Higher quality, lower costs: India’s cancer grid promise

No matter the time of day, the visitors in queue at Mumbai’s Tata Memorial Hospital (TMH) always have a discomfiting poise. Most have travelled long distances; but the group seems curated by one illness, cancer. An illness that can be manageable, like a chronic disease, but often isn’t. 

In 2012, the leadership at TMH, the largest cancer centre in the country, took a decisive step to address parts of the colossal task at hand. Having brought existing centres in Guwahati, Chandigarh and Visakhapatnam into its fold that year, it set about framing common standards, setting up an IT platform, and sharing best practices—the entire structure for a functional network. 

Then, in a benevolent gesture, they decided to open this up to scores of regional cancer centres across India. Thus, the National Cancer Grid (NCG) was born. An unprecedented initiative to tame a disease that the World Health Organisation (WHO) estimates will affect one in three household in India by next year. The numbers look ominous—1.73 million new cases by 2020, with only 12.3% of patients receiving early treatment.

Already under Ayushman Bharat—the government’s universal healthcare insurance scheme which covers 40% of the population—30% of reimbursements are for cancer treatment. Is that money optimally spent? It’s certainly worth examining since there are rumours the scheme may be expanded to cover more people. 

Seven years on, the NCG sees 700,000 new cancer patients pass through its network of 177 centres each year. Some of the world’s leading cancer centres are even helping the NCG build out its capabilities since it’s also serving 40-plus countries in one way or another. These include the National Cancer Institute and American Society for Clinical Oncology in the US, King’s College London, and Cancer Research UK.

Fast emerging as a global health centre, could NCG also impact the sprawling, yet largely unregulated, private healthcare providers in India which serve the remaining 60% of cancer patients? CS Pramesh thinks it could. A director at TMH, Pramesh, a practising thoracic surgeon and the lead architect of NCG, talks about this democratic, ground-up machinery that has caught the world’s attention.

The Ken: Why have a cancer grid? 

The single most important mandate of NCG is to have uniform standards of care. Look at the patients that come here or at any top centre; only a small percent comes from the state where the centre is. At TMH, only 15% of our patients come from Mumbai; 25% from other parts of Maharashtra. We geotagged 75,000 patients (map below).  A large percentage comes from pockets like North, East, or North-East; not so much from the West or the South. 

Overall, the biggest challenge for patients is to stay here with their family. Think of the cost of staying in Mumbai, the loss of income for the family… So our main aim was to provide the same level of care close to their homes.

The Ken: In seven years, how far have you come? 

The network has grown phenomenally. From the 14 centres which participated in our first meeting in August 2012, when 29 regional centres were invited, when there was a lot of scepticism, it has grown to 177 centres. These centres see 700,000 new cancer patients every year, almost 60% of India’s total cancer cases. 

The Ken: That’s volume. But what about quality and impact on clinical practice? 

NCG has grown in size and scope. From the single mandate of quality care, it grew to improving the quality of human resources. We have stringent rules in this country which determine which centres can train medical people and which cannot. This means several centres which can train are not training because of these rules. We wanted to break these silos and get any centre capable of training to train. If not in a formal way, then at least in an informal way—by task sharing and task shifting, where the time of the oncologist, a rare expertise in India, is better used. 

We run so many quality [testing/assurance] programmes for pathologists and physicians. For instance, somebody from the North-East (NE) said they were finding it difficult to attend medical conferences in big cities—traveling from Naharlagun (in Arunachal Pradesh) to Chennai is a two-day affair. We created continuing medical education (CME) programmes and ran them across 11 cities in 26 days, covering the entire NE. This kind of a model doesn’t exist anywhere. 

Quality control in cancer pathology is critical. TMH follows the College of American Pathology (CAP) guidelines, but at NCG we have created a leaner version of CAP and put it online. It’s offered free of cost to any centre voluntarily wanting to upgrade. Today, 100 centres avail this quality certification. They think getting an NCG stamp is important. Now the National Accreditation Board for Testing and Calibration Laboratories (NABL) has started suggesting to centres that they go through NCG’s quality control of pathology.

Then there’s research, which is uncommon in India. TMH is the largest cancer centre in the country, and hence it can do all kinds of research by itself that other places can’t. It’s a very inefficient way of doing research. If you are doing a 1,000-patient study, it takes 7-8 years to do it. By the end of it, and when the outcome is analysed, we realise that the original question may or may not be relevant. We need to be quicker, more efficient; we need to know if this research, which works in TMH, will work in Silchar or Guwahati or Kanyakumari. 

The Ken: Can NCG drive the cost down? Magical cell therapies like CAR-T are available, which cost anywhere from $500,000 to $850,000. Will India have to wait a decade or more for such treatments?

CAR-T is not sustainable, even in the US. In fact, it’s at the tipping point. They are at 18.5% of GDP expenditure on healthcare. If they reach 20%, the bubble will burst. 

We are looking at it in two to three different ways. First, educate people and physicians about the value of care. This doesn’t come intuitively to either patients or physicians. If you ask an individual ‘what is the cost of your life?’, the person will say, the earth. The reality of life is money is finite. Public health budget is earmarked for it. While I agree that India’s health expenditure must go up, what we can do now is make sure that the 1.5% of GDP that is spent on public health is spent well. Unfortunately, that’s not happening now. It’s mostly because of the market hype. When you have blockbuster drugs, advocates of that disease want that drug to be paid for in all cases, regardless of patients’ ability to pay. 

I am all for universal health coverage. But do we know that money is spent well, based on value? Let’s assume there are drugs which improve survival by two months, but cost Rs 10 lakh ($14,286). What is happening today is that with this Rs 10 lakh expense, somebody with a perfectly curable condition is not getting those funds. We need to make value judgments. It’s not easy. You could effectively be saying you can’t fund two months of someone’s life. 

I’ve been on panels where government officials have said they did not know most of the cheques they have signed are for treatment of patients in their final months.

Which is why our revised guidelines are stratified. 1) Optional care: You can have state-of-the-art care. If the richest man wants to spend $1 million for two days, so be it. It’s his life. He can get that. 2) Optimal care: Where we bring value into the equation—what is the quality of value adjusted as years of life saved versus the cost one pays. If Rs 10 lakh improves survival by two months, say no; if it saves 10 years, say yes. This may seem like rationing, but this is the rational way of rationing. Better than what we have today where the first 50 people get the treatment and the remaining 950 are deprived because the money has run out. 

The Ken: Is there a life before and after NCG, for patients and for doctors? 

There are some areas where we can see the impact. We are nowhere close to conquering the cancer problem in the country, but I can say that serious inroads have been made. We are very conscious of the fact that we need early surrogates of success. We started with a flat way of how the system would operate. We didn’t say these are 1-6 things that need to be done and let’s start with #1. In the past, most collaborations in India have been top-down and prescriptive. One of the reasons NCG has worked is because every centre feels it is contributing.

Mind you, TMH is not driving it. To say that would be undermining the effort of many, many people. NCG is extremely democratic. Most ideas have come from member centres. For instance, guidelines for treatment is not a new idea; we have set these in the past. Typically, they are formed by getting a group of experts from elite cancer institutes, who look at the guidelines from abroad and select a bunch based on evidence. We [at NCG] are not trashing that effort, it’s systematically done. But they are extremely cumbersome for physicians to follow. Some guidelines for a single cancer, like colorectal, run into 70 pages. The moment you have 70 pages, no chance a busy physician would even turn the pages. So we made it very concise—two pages, and in an algorithmic format.

The Ken: You mean input-based?

Yes, all that the clinician needs to do is to fill the specific figures/report outcomes in the matrix and the algorithm comes up with a treatment recommendation. For instance, if your patient has early breast cancer, then what’s the size of the tumour, has it spread to lymph nodes or any other part of the body, what is the biopsy report, etc. You fill in the data and the guidelines will tell if surgery has to be followed by radiation or chemo and so on. The same information is available in 72 pages otherwise.

An important part of this method is that the moment you get new evidence, you revise your guidelines. Our first set of guidelines came in 2017; a revision is underway as we speak.  

The Ken: Talk about one instance of data-based treatment driving this revision. 

Take the breast cancer drug, Herceptin. [Sold in India by Roche (the innovator), Mylan and Biocon; costs upwards of Rs 10 lakh ($14,286) for a full cycle.] It’s a breakthrough drug. We did a survey in 2008 at TMH where we looked at what proportion of women eligible to get the drug actually get it. It was 8%. Half of those got the drug because they were part of the clinical trial. Effectively, only 4% could afford to take the drug. This is true in most cancers based on western guidelines. 

We looked at data afresh. A study shows that instead of a year, if you give Herceptin for nine weeks, it is almost as effective as giving it for a year and at a fraction of the cost. We put this in the guidelines and now we repeated the survey, 10 years after the first survey. Now, 50% of women who need this drug are getting it, up from 4%. Of course, we were supported by philanthropic money, but still. We cannot allow ‘perfect’ to become the enemy of ‘good’. This practice is now being adopted in several other low-income countries, including several in Africa. 

The Ken: Have you been able to reduce migration? 

A lot of patients travel for the second opinion. Even coming from a capital city like Bhubaneswar in Orissa to Mumbai—to see the doctor, do the tests, come back to the oncologist and go back home—is an ordeal. We created an online second opinion platform in partnership with Navya Networks. Any patient, either from India or anywhere in the world, can take a photo of their reports and upload. We have given them, at the backend, a set of minimum requirements, what reports to collate in a structured manner for each cancer. For example, if it’s lung cancer, then we need a chest X-ray, a biopsy, a CT scan; and if there are other symptoms, then an MRI or a PET scan.

Entire scans can be uploaded. This is then structured and sent to experts at NCG. I get formal and informal reports seeking second opinion. But to look at 75 pages of a report over email isn’t possible. But if it comes in a structured format, it takes just 3-4 minutes to give my opinion. This platform has machine learning technology at the backend which continually improves it. It already comes up with 2-3 suggestions, which takes into account evidence elsewhere in the literature. In many cases, this is all that the patient requires. If the second opinion is different from the local doctor’s prescription, she can share it with the local doctor. 

