulatory services which adhered to global quality standards. Emergency medical service became a public good. In a study conducted by Grameen Foundation with the Acumen team in 2014, it was shown that ZHL’s reach among the poor in Punjab and Orissa was between 65% and 78%. In both states, ZHL had a disproportionately high outreach among women users.

Ziqitza’s emergence as a world-class and – most importantly – accessible service provider for those living in poverty is no ordinary story. It requires a steadfast commitment to build the business with integrity and a hyper-focus on operational efficiency.