We were doubtful about how confident the patient will be in showing this virtual opinion to their local doctor. So we ran a survey on 1,000 patients and 78% had shared it with their local oncologist; more than 75% went for the second opinion treatment. 

This system was meant for patients in India, but the internet has spread it. Now, 80% patients are from India, 20% from overseas. People in close to 48 countries have availed this virtual second opinion service. It costs about $100. Poorest patients get it free. Doctors here get zero fee, they do it pro bono. 

We haven’t marketed ourselves well. We curate the experts carefully. We could handle much more but we don’t want to make it a commercial product. It’s spreading by word of mouth.

The Ken: Is the rising tide lifting other boats?

It is. And in many subtle ways, too. Earlier, smaller centres faced the problem of not getting a multi-disciplinary approach. It’s non-trivial in cancer. Even in developed countries, if you go with a problem to a surgeon, he’ll suggest surgery; if you go to a radiation oncologist, he’ll suggest radiation; if you go to a medical oncologist, he’ll suggest chemo. There’s a really nice study in prostate cancer in the US which proves this. Getting all specialists in the same room is important to arrive at a rational decision. Very few cancer centres in India have this kind of expertise or system. This is increasing but not as high as it should be. 

At NCG, we have created a virtual consultation service. In the last 30 months, for over five hours, three times a week, multiple centres log in and discuss cases disease-wise. Some 25-30 centres and 100-120 oncologists log in every time and complex cases are discussed. When we started the virtual tumour board, we wondered why simple cases are coming up. Now the cases discussed are so complex it’s safe to assume the local centres are addressing simple ones themselves. 

The Ken: You recently signed an MoU with Ayushman Bharat (AB). What for? 

Ayushman Bharat can truly be a game changer in cancer care. We want to give roadmaps to governments for optimal care. Under AB, we are partnering with the government to rationalise the packages because the tariffs in many cases are irrational and it would make no sense for any hospital to participate. We are also introducing evidence-based packages. AB was launched in a hurry [last year] and several things were missing. 

We are linking pre-authorisations [of hospitals] or reimbursements to the NCG guidelines. Earlier, there was no regulatory mechanism to find if any guidelines were followed. If any hospital wants pre-authorisation, our software gives recommendations. If the hospital treatment follows the guidelines, it’ll automatically pre-authorise. No human intervention is required. This will cover 70-80% of the situations. In the remaining 20-30%, if doctors disagree with the NCG recommendations and provide a rationale, then that goes to an anonymised expert in the NCG. If approved, then that case also gets pre-authorised. Considering that AB covers 40% of India’s population, and 30% of AB’s reimbursements so far have been cancer-related, NCG can extensively aid cancer care in this country. 

This should be a model for anyone else to follow. How can a cardiologist take a decision for stenting without getting an opinion from a surgeon. Or vice versa. Unless this kind of dialogue happens, patients will continue to get suboptimal care.  

The Ken: So the NCG takes care of 60% of patients who come via its centres. Can the remaining 40% who go to private hospitals or doctors benefit from NCG in any way? Moreover, the private sector is pretty unregulated, to each their own. 

It’s a difficult question. We need to look at it in two ways. There’s growing mistrust between providers and people. On private providers’ part, there’s reluctance to be regulated. And to be transparent about themselves. Take electronic medical records (EMRs). Most centres have adopted EMR, but it is merely a way for them to keep a record. The patient doesn’t benefit in any way. When we introduced EMRs at TMH 10 years ago, we ensured the system permits patients to access their complete records from anywhere in the world through a user ID and password. They get unrestricted access to all their records. Even in the US, patients get only partial access.

We encourage our doctors to share outcomes, long-term survival, short-term survival, and compare. It may not be useful for the uneducated patients, but this is available. This kind of transparency is lacking in the private sector. At some point, some kind of regulation is required. No healthcare system can work well without regulation. 

I believe at least 40% of the population getting the right treatment is a form of regulation. If I were the insurance provider, I’d be sold on the idea that patients get treatment under this. Why wouldn’t they? It saves money, both for the patient and the insurance provider. 

Ten years ago when TMH had paper records, 30% of them were lost. In fire, floods or stolen in train. EMR saves you. It must be accessible

Dr CS Pramesh, Director, TMH

The Ken: There are rumours that AB’s scope could be expanded beyond the 40% population it is now meant for.  

Even I hear that rumour. That’s how taxes in Canada and Australia work, and everyone gets the best college, healthcare and what not. 

You don’t want AB to be seen as a poor man’s policy. You want it to be a policy that is the best. It’s great that it starts with the poorest, but it should not stop there. Then it begins to be associated with low-quality, low-value care. Instead, it should be high-quality, high-value service at low cost. 

The Ken: With the volumes at NCG, are you able to leverage it for a national cancer drug pricing negotiation?

It’s already happening. About six months ago, we began collating demand for drugs from cancer centres. As we speak, the request for proposal and tender processes are being discussed. But you have to be very transparent in your processes because these are big sums of money we are talking about. We follow government norms—right from the choice of government-approved e-tendering vendors and other best practices.

We’ve collated demand, but not all centres are participating because the current government rules do not allow centres to negotiate as a group. (A hospital like AIIMS in Delhi cannot procure at rates that TMH has got for itself. Instead, it must float independent tenders.) This news reached the deputy CEO of AB. The government is drafting an advisory that will go to all central and state health agencies stating that if they are unable to procure at lower rates, they are free to procure at NCG rates.

Some change has already begun. The Punjab government asked us to share our procurement tender—our costs are low because of our volume. Punjab is procuring at our price, without floating a tender. But this is an exception, rather than the rule. 

The Ken: What kind of price reductions are we talking here? 

We studied six different states’ procurement to see what the variation was. It was anywhere from 5% to 60%. That’s substantial. We are also conscious of the fact that some states are procuring at rates lower than TMH, which is surprising because owing to sheer volume, we get the lowest rates. [Maybe quality is suspect.] We’d have be assured of best practices. TMH doesn’t buy off the shelf. We have a set of 17 criteria, which are surrogate markers of quality. 

The Ken: Many pharma multinationals in India are downsizing. Do we run a risk, as a country, of missing out on new drugs? All said and done, many of them work wonderfully. 

Why are costs high in India? Look at the price at the company’s point of sale and then you add the multiple levels of margins by distributors and retailers or hospitals. The markup is huge, often many times more than the actual price. The moment you eliminate that and factor in the volumes, India becomes a huge market. Even if cancer incidence is low, we see around 1.5 million patients every year. Just work those numbers out. In Herceptin, moving from 4% to 50%, they made profits. It’s the Walmart model. MNCs would be foolish to move out of India. 

The Ken: How about the really high-value, high-cost drugs? 

For high-value ones, we should work out ways. CAR-T is a good example. But at half a million dollars, which will fund a full cancer centre in India for a year, you are saving one patient. We should be asking how can we reduce the cost. You can develop your own CAR-T cells.

The Ken: But that’s proprietary technology. Plus, no Indian pharma company is interested in next-gen biologics. Who will produce it in India?

There are many ways to skin the cat [and not use Novartis’ proprietary tech]. Several academic centres in the US are doing it, and there’s no reason why we can’t. We are coming up with a CAR-T therapy centre at TMH, which is outside of pharma. We are building a GMP [good manufacturing practices] facility. It shouldn’t cost that much. Less than a tenth of the cost of CAR-T. 

The Ken: What is your baseline? Can you say this is how the average survival rate in XYZ cancer has improved? 

That’s something that has tormented us for a very long time. Even when we started we wanted some baseline to evaluate ourselves. The hardest endpoint is mortality or survival, but unfortunately, getting that kind of data is the toughest nut to crack. We wanted to start with getting the IT linkage. But two-thirds of these centres have no EMRs, at the remaining third, EMRs don’t talk to each other. Now, we are partnering with iSpirt (a think tank for the Indian software products industry) to sort this problem. Using speech-to-text and a few other technologies, we are running a pilot between four centres to see how we can capture and use the best patient data. 

So, we are forced to look at other surrogates, like how many people have we been able to train, how do people continue with research after our six-day boot camp, etc. But if you are asking for the big picture, how have we impacted the mortality of cancer patients, we are at least a decade away. That kind of data doesn’t exist. 

The Ken: Could NCG, at some point, become the audit bureau for private hospitals’ cancer centres? 

It most certainly could. It should. But from the NCG’s point of view, we’d like to make it voluntary. Restrictions and rules keep centres away for real and unreal reasons. 

If you have an NCG-approved process, that entitles you to 15% extra of AB tariff, that is an incentive. That’s how NABH (National Accreditation Board for Hospitals & Healthcare Providers) has done it—if you are accredited, your reimbursement from the government will be 15% higher. 

Resisting upto 99.9% antibiotics: India’s superbug war begins

When it comes to antibiotics, an over 10% resistance is almost too high.

Indians show resistance as high as 99.9% towards some antibiotics. This, as per a paper published in the Indian Journal of Medical Research (IJMR) on 3 June—the first paper that indisputably establishes that Indians are alarmingly antibiotic resistant. Not only are Indians resistant to older antibiotics like penicillin by over 90%, the resistance to newer antibiotics like ciprofloxacin is also over 40%. The World Health Organisation (WHO) classifies antibiotics into three categories—access, watch and reserve, with each category stronger than the last.

In India, the drugs in the watch category have long crossed the 10% resistance mark. Even worse, Indians are becoming more and more resistant to some of the precious few drugs in the reserve category as they enter the human body through meat. The reserve category drug, colistin, for instance, is used to fatten the chickens in poultry farms.

India is now starting to look deep into this problem. Starting with a government conference in Kerala’s capital Thiruvananthapuram on 11 June. One that the deputy director of the national health mission in Madhya Pradesh (MP), Dr Pankaj Shukla, attended.

Shukla returned to MP, and at a never-before-for-an-Indian-bureaucrat pace, he framed and executed an antimicrobial resistance (AMR) action plan. In six weeks. As you read this, he’s giving final touches to it. Other states have also swung into action. Assam hosted its first meeting last week. Delhi has started the process to frame its action plan. The bureaucrats plan to finalise it next month. Shukla is ahead of the pack and plans to launch MP’s action plan on July 25. 

The conference convinced Shukla that AMR, which is killing more and more Indians every day, can be controlled. By not feeding antibiotics to chicken in poultry farms. Shukla was astonished to learn that resistance to antibiotics could be so easily avoided. Moreover, the weight of the chicken and size of the egg remained the same, he says.

Finger lickin’ antibiotics

According to a bureau of investigative journalism report, animal pharmaceutical companies in India were openly advertising products containing colistin as growth promoters – including Venky’s, which supplies meat to fast food chains such as KFC, McDonald’s, Pizza Hut and Dominos.

This chicken-and-egg solution is a precedent to a larger drive—an ‘antibiotic stewardship’ programme. And as per Dr Sanjeev K Singh, who instituted the programme in Kerala five years ago, it has led to a significant reduction in the use of antibiotics.

Singh, medical superintendent at Amrita Institute of Medical Sciences in Kochi, narrates the story of a 3-year-old boy who was brought to Amrita with congenital heart disease. He caught an infection that resisted all antibiotics; he died after three weeks. Singh encounters at least one or two such pan-drug resistant cases every month. The only ray of hope for Indians are the preliminary results of the stewardship programme; Singh claims it’s brought down mortality by one-fourth.

Shukla, meanwhile, has commissioned the training of 100 doctors in antibiotics stewardship, who will then train other doctors.

What does the programme do that can save lives? It teaches doctors a combination of practices to rationalise antibiotic use through the “right dose, right drug, right duration, right frequency, right patient and right indication,” says Singh. The current practice in India is exactly the reverse. A combination of prescribing antibiotics to those who don’t need it and denying those who do has led to superbugs that are stronger than every antibiotic available. The country is now waking up to this reality.

Over the last few weeks, representatives of patients unable to fight tuberculosis due to drug resistance met in Delhi to discuss the lack of medicines stocked by government centres. Meanwhile, Dr Kamini Walia, head of the Indian Council of Medical Research on AMR, who co-authored the IJMR paper, wades deep into telling data. It has taken her over five years to build evidence from India for something the scientific community already saw coming since antibiotics were discovered. 

Chronicle of data foretold

Sir Alexander Fleming, who was one of the three scientists to be awarded the Nobel Prize in 1945 for the discovery of penicillin, the world’s first broad-spectrum antibiotic, had warned that this day would come, says Walia.

“The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself, and by exposing his microbes to non-lethal quantities of the drug, make them resistant,” Fleming had said in his Nobel Prize acceptance speech. AMR is not new, but the data from India is. As alarming as it looks with Indians showing such high resistance percentages, Walia says that this data is an indication, not a reflection of the community.

The data  has been collected via a network of 20 hospitals that form the AMR surveillance network that ICMR set up. The problem with this data, she says, is that it came from only tertiary care centres, where people come after being prescribed multiple rounds of antibiotics at the primary and secondary levels. The samples are collected from the sick. Still, she says, over 70% resistance is madness. And it is growing.

Going forward, ICMR intends to start collecting data from secondary care hospitals and nursing homes to get a better understanding of resistance to antibiotics among Indians. A clear answer would still be elusive as India does not have microbiology labs at the primary care level. Even if the surveillance network does build evidence from the ground to support nationwide policy intervention on AMR, the future seems exactly as Fleming had warned.

You see, India has almost no alternative to pumping people with antibiotics. 

Sneezed? Here’s an antibiotic

The flow of antibiotics, after being produced by drug manufacturers and before they reach the patients, can be checked at two points—at the pharmacist’s and the doctor’s. Except neither has reason to avoid sales or prescriptions, respectively. 

In 2015, Dr Singh started collecting evidence from the ground. His team interviewed 3,000 doctors, over 200 labs and over 100 pharmacists across Kerala. The data (that would eventually lead to Kerala’s AMR action plan) established that the doctors prescribed newer antibiotics without any knowledge of AMR, as medical representatives (hired by pharma companies to market antibiotics) never warned them about the risks associated with them. It also indicated that about 50% of the time, patients asked doctors to prescribe antibiotics in the hope that they would recover sooner. Finally, doctors did not have a choice but to prescribe antibiotics as they either didn’t have access to detailed diagnostic lab reports or they didn’t trust the labs.

Doctors don’t want to lose the patient and want to go all out to save them, says Singh. For instance, every patient in need of surgery requires just one dose of antibiotics pre-surgery, but doctors, as a precautionary measure, end up prescribing three doses a day for 5-7 days. This, says Singh, is an irrational but common practice. Another example of bad prescription practice, he notes, is dual prescription. For instance, in the case of typhoid, clinical protocols require starting with old-generation antibiotics like chloramphenicol (over six decades old), then moving on to the newer ciprofloxacin family (five decades old) and then trying the decade-old ceftriaxone, moxifloxacin and gatifloxacin. But doctors, explains Singh, usually prescribe two drugs that do the same thing together as a safety net. This doesn’t make any clinical difference in outcomes, but it increases the chances of resistance to the newest drugs available. 

Not only do Indian doctors prefer to prescribe newer antibiotics, they prefer broad-spectrum antibiotics over narrow-spectrum ones, says Walia. The former can be used to treat a variety of illnesses without diagnosing the underlying illness, while the latter requires proper diagnostics.

A doctor can prescribe a combination of antibiotics for immediate relief and order a test at the same time. This sort of thing happens the most with upper respiratory tract infection and diarrhoea. Both, Walia adds, are self-limiting and not always caused by bacteria. However, when the diagnosis of the disease is more expensive than the drug, drugs are prescribed. A blood culture costs between Rs 500 ($7.3) and Rs 1000 ($14.6) but drugs cost Rs 200 ($2.9) to 300 ($4.4). Taking a drug that is widely available is often easier than getting a test done that is not available everywhere, says Walia.

ICMR has recognised hospital-acquired infections as one of the primary reasons for mortality among patients who are resistant to antibiotics. Also, doctors don’t de-escalate dosage with hospitalised patients for they’re vulnerable to bacteria present in the environment. After seeing the results of diagnostics, they are supposed to de-escalate the therapy, but doctors often don’t to avoid the risk of patients deteriorating, says Walia.

Walia says that hospitals often see infection control as a resource-intensive exercise, involving cleaning AC shafts to prevent bacteria or fungal survival. Pills are cheaper, she says. “Overall, people see eating and prescribing medicines as easy but washing hands as difficult. This is precipitating AMR,” she adds.

Apart from hospital-acquired bacterial infections, Neonatal Sepsis and Tuberculosis are the leading causes of mortality from antibiotics resistance, she says. ICMR has framed guidelines on hospital-acquired infections, but these are not mandatory as government hospitals are overburdened and cash-strapped, while private hospitals are outside regulatory purview. 

And the government does not want to regulate pharmacists.

An antibiotic a day

Every time there has been a discussion to regulate the 800,000 pharmacies in India from selling antibiotics over the counter and making them prescription-only, the central government stops in its tracks. Because doctors who can prescribe drugs are not available in remote parts of the country but pharmacists are.

“The government worries that antibiotics can save lives where a doctor is not there to write prescription,” said a senior bureaucrat with a body associated with the ministry of health. He requested anonymity as he did not want to criticise the government policy on what he sees as a sensitive issue. “Pharma companies have reached every village, but the government has not been able to ensure that the doctor reaches every village,” he said. 

In 2013, under the Drugs and Cosmetics Act, the health ministry had put certain 3rd and 4th generation antibiotics in a Schedule H1—they can be sold under certain conditions. While drugs under the Schedule H and Schedule X can only be retailed to a buyer with a prescription from a registered medical practitioner, the drugs under the Schedule H1, when sold, need to be recorded in a separate register (with the name and address of the prescriber, the name of the patient, the name of the drug and the quantity supplied, and such records shall be maintained for three years and be open to inspection). But this is not effectively implemented. 

The bureaucrat acknowledged the central government’s failure in regulating pharmacies and building healthcare infrastructure at the primary and secondary level. When Singh had surveyed Kerala, he had found that 76% pharmacists admitted to selling antibiotics over the counter even when they were prescription drugs. 

Shukla, in MP, intends to enforce the law at the state level. “We are making software to ensure every H1 antibiotic will be uploaded in the software. We can see who were the prescribing doctors, patient and the pharmacist,” says Shukla. Last year, he had found that most of the antibiotics were prescribed in excess for diarrhoea and pneumonia, both of which may not need antibiotics at all. 

The problem, however, doesn’t end at the lack of regulation in sale. The governments (both centre and states) are also unable to ensure the sale of newer antibiotics at government centres for those suffering from drug-resistant tuberculosis (DR-TB). A form of drug-resistant disease that leads to mortality.

Missing drugs

According to a government’s survey conducted between 2014 and 2016, 2.84% of about 2.79 million TB patients added annually have multi-drug resistant TB. The highest in the world.

And yet, it’s all too common for government-funded TB centres to run out of life-saving DR-TB drugs. This was the topic of discussion at the Delhi meet on 1 July, where representatives of patient groups, DR-TB survivors and public health activists came together to “assess the extent of the shortages and find out why they were happening,” says Blessina Kumar, CEO of the Global Coalition of TB Activists. 

An activist from Jharkhand, who did not want to be named, reported a stock-out of levofloxacin, cycloserine, ethionamide and pyrazinamide in his state for over three months now. A DR-TB survivor, who lost her hearing during the treatment, reported a stock-out of pyridoxine, a supplement used for DR-TB treatment, in Maharashtra government centers.

Bio and antibiotics

In 2016, researchers at IIT, Hyderabad reported high levels of antibiotics (fluoroquinolone) residues in water and sediment samples of the Musi river. Another study, published in Infection, shows that water samples from the direct environment of bulk drug manufacturing facilities were contaminated with antimicrobial pharmaceuticals and resistance genes.

“Community representatives have been reporting shortages and stock-outs of TB and DR-TB drugs for months,” says Leena Menghaney, an HIV and TB treatment activist. She also manages the access campaign at nobel laureate not-for-profit Médecins Sans Frontières (MSF). “It could be for a variety of reasons, like delay in finalising tenders, supply chain inefficiency, or just red tapism,” she explains. When one of the activists wrote to the government TB department in Delhi, they said that the drugs were available in the central government warehouses and blamed the states for not ensuring access in district centers. Menghaney says the solution lies in supply chain reforms recommended by the World Health Organisation. Reforms, she says, can bring transparency, show which warehouse holds which medicine and ensure access. However, without transparency, the central government can blame state governments, states can blame the district TB officers, and no one knows the reason for the shortage of a crucial antibiotic at the government centre. An opaque supply chain for drugs where stock-outs are common can lead to even more drug resistance, she adds.

With every dose missed in the treatment regimen of a patient suffering due to drug-resistance, the chances are that the bacteria has become more resistant. Similarly, every misuse of last-resort drugs by patients who never needed them ruins their chances of getting better should they ever need a newer drug.

The result is fear. Fear that patients, doctors and bureaucrats feel for the future of AMR in India. 

MSF has recommended that linezolid—a higher-end antibiotic categorised as reserve by the WHO but sold over the counter in India—be withdrawn from the private market to prevent AMR. Meanwhile. the Delhi based not-for-profit Center for Science and Environment  is lobbying to ban colistin in chicken feed. 

States can do their part, but the clock is ticking. If the national government does not wake up to the dangers of AMR, soon there won’t be any drugs left that Indians wouldn’t be resistant to.

Fiinovation and the CSR funding pot at the end of the rainbow

On 18 February at the World Corporate Social Responsibility (CSR) Congress in Mumbai, Soumitro Chakraborty, CEO of Innovative Financial Advisors Pvt Ltd (Fiinovation), was the toast of the town. The Congress focused on companies helping implement sustainable development goals in health, education and the social sector. That night, Chakraborty won the ‘CEO of the year’ award for Fiinovation’s work in the social development sector.

This was hardly a coming-out party for Chakraborty. Indeed, the bespectacled CEO and his Delhi-based organisation have frequently been conferred with a number of CSR-related awards.  Already a decade-old, Fiinovation calls itself a fundraising consultant firm—helping non-profits raise CSR funds from corporates.

The homepage of Fiinovation’s website

Fiinovation’s rise to prominence in the CSR space coincides with the government’s 2014 mandate that companies spend 2% of their three-year average annual net profit on CSR activities each financial year. This is applicable to firms with at least Rs 5 crore ($730,000) net profit or Rs 1,000 crore ($146 million) turnover or Rs 500 crore ($73 million) net worth, starting in the year ended March 2015. 

Ever since then, CSR funding has snowballed. According to estimates by ratings agency CRISIL, CSR spends by Indian corporates in the four years since the government mandate crossed the Rs 50,000 ($7.3 billion) crore mark earlier this year.

And as this pot of CSR gold grows larger, it presents an opportunity for shrewd firms like Fiinovation looking to be the go-between in these interactions between the worlds of commerce and social work. Fiinovation’s revenue grew by 13% in the year ended March 2018, clocking in at Rs 9 crore ($1.31 million). 

But even as revenues grow and accolades come thick and fast, there is a rising tide of accusations against Fiinovation. Small, disparate organisations across the country claim that Fiinovation signed agreements with them to raise CSR funding, but never came through. The upfront payments—the company charges a 10% commission, of which 4% is paid in advance—made to Fiinovation were, in many cases, never returned. 

According to a list accessed by The Ken, somewhere around 5,000 organisations have faced similar issues. The list was shared by a former company insider who requested anonymity. The Ken could not independently reach out to each one of them, but of the thirteen we reached out to, all told a similar story—Memorandum of Understanding (MoU) signed, no funds raised. Only two of them got a refund of commission.

The Ken also has a copy of the police complaint filed against Fiinovation by one of the organisations—Samekit Jan Vikas Kendra, a Christian non-profit based in Jharkhand. In addition, The Ken has accessed a letter sent by 35-year-old NERD (Non-conventional Energy and Rural Development) Society, Coimbatore, as well as a copy of the MoU and receipt issued by Fiinovation to Tarapur Social Development Society (TSDS), West Bengal.

As small, needy social sector organisations blindly queue for their serving of CSR largesse, they open themselves up to a host of potential pitfalls.

Out of reach

Abhishek Humbad is the founder and CEO of Goodera, which manages the CSR funds of more than 200 companies. All told, Goodera is in charge of about 25% of the country’s CSR spends, according to Humbad. He estimates the total annual CSR spend in the country is around Rs 10,000 ($1.45 billion)-12,000 ($1.75 billion) crore.  

The sheer size of the annual CSR pool has necessitated a more professionalised approach in the way it is disbursed. Monitoring and evaluation of projects is now a board-level responsibility. As such, CSR is no longer simply a matter of benevolence—companies need systems, processes, technology, tools, and professionals to handle it. 

“This means that there is a segment—an opportunity to create more value from the huge quantum of money. There is a rise across the value chain, right from defining the strategies. There are consultants who will do NGO matchmaking and contracting. This is [leaving] material impact in terms of reducing leakages or having the smaller nonprofits also get access to corporate capital,” Humbad says, adding that these are ideal outputs.

Goodera does not raise funds for NGOs as it is a conflict of interest. It only manages CSR funds for corporates. “In the case of our platform, the company sets up a request for proposal, which goes out to NGOs. Then, NGOs bid for it… it is a huge evaluation process,” Humbad explains.  

Ultimately, Humbad explains, it is essentially a sales job to get funding, and this is where Indian NGOs fall short. “There is a lot of difference between a US NGO and the Indian NGO in terms of fundraising capabilities. The US NGO is almost like a sales organisation. Whereas, Indian NGOs are implementation organisations without a sales arm,” he said. 

Opportunity knocks

Limited in their ability to raise donations independently, smaller social sector organisations are susceptible to the sales pitches of firms who say they can facilitate funding. “We hear from NGOs that many aggregators come to them saying we need all your documentation and then create a profile on a platform. They pay for the flow, and then nothing happens for a couple of months. It eventually dies down,” he said.

Fiinovation, for its part, promises to mobilise funds through the Pradhan Mantri MUDRA Yojana (PMMY) scheme as well as CSR funds from corporates. PMMY is a scheme launched in 2015 which provides loans up to Rs 10 lakh ($14,600) to non-corporate, non-farm small/micro-enterprises. These loans are disbursed by commercial banks, regional rural banks, small finance banks, micro-finance institutions and non-banking finance companies, and don’t require third-parties to facilitate them. Instead, the borrower can approach any of the lending institutions mentioned above or even apply online.

In exchange, the non-profits partnering with Fiinovation agree to pony up 10% of the total funding raised as a commission—4% as an advance and 6% on completion. For small organisations, the lure of a CSR windfall can be heady, overriding apprehensions about the size of the commission. According to Yashasvini Priya, human resource manager at Fiinovation, organisations that partner with Fiinovation go through multiple levels of vetting. The initial vetting is based on documents, but as the donor proposal nears finalisation, an onsite and physical vetting is mandatorily done. Multiple non-profits The Ken spoke to, however, claim that no such vetting was ever done. One of them was the Bharat Vikas Parishad Seva Sansthan (BVPSS).

Arvind Goyal, a chartered accountant by profession and the president of BVPSS, vividly remembers walking into Fiinovation’s office in Okhla, Delhi, two years ago. Goyal, then still the secretary of BVPSS, came bearing files. He had flown all the way from Kota, Rajasthan, where the 26-year-old BVPSS runs a hospital and research centre. Goyal was hoping to raise funds to expand the hospital.

Goyal’s visit was the culmination of a series of telephone conversations with Fiinovation’s Chakraborty. Finally, he’d been asked to visit Delhi, documentation in tow. He only met Chakraborty once, but his first impressions put him at ease. “Their office was well-furnished and impressive to look at. They (Fiinovation senior management) told me that they hadn’t raised such a large amount—Rs 2.2 crore ($321,000)—before but have successfully raised smaller amounts. They said that they have done a lot of rural development work,” Goyal recounts.

That same day—10 March 2017—Goyal signed an agreement with Fiinovation, agreeing to pay an upfront fee of Rs 10.12 lakh ($14,800) along with tax. “I transferred the money through a bank transaction. They promised Rs 2.2 crore funding within 240 days—by November 2017,” he said.

The funding never materialised. The advance money was never returned. 

Fiinovation’s Priya accepted that some fundraising efforts do not work out as proposals for donations sometimes fail to pass muster with audits done by donors, but Goyal and other non-profits claim that this was never mentioned at the time of signing the MoU. This possibility is also not explicitly mentioned in the MoUs The Ken has accessed. And while Fiinovation claims to “have a dedicated customer support department which deals with clients’ queries and grievances” and tries to resolve them as fast as possible, conversations with their clients tell a different story.

Selling dreams

“I’m made false promises every time I contact Fiinovation for my refund for the past two years. Finally, I sent a legal notice (a copy of which The Ken reviewed) in April this year for which I did not receive any reply. I’m fed up now,” Goyal rues. The BVPSS eventually raised money on their own to fund the hospital expansion.

BVPSS is hardly the only organisation that bought into Fiinovation’s allure and was left counting the cost. Most of them have a similar story. They stumbled across the company in their search for funds. Some found out about it through SMS announcements sent out by Fiinovation, others found the company’s website—the homepage of which is emblazoned with Chakraborty receiving a plethora of awards—compelling.

What came next was a convincing pitch from a sales executive, followed by a visit to Fiinovation’s plush Okhla office. Here, they’re treated to stories of funds raised and organisations that benefited from Fiinovation’s services. And then the clincher—promises of funding in less than a year.

Sold on the prospect of CSR funding, most are quick to sign on the dotted line. But what makes the decision easier is the refund clause in the MoU. Both MoUs explicitly mention a refund if Fiinovation fails to fulfil its fundraising—a complete refund if Fiinovation is unable to raise at least 50% of the committed value by the agreed deadline, or a 50% refund if Fiinovation fails to raise at least 75% of funding by the deadline. With these safeguards in place, small organisations with big dreams find it easier to part with the advance amount.
Mainak Roy, founder-CEO of Delhi-based Simple Education Foundation, says his organisation signed an MoU with Fiinovation to raise funding within a ten-month period. The Ken has accessed a copy of the MoU (signed in November 2017), which states that the advance would be returned should Fiinovation fail to raise funding by the stipulated deadline (September 2018).

Initially, Roy was informed that Century Plywood was interested in funding Simple Education. Later he was told that they’d dropped out, but other companies were interested. When he asked to pitch to interested parties in person, he was refused.

Simple Education hasn’t received any funding to date through Fiinovation, and it has been more than two months since they formally raised a refund request with Fiinovation. “Young and financially unstable non-profits are coming under their influence and losing out on valuable capital. Their work is getting stuck too,” Roy said.

Inside Fiinovation’s CSR gravy train

From the outside, Fiinovation presents a perfect picture. Big-name corporate partners such as the Aditya Birla Group and the Bill and Melinda Gates Foundation. Awards from all and sundry. A range of projects across sectors such as agriculture, education and healthcare. Ex-employees, though, say that this is only half the story.

According to one ex-employee, who asked not to be named, around 20 non-profits are brought in on a daily basis to the company’s Okhla office. Explaining the company’s functioning, the second ex-employee says that the two main teams are the sales and CSM (Client Support Management) teams. “While the sales team is big and robust—making hundreds of calls to NGOs across India every day—their CSM team is responsible for holding on to clients,” he said.

“Employees there work in silos, and it takes time for them to grasp what exactly is happening there. Day in and day out, project reports are churned out. Detailed project reports in every sector like health, education, livelihood and agriculture. Out of 100 NGOs they call, funding is raised for 25% of them and the contact numbers of this small group of people are given out to newer clients for giving good testimonials,” he said.

One such non-profit based out of Odisha which works in the agriculture sector reached out to The Ken saying that they had successfully raised more than Rs 50 lakh ($73,000) through Fiinovation. The caller, while refusing to identify her NGO, said while three of their projects are pending, one of them has been successfully funded. She says that she’d personally provided positive testimonials to prospective Fiinovation clients.

For those with less positive experiences, though, the CSM team is deployed to pacify them. “They are trained on how to handle callers. First, pacify and keep delaying the refund. If they sense that the client is powerful and has political connections, they put them in touch with a senior. If they threaten legal action, their money is refunded,” says the second ex-employee.

Multiple sources who claim Fiinovation reneged on its fundraising commitments say that when they demand refunds, they’re not even allowed inside Fiinovation. Requests to speak to the CEO are denied, whether in person or over a call. Fiinovation’s Priya indicates that such a situation is an outlier. “I can assure you that our intent has always been clear and once a client solicits refund (which is a procedural requirement as per a clause in the agreement), the process is taken up immediately upon confirmation. If there is something that has skipped the system, I will be happy to help them in this regard. Our entire business prophecy is based on ethics, transparency and workmanship,” she wrote in an email.

However, out of the 13 organisations The Ken reached out to, only two had received a refund at the time of writing this piece. Many have been chasing their refunds for years.

When the music stops

As non-profits begin to realise they aren’t isolated cases, many are now banding together to seek remedial action. “A few days back, I received an email where companies defrauded by them were getting together to form a group and file a police complaint,” says Palash Chandra Konai, head of 18-year-old TSDS. Maybe Fiinovation got a whiff of the impending complaint, he says, because they’ve said they will refund my money with 12% interest by July. “I will wait till the end of this month and then proceed legally,” he added. 

Konai had already wanted to file a complaint but didn’t do so because of what it would entail. “The company falls under Delhi’s jurisdiction, that is why I couldn’t file a complaint and pursue it,” he says.

Jamshedpur-based Samekit Jan Vikas Kendra (SJVK), meanwhile, filed a police complaint at the Okhla police station in December 2018. SJVK has accused Fiinovation of failing to refund the sum of Rs 20.53 lakh ($30,000) SJVK had paid the firm as commission. The complaint was filed some 15 months after the MoU was signed with Fiinovation, well after the MoU’s 240-day deadline had passed. As per the signed agreement, Fiinovation was supposed to raise funds for four of SJVK’s projects. NERD Society has also sent the firm a legal notice to which there was no reply.

(To read the full legal notice above, click here.)

While Fiinovation did respond to some questions from The Ken, it also avoided specific questions about how its tie-ups with non-profits come about, the amount of funding it has helped raise so far, and the success rate of its fundraising efforts.

Noshir Dadrawala, CEO of Mumbai-based Centre for Advancement of Philanthropy (CAP), says approaching ‘consulting firms’ for raising funds is never a good idea. CAP specialises in charity law and good governance practices for non-profit organisations. 

“People think there is a lot of potential with CSR funds with foreign funds not coming in (due to the government’s crackdown on foreign funding)… Never trust these consultant firms. I myself get calls with proposals and a fee. It’s been going on for years, and now it is going on more,” he warns. Further, he says, there’s no provision under the Indian Companies Act that punishes such firms. “The only way to go about it is filing a police complaint,” Dadrawala says.   

So what then for non-profits in need? “You have to fund yourself. One cannot trust these agencies to raise funds for you. If you’re unable to fund your project, then probably something is not right with your project. That’s why you’re not getting funding. You have to build your capacity so people would fund you, else you will be duped like this,” he said.   

Goodera’s Humbad reiterates this. “We need to look at how we can equip or empower these NGOs to effectively engage and communicate with potential and existing donors so that they can do more fundraising. But it is essentially a sales job to get more and more donations, and more digitally-enabled donations, rather than doing charity dinners, auctions, etc.,” he says.

Meanwhile, Fiinovation is growing. It announced the opening of a new office on its LinkedIn page. At what cost this growth has been achieved, though, is anyone’s guess.

In a post-polio world, India cannot sit still

The global initiative to eradicate polio had big dreams for 2019. It was the latest deadline for the eradication of the polio virus in both Afghanistan and Pakistan. Reports in July, however, indicate that 2019 can be added to a growing heap of missed deadlines. Not only is polio still rife in both countries, but its prevalence seems to be increasing. 

Pakistan has seen four times as many cases of polio thus far in 2019 as it did in the same period last year. Set against this backdrop, the situation in India seems comparatively sanguine. The World Health Organisation (WHO) declared Indian polio-free in 2014, and it has stayed that way since.

But while polio may be in India’s rearview mirror,  other viruses may be rushing to fill the niche left by its eradication. Back in 2015, reports emerged of 208 children in Uttar Pradesh, India’s most populous state, developing polio-like symptoms. Given that the World Health Organization had declared India polio-free scarcely a year ago, the news triggered panic. Had the dreaded virus made a comeback? 

Eventually, a 20 June press release from the Ministry of Health and Family Welfare calmed these apprehensions. It said that even though the cases looked like polio, samples from the children were negative for the virus. What the children had was Acute Flaccid Paralysis (AFP), a broad basket of symptoms with causes other than polio. “India is polio-free,” the press release assured.

Four years later, it isn’t clear what happened to these children. Did they recover—many cases of AFP are transient, and patients make a full recovery. Did some remain paralysed for life? What caused their illnesses, if not the polio virus? No central or state agency knows the answer. This is because India has no systematic program to investigate non-polio AFP cases, even though 36,338 cases were recorded in 2018. 

The lack of research in this critical area is “very tragic,” says C Durga Rao, a microbiologist at Bengaluru’s Indian Institute of Science. Rao has studied viruses associated with AFP in the past.

Even though no central agency investigates every case of AFP, sporadic studies conducted by Rao and other scientists point to the role of some troubling viruses. Many children with paralysis are infected by members of the genus enterovirus, to which polio belongs. This genus has microbes like EV71 and EVD-68, which have been dubbed “the next polio” because of the crippling disease they can cause. 

For example, EV71, which circulates widely in East and Southeast Asia, kills or paralyses a large number of the children it infects. A study by Rao between 2007 and 2009 and another by Mumbai’s Enterovirus Research Centre between 2008 and 2012 found EV71 among AFP cases in India.

Meanwhile, EVD-68—which attracted global attention for being linked to major AFP outbreaks in the USA and Europe recently—was identified in a 2-year-old Maharashtrian child with respiratory illness in 2017.

But these viruses are merely the headline-makers; there are around 70 other enteroviruses capable of harming humans. Out of these, researchers have also identified echoviruses and coxsackieviruses in the stools of India’s AFP-afflicted children. These studies are not definitive proof that the viruses are causing the AFP (the viruses may be present in the children’s bodies without causing harm), but they provide a reason to look deeper. 

Such deeper investigations may reveal that many AFP culprits are not enteroviruses at all. For example, the West Nile Virus and Epstein Barr virus are also known to trigger paralysis. The botulinum toxin, which contaminates foods like milk, can cause a similar syndrome. Finally, some vaccines, such as the influenza jab, trigger an autoimmune illness called Guillain-Barre Syndrome, which looks a lot like AFP.  Nobody has tried so far to pick apart this grab-bag of AFP causes in India systematically. But experts say it is high time to do so.  

The double-edged victory over polio

AFP was first used as a surveillance tool in 1985 when the Pan American Health Organization decided to end polio in the Western Hemisphere. Polio is a difficult disease to diagnose; many other afflictions look a lot like it. So, instead of leaving it to doctors and ill-trained medical workers to spot its symptoms, a decision was made to collect stool from every case that looked like polio. Basically, every AFP case. WHO soon recommended the same strategy, and India followed suit in 1997.

But things didn’t go as expected. Since polio was the biggest cause of AFP in the nineties, the assumption was that the AFP burden would shrink as polio declined. The WHO even estimated the number it would drop to: non-polio AFP cases for every 100,000 children under 15 years (NPAFP rate) ought to shrink to around 1-2 each year, it said.

This happened in countries such as the US and Sri Lanka. But in India, AFP numbers rose. Between 2001 and 2011, for example, India’s NPAFP rate grew from 1.88 to 16.14. Total AFP cases, which include NPAFP as well as confirmed and suspected wild poliovirus infections, jumped from over 7,000 to 60,000 per year. And the numbers still haven’t fallen to WHO’s estimate. Even in 2018, polio-free India had an NPAFP rate of 9.73.

Polio experts have proposed several explanations for this spike. The most common one is that India has an exceptionally intensive AFP surveillance network—one of the best in the world. And around 2003, already struggling with a huge number of cases, India dialled its surveillance up a notch, counting even borderline cases as AFP. Further, it began increasing the number of centres that reported AFP cases—from over 20,000 in 2004 to over 35,000 in 2012. And some of the reporting sites weren’t hospitals at all, but even temples and quacks, where families often took stricken children.

The consequence of this was that a number of mild cases, and cases which weren’t even paralysis, were caught in the AFP net, some experts say. “Even a slight injury, which leads to 2-3 days of limping, gets reported by hospitals because surveillance is intense,” says Jagadish M Deshpande, who previously headed the Enterovirus Research Centre and worked on polio surveillance systems in India. This would mean that a number of AFP cases may not be paralysis at all.

Yet, there are other children who do become permanently disabled. And neither the National Polio Surveillance Project (NPSP), nor any other Indian agency has any idea of how many cases fall in this category. This is because of a blindspot in India’s AFP monitoring. “Once the sample is negative for polio, the story ends,” says Govindakarnavar Arunkumar, a virologist at the Manipal Centre for Virus Research in Karnataka. The negative samples are typically not investigated further by NPSP, although external researchers like Durga Rao have conducted occasional studies. 

The patchy data that exists, however, suggests that a significant number of AFP cases end in permanent paralysis.

A critical blindspot

Over a decade ago, C Sathyamala, a researcher from Delhi’s Council for Social Development, sought information on the number of children with long-term symptoms under India’s Right to Information Act. She found that in 2006, NPSP had tracked some 2,043—around 18%—AFP cases in Uttar Pradesh. Out of these, 989 had residual paralysis and 244 died. 

Based on this, Sathyamala argued in a letter to the Indian Journal of Medical Research that intensive surveillance systems couldn’t fully explain the high number of AFP cases in India.

Of course, the information received by Sathyamala pertains to UP alone; nothing is known about NPAFP elsewhere. This paucity of information even when NPSP collects samples from all paralysis cases is disturbing, says T Jacob John, a Vellore-based virologist known for his work on polio. “Doing AFP surveillance from late 1990s, and not knowing the exact clinical diagnosis of every case even in 2019 is diagnostic of a paralysed health management system,” he says.

When asked why no systematic attempt was made by India to uncover top causes of NPAFP, Deshpande said the NPSP had been geared towards polio, because it was the most common illness.  Identifying the reason behind every other case of AFP would be expensive and difficult, given the hundreds of viruses, bacteria and other factors involved, according to him. “If there are ‘n’ number of causes, every cause may not get investigated in the program because the program has to focus on something.”

“Doing AFP surveillance from late 1990s, and not knowing the exact clinical diagnosis of every case even in 2019 is diagnostic of a paralysed health management system,”

—T Jacob John, virologist

Varun Sagar, a resident of Karnataka’s Tumkur district, is one of the children permanently crippled by AFP. Two years ago, Sagar, a six-year-old with a shy, milk-toothed smile, lost the use of his right arm after a bout of fever. “He woke up one morning and his arm was hanging loose,” says N Gangaiah, his father. Sagar has now begun attending upper kindergarten and is learning to write with his left arm.

In August 2017, after consulting many doctors, Gangaiah took his son to paediatric neurologist Vykuntaraju KN of Bengaluru’s Indira Gandhi Institute of Child Health. The doctor diagnosed the child with Acute Flaccid Myelitis (AFM), a type of AFP in which the myelin—the protective sheath around nerves—is damaged.

Sagar was not the only child with AFM who came to see Vykuntaraju that month. During July and August 2017, nine others with strikingly similar symptoms visited the hospital– an unusual occurrence, says the neurologist. Such a cluster of cases typically points to an outbreak, and so Vykuntaraju conducted further investigations to identify the cause. But despite testing for dozens of pathogens, including West Nile Fever and Zika, the group wasn’t able to identify the culprit, as they reported in a 2018 paper.   

The spectre of the next polio

While Sagar’s family may never know what was behind his illness, one emerging AFM cause that has attracted global attention recently is EVD-68. Around five years ago, the US and Europe saw a sudden rise in children with severe respiratory illness, with a fraction developing AFM. Investigations revealed that the cases were likely due to EVD-68, an enterovirus first isolated over 50 years ago. 

The sudden spike in severe EVD-68 disease was a surprise because this microbe had historically caused only a mild cough and cold. But the AFM outbreaks kept coming. After dying down in 2014, they recurred in 2016 and in 2018, too.

To some researchers, the unexpected emergence of EVD-68 after decades echoes polio’s rise as a global scourge. Before the twentieth century, paralytic polio occurred sporadically, causing small outbreaks. Then, driven by a combination of factors, the disease exploded onto the world scene, afflicting tens of thousands of children at its peak in the mid-twentieth century.

Nobody knows what trajectory EVD-68 will take, but it does look a bit like polio. “It is clear that EV-D68 has increased in pathogenicity since 2014,” says Nicholas M Grassly, an epidemiologist at the Imperial College of London. According to one estimate, EVD-68 attacks neurons and causes AFP in roughly 1 in 100 symptomatic cases. But what made the virus shift its behaviour so dramatically? Some studies suggest that specific mutations that occurred since 2006 may have helped EVD-68 target neurons instead of just the respiratory system.

It is impossible to say if EVD-68 will ever become as widespread as polio. “The simple answer to this is that we don’t know,” says Grassly. But, he adds, it is important to track emerging enteroviruses so that vaccines can be developed to keep them in check.

India’s Pandora’s box

In India, however, such tracking doesn’t happen, so it isn’t even clear if EVD-68 is circulating here. It is present, however, as the Pune-based National Institute of Virology’s finding of the virus from a child in Maharashtra shows. Vykuntaraju, who has treated children with AFM, says his team couldn’t test for EVD-68 because they didn’t have the lab facilities to do so. 

Mumbai’s Enterovirus Research Centre also looked for EVD-68 in an as-of-yet-unpublished study of over 4,500 stool samples from NPSP in 2014 and 2015, says VK Saxena, the scientist who led the study. They didn’t find the virus, but this doesn’t mean much because EVD68 is difficult to isolate from stool, and requires respiratory samples. 

Meanwhile, India has several other concerning viruses. Take EV71, whose historical trajectory has also reminded scientists of polio. The virus has caused large outbreaks of hand, foot and mouth disease in China and other east Asian countries, with a fraction developing AFP or dying. 

Studies by IISc’s Durga Rao and Mumbai’s Enterovirus Research Centre have found this virus in the stools of AFP patients across India. The mere presence of EV71 in stools doesn’t mean it has caused paralysis—enteroviruses are widely found in the stools of healthy children too, and scientists typically compare the prevalence in healthy children with sick children to find out if the virus is really causing the disease. However, it’s reason enough to stay alert. 

Scientists are not very sure why India hasn’t yet seen massive outbreaks of hand, foot and mouth disease like neighbouring China has, given that EV71 is here too. But according to Saxena, this could be due to the milder varieties of the microbe circulating in India. This situation may change quickly, though. 

In their 2014-15 study, Saxena’s team found a virulent variety of EV71—the genogroup B, linked to hand-foot and mouth disease in Southeast Asia—among AFP-afflicted children in Mizoram. “This is very bad news,” Saxena said. “If the virus spreads to the rest of India, we will be in deep trouble because we are not prepared for anything like that,” he said.   

State of surveillance

The only way to be ready is surveillance. It may not be possible to diagnose all, “but it will be nice to know the top five reasons for AFP in India,” says Gagandeep Kang, a microbiologist and the executive director of Delhi’s Translational Health Science and Technology Institute. 

Such surveillance will neither be straightforward nor cheap. AFP is a huge basket of diseases, under which distinct syndromes like Guillain-Barre and AFM are lumped. So, the first step will be for doctors to identify these syndromes based on a child’s symptoms, says Arunkumar. Merely identifying the virus in stool without correlating it with symptoms is misleading because healthy children excrete viruses too.

Once symptoms are mapped, hospitals can send their samples to a network of well-equipped labs, which will use this data to decide which viruses to test for. For example, a cluster of Guillain-Barre cases could point to zika, while a cluster of AFM incidents could indicate EVD-68 or West Nile. 

This two-step process is important, says Arunkumar, who runs a surveillance project to identify causes of fever across several Indian states. “We need to sub classify cases and investigate appropriately because otherwise it is a very huge investment and you won’t get anything for it,” he says. The fever surveillance project run by Arunkumar was started with a 4-year grant of $9 million from the US’ Centres for Disease Control and Prevention.

Expensive or not, such a system could help identify AFP’s biggest causes and prevent further cases like Varun Sagar’s. At the very least, it will allow the families of affected children to understand why the paralysis occurred. Today, in the absence of a known cause, Sagar’s mother wonders if the cellphone tower next door was the culprit. They will keep guessing at the reasons for years to come.

Up all night: Capitalising on India’s big sleep gap

It was in early 2018, in the temperature-controlled Sleep Research Laboratory in the Life Sciences department of Delhi’s Jawaharlal Nehru University (JNU), that seven mice took us one step closer in the quest to unravel the mysteries of sleep. Shepherding them was Dr Sushil K Jha, a neurologist who’s devoted 20 years to mine whatever there is to know about sleep and memory consolidation.

In his experiment built on classical conditioning, Jha trained the mice to respond to a light that’d flash before a dispenser apportioned some juice. He then conditioned some to sleep after the ‘treat’, and restricted the others’ sleep. His findings? One: that sleep-deprived mice didn’t respond to the sequence of events and forfeited their chance to get juice. Two: proof that sleeping cements appetitive memory, or memory of food-related stimuli. Appetitive memory is what makes us pick a cola in a clear, chilled bottle over cola in an opaque plastic bottle. It’s what prevents animals from visiting an area rich with food if they’re conditioned by the stimulus of a threat (read: predator) there. Sleep dictates responses to stimuli and can be the difference between whether you have, or are had.

“In essence, sleep deprivation after the acquisition of a new memory leads to some impairment of that memory,” Dr Jha underlines.

Let’s zoom out and view things in perspective. In March 2017, activity tracker Fitbit announced its India-specific data for 2016. India was the second-worst sleeper (6.55 hours) after Japan (6.35 hours). As per the Sleep Cycle app, which updates country-wide findings every week, fewer than 20% Indians sleep for eight hours. Godrej Interio’s 2018 survey, which had 8,000 participants in metros, revealed that 93% reported sleep deprivation. Mattress startup Wakefit, which has an ongoing survey called the Great Indian Sleep Scorecard, released its findings across Bengaluru, Hyderabad, Delhi, and Mumbai in March 2019. Mumbai had the worst sleep, with 81% respondents reporting insomnia and 36% sleeping less than seven hours, followed by Delhi, Bengaluru, and Hyderabad.

It’s fair to raise a brow over sleep surveys by commercial stakeholders in the ‘sleep economy’. But India has no official or government-mandated sleep survey to date. We’re one of many countries on a bandwagon that equates the lack of sleep with success. Nowhere is this more apparent than in the US, where Silicon Valley is obsessed with attaching metrics to sleep, turning a necessity into a task to be perfected in the cult of productivity. Sleep, as they know it, is an inconvenience in the pursuit of optimum wakefulness, something to be hacked through. Consider Oura smart rings, electromagnetic field-blocking Faraday tents, mattresses with sensors, white noise machines, lights that simulate sunrise, mulberry silk eye masks, and Nightfood.

Yet, the US’ Centers for Disease Control and Prevention declared sleep deprivation a public health epidemic. No such concern in India, whose prime minister uses lack of sleep (3-4 hours) as some kind of calling card.

India’s sleep economy largely operates on the fulcrum of bedding and treating disorders like obstructive sleep apnea (OSA) and insomnia. These seem drab compared to flashy sleep tech developed elsewhere — unless you listen to those who harbour dreams of culturing a sleep ecosystem in the country.

But first, a crash course. Why do we need sleep?

Short answer: We don’t know.

Sleep science

“As far as we know, the only reason we need to sleep that is really, really solid is because we get sleepy.”

This, one of the most famous quotes in sleep science circles, is attributed to William Dement, who helped establish the Stanford Center for Sleep Sciences and Medicine.

To gauge where today’s sleeping patterns could take us tomorrow, we must first understand how, of all basic biological functions (eating, hydrating, excreting, sleeping, and mating), sleep is the least known, but the most compromised.

“Here’s what we can confirm. It governs memory, emotional fluctuations, metabolic rate and hormonal balance, immunity, and protein synthesis,” says Dr Jha. “It’s only during sleep that growth hormone — essential for cell repair and reproduction and by extension, bone and muscle health — is secreted.” Growth hormone is why children need more sleep than adults. Infants can sleep up to 17 hours daily because their brain’s mushrooming synaptic connections, bombarded with information after they come into the world, need rest to make sense of it all.

Adults aren’t immune to sleep’s domino effect on every bodily function either; not for nothing is sleep deprivation a popular torture method. “In the head of the interrogated prisoner… he has one sole desire: to sleep. Anyone who has experienced this desire knows that not even hunger and thirst are comparable with it,” wrote former Israeli prime minister Menachem Begin, on being a political prisoner of the KGB (Russia’s spy agency) in Soviet Russia.

Sleep’s cyclical nature is something to behold. It’s at night that the brain truly comes into its own after retreating from the sensory overload of the day. It decides which memories to keep and which ones to junk in stages one and two. It then kicks deep sleep (stages three and four) into gear, prodding cells to secrete growth hormone. Deep sleep is also when the brain literally cleans house.

“Neurons in the brain, densely packed during daytime, expand at night. This is so that accumulated metabolites (cellular metabolic waste) can be flushed out,” Dr Jha explains. “The spaces between these neurons then become like roads after dark. It’s like going on a long drive at night versus driving in the day.”

Flights of fantasy: Dreams manifest during REM sleep, which typically surfaces in the early morning hours

Our body cools and breathing slows during deep sleep before we wake briefly, only to be taken through REM sleep. This is when we dream. This is when our eyelids flutter, moods are regulated, protein synthesis reaches its peak, and bodies reach their lowest temperature. This is when our breathing becomes shallow. This is when the brain is free to play.

Non-REM and REM sleep together form ‘sleep architecture’, so called because it resembles city skylines on a hypnogram. Think a sleep graph, measured on polysomnography machines. “Each stage lasts a certain duration and is repeated a number of times at night,” says Dr HN Mallick, president of the Indian Society of Sleep Research (ISSR). “Inadequate or poor quality sleep affects this architecture. Which we’re seeing a lot more of.”

Material designs

OSA or sleep apnea is the most visible sleep disorder. Yet, there’s just 1% market penetration for diagnostic and therapy equipment in India, where an estimated 50 million people have the condition. Again, no official figures are available for OSA.

Now, consider that research on understanding sleep, rather than sleep disorders, is even more nascent. Philips India, an arm of global conglomerate Royal Philips, alone has 500-plus sleep labs to develop iterations of its Respironics line of devices like continuous positive airway pressure (CPAP) machines. These are some in a host of offerings to help patients with breathing problems sleep better. Compare this to just five labs (in JNU and All India Institute of Medical Sciences in Delhi, National Institute of Mental Health and Neurosciences in Bengaluru, Sree Chitra Tirunal Institute for Medical Sciences and Technology in Thiruvananthapuram, and Lucknow’s King George’s Medical University) fully involved in researching the mental and physiological repercussions of sleep deprivation.

“India’s sleep labs are focused on clinical solutions for disorders because that’s where the money is,” says Dr Mallick.

When data on sleep evolution is virtually nonexistent, it’s easy to make hay while the sleep economy shines. Nowhere is this more evident than in the mattress market.

In 2014, entrepreneur Philip Krim launched Casper, a direct-to-consumer mattress-in-a-box that attracted investors like Leonardo DiCaprio and a rash of other celebrities. The company did something genius; it never claimed to better sleep but instead, made mattress-buying mighty convenient. Casper’s “obsessively engineered” minimalist aesthetic — created by Japanese designer Gen Suzuki — a low price point, and 100-day trial period (a) turned it into a $1.1 billion company, and (b) inspired clones in both the US and India.

India has six ‘sleep startups’, all focused on bedding. Think spring and foam isn’t technology enough? Bourgeois mattress-makers want you to believe otherwise. If India had a modern history timeline of the mattress, it’d read like this: bare-bone khatiyas (cots), lumpy cotton gaddas (mattresses), coir mattresses, spring Kurl-Ons and Duroflexes, and PU foam and latex bedding. Branded variants make up 34% of India’s $1.7-billion mattress market. This number is expected to rise in contexts where people don’t think twice about renting mattresses, or paying more for proclaimed patented technology to keep bedding cool.

Think spring and foam isn’t technology enough? Bourgeois mattress-makers want you to believe otherwise

But this isn’t just about mattresses. It’s about how startup founders consider bedding to be one spoke in the sleep wheels they want to build. Bengaluru-based Wakefit, which sells an average of 10,000-12,000 mattresses (priced from Rs 7,100-9,500 or $103-138) monthly, suspects functional bedding is the way to go. Which is why co-founder Chaitanya Ramalingegowda has plans for maternity, nursing, and baby pillows.

“We also wanted to tie up with Xiaomi to gift Mi Band trackers with our mattresses and get sleep data from customers who opted in. But they (Xiaomi representatives) weren’t receptive,” he shares. “That’s the intent, though. To go deep into India’s sleep patterns.”

Ramalingegowda, in whose startup Sequoia Capital invested Rs 65 crore ($9.4 million), could be onto something. India’s wearables market may be growing, adding to the likelihood of more people using trackers to monitor sleep. But there are doubts about sleep logging. One, movement sensors in current fitness trackers sometimes peg tossing or turning as wakefulness — an inaccurate reading of sleep. Two, heart rate and breathing sensors alone aren’t enough to monitor brain waves in each sleep stage to provide accurate readings. Three, sleep scientists have a term for the sleep tracking obsession: orthosomnia. Treating sleep like a project, they say, could worsen rather than improve your quality of shut eye.

“We already deal with information overkill in our waking lives. We don’t just need metrics. What we need are actionable solutions”

Dr HN Mallick, president, ISSR

Shashank Palli, founder of pillow company Cuddl, admits India’s sleep startup founders can’t use wearables data to claim improvements in sleep, regardless of beta testers who report sleeping better. So if ‘smart bedding’ or bedding sensors won’t yet make business sense in India, what will? Features. Casper, remember?

Cuddl has three stock keeping units (SKUs) of shredded foam pillows. Over the next three years, Palli plans to have 40 SKUs spanning materials beyond latex and memory foam so he can cover a large market base. He knows no one goes shopping for a branded pillow. He wants to change that.

“I want to be the Apple of pillows in India,” Palli chimes. “People didn’t know they needed 1,000 songs in a pocket until iPod came along. And they lapped it up. But with respect to positioning, we want to be the Android of pillows.” Cuddl currently has four pillows ranging from Rs 1500-2500 ($22-36), all sold online. Palli plans to introduce options that go for Rs 700 ($10).

What’s in the offing? Multiple iterations with aromatherapy and waterproofing; kids’ pillows that go from one inch to six inches and “grow with the child”; hybrid pillows with a mix of fibre and foam; better bolsters and cushions; pillows for different body types, like for people with wide shoulders. “Because they typically have problems sleeping on their side,” he claims.

Niche and custom sleeping solutions are the way in the near future for Alphonse Reddy too. Reddy heads Sunday, another Bengaluru startup that hinges its unique selling proposition (USP) on Belgian latex and European-certified mattresses. But he’s thinking software, not hardware. He’s also refreshingly candid about his own problems with sleep — a rarity for a mattress founder.

“If I don’t sleep well myself, I’m just a foam seller,” Reddy jokes. So while working on Sunday, he’s also involved in research and development (R&D) for “an operating system that will turn sleep data into solutions.” Think mattress recommendations based on whether you prefer sleeping on your back or your sides. Information on how exactly your patterns differ from typical sleep architecture, and whether hitting the gym, cryotherapy, or working less will help you sleep better.

The workarounds

There are those who see opportunity in offering actionable sleep solutions. Then there are those who see opportunity in a world that’ll have little choice but to operate on frugal and disjointed sleep. One of them is Masthan Adam, Dubai-based CEO of Aviserv Airport Services.

In January 2018, Aviserv established India’s first transit lounge in an airport arrival area, in Terminal 2 of Mumbai’s Chhatrapati Shivaji Maharaj International Airport. In a departure from lounges that are almost always equipped with WiFi and/or TV screens — Aviserv’s compact and more private egg-shaped, reclining GoSleep pods, located in the exclusive Aviserv Lounge, have just a charging point. The message is clear: you’re here to sleep, not keep yourself busy.

Pod ‘combo plans’, which range from Rs 1,875-5,985 ($27-87) depending on how long you want to sleep, come with a la carte add-ons such as wifi, cloak room services, and steam press.

“Whenever I arrive at the airport and exit customs in early morning hours, I see passengers either sleeping on gang chairs or on the floor during transits or layovers. This is a huge untapped opportunity in India,” says Adam, who introduced the Aviserv Lounge in the departure zone of Bengaluru’s Kempegowda International Airport in November 2018. He now wants to set up pods in ‘dead’ or unused spaces within other Indian airports by the third and last quarters of 2019 – he didn’t specify which ones.

Transit napping

Rest zones are common in European and Southeast Asian airports. The airports in Singapore, Seoul, Tokyo, Finland, and Estonia are regulars in online surveys on the best and worst airports to sleep in (yes, that’s a thing). Delhi’s Indira Gandhi International Airport has pods by Sams Snooze At My Space. But the ‘pods’ are more rooms, complete with WiFi, TV, mini bar, and work desks.

But airports aren’t the only gears to be oiled for India’s budding sleep economy. Ever been an attendant at a hospital? Chances are you’ve either slept on a chair, an uncomfortable Rexine sofa, or not at all. Another opportunity for Aviserv and Adam, who’s considering sleeping pods for hospital attendants, equipped with tech to alert nursing staff, much like the alert system near a patient’s bed in case of emergencies. He’s also thinking pods at railway stations, which he thinks is more doable than not due to ‘far cheaper rentals than airports.’

And what if there was a way to enhance sleep quality while sleeping for fewer hours? A way to truly hack slumber: spend less time drifting off, and more time in the deep sleep stages? For that, there are the Dreem and Philips’ SmartSleep DreamSleep headbands, which use cranial sensors and white noise to enhance delta wave range and frequency during deep sleep. Philips’ DreamMapper app, which, in India, is coupled with its breathing therapy devices, has some element of gamification in the US version when paired with the DreamSleep headband. It uses scores and points to incentivise sleep. Turn sleep into a game, and people are more likely to play it.

“Whether India will have the affordability range ($400) for the DreamSleep remains to be seen, but we won’t rule it out. We want to govern the entire portfolio of sleep,” says Harish R, Head of Sleep & Respiratory Care, Philips India. “Currently, what makes sense in India is affordable devices for sleep disorder management. More so equal monthly installments (EMI) for such specialised equipment — something you don’t often see here.”

Meanwhile, in Bengaluru’s Koramangala, fintech startup Razorpay is planning to add another nap room for its employees. Its current nap room, with two bunks (four beds) has takers among its workforce, interns, and even outstation interviewees who want to catch some Zs before being questioned in conference rooms. Anuradha Bharat, the company’s head of people operations, cites nap rooms and lounge areas a must for companies that sometimes demand long hours from employees. Not all jobs offer the option — nay, the luxury — of switching off. So it’s only fair to offer spaces for sleep, and some empathy.

“Good sleep makes one more productive. Nap rooms aren’t a distraction, but a sensible solution. Employees no longer have to pretend to be sick if they want to nap or catch up on sleep.”

Ah, optimum wakefulness. A laminated card that will never fold.

What’s bugging Truecaller

“Delete Truecaller.”

These two words threatened the very existence of Truecaller, after a user’s chance discovery went viral, last week. The app, which actively filters spam calls and messages for more than 100 million smartphone users in India—and tens of millions more worldwide—was found to enroll some users for UPI without their knowledge. UPI or Unified Payments Interface is India’s mobile-based instant payments system.

It began with a seemingly routine update. But after the rollout, a number of users noticed that Truecaller sent messages with garbled text from their phones to an unknown number. Following this, ICICI Bank—Truecaller’s partner bank—sent messages notifying users saying that their registration for UPI had begun. 

Truecaller blamed the incident on a bug. A spokesperson told The Ken only its Android users were affected. The spokesperson declined to disclose how many. The company also assured that the bug only enrolled users—no transactions had been made. Nonetheless, it’s worrying just how easily it could have led to a transaction.

Following the text from ICICI, the Truecaller app correctly identified users’ bank accounts too. It could do this by simply using the message-access it already has to find which accounts were linked to the number, said Ramanathan RV, founder and CTO of Juspay, the company that made the BHIM app. In one case, Dheeraj Kumar—one of the users affected—was nudged by Truecaller to link his HDFC Bank account to the company’s app. Kumar uses HDFC Bank for making payments using BHIM, the government-backed mobile payments app. 

Aashish Bansal, another user, was prompted to link his Indian Overseas Bank account to the app. While neither Kumar nor Bansal suffered financial loss, the issue highlights the gaps in India’s regulatory framework, where companies operate in the absence of a data protection law, with users often becoming collateral damage.

Truecaller seemingly has everything going for it in India—100 million daily active users and that it’s the fourth most downloaded app, according to the Mary Meeker Internet Trends Report 2018. It’s an app with near-limitless permissions to user data from Google’s Play Store. All of this should have the company sitting pretty, but it hasn’t quite lived up to its early potential.

Truecaller has, over the years, pivoted from one business model to another in its quest for profitability. One of its primary revenue streams was advertising, but that has proven less than sustainable.

This, despite Truecaller diluting its value proposition to attract ad revenues. One way it makes money is by allowing advertisers to call users—it whitelists those numbers so they show up as names users would be inclined to take calls from. Sometimes even celebrity names. In one campaign, it claimed 50% of users picked up such calls. 

It has also added an ad-free premium subscription service. But despite its best efforts, it remains decidedly loss-making—in 2018, revenues stood at $22.2 million with losses of $6 million, the company said. That compares to $11.2 million in sales and a $6.2 million loss in 2017, according to regulatory filings from Sweden.

But as India’s digital payments space has taken off in recent years, Truecaller finds itself enamoured by India’s $100 billion digital credit opportunity. This latest incident is but a symptom of Truecaller’s search for its ultimate identity. 

There is no need for the UPI registration code to be present in the update life cycle of the app. So, it is hard to understand how this is a bug. If it was indeed, then it is quite an unreasonable one. Given its huge install base, if such a bug escapes to production, it questions the testing process. This is unexpected from a mature company

Ramanathan RV, Founder and CTO of Juspay, the company that built the BHIM app

A foreign phenomenon

Truecaller is not the kind of company you’d expect to find at the centre of a fintech blunder in India. For one, the business isn’t Indian.

The company was founded in the summer of 2009 by Swedish duo Alan Mamedi and Nami Zarringhalam. Their rapid rise is a validation of the freedom of opportunity in Sweden since both had challenging upbringings. Mamedi was born in a refugee camp— his Kurdish parents moved a month before his birth—while Zarringhalam’s parents fled Tehran, Iran, where he had been born.

Truecaller has been around so long that it actually first launched on BlackBerry—the once-ubiquitous devices with physical keyboards—before rolling out months later to iOS and Android.

The concept was straightforward. Truecaller stops spam calls, something that plagued people back when smartphones first began to take off, by letting you know who is calling. Truecaller’s twist is that it allows users to tag unwanted callers—helping to publicly identify spammers. Once a user has identified a caller—perhaps it is a bank or a loans company—all other Truecaller users see that ID when receiving a call.

The service pre-dates the global app phenomenon, and as smartphone adoption increased and apps became common, Truecaller’s popularity grew. It reached five million registered users by September 2012, and 10 million by January 2013 thanks to network effects. 

Fours years later, as iOS and Android became dominant platforms, Truecaller clocked 250 million registered users. Today it boasts 140 million active users—a more accurate metric than merely ‘registered users’—of which 100 million are in India.

Its growth attracted investment and top names. The company has raised $98.6 million, according to data from Crunchbase, from firms like Sequoia, Kleiner Perkins and Atomico, the Europe-based fund from Skype co-founder Niklas Zennström.

In search of a true calling

But despite explosive growth, a service that thrives in today’s mobile app economy, and lots of money from top-tier VCs, Truecaller has struggled to lock down a revenue model to match. It currently makes money through a combination of advertising, an ad-free premium service—for which it has 500,000 subscribers paying at least $0.99—and an ambitious play to build an ecosystem.

The latter is a new addition, coming after Truecaller began to focus on the Indian market. That crystallised in 2017 when the company acquired India-based payments startup Chillr. The plan was to offer payments and financial services to its massive audience in the country—its largest market worldwide.

The India story was of critical importance for Truecaller since it had pivoted and gone through startup growth pains before identifying this huge emerging market opportunity.

At its peak in 2015, Truecaller was the next big thing. Facebook released its own caller ID app, validating and challenging Truecaller in the same breath. TechCrunch reported in June 2015 that the company was in talks with investors to raise $100 million at a valuation of $1 billion, a deal that would see Truecaller join the unicorn club. 

At that point, Truecaller had raised $80 million, so the capital increase would have been significant. But the round never materialised. Instead, Truecaller closed the year with layoffs and killed off one of its auxiliary apps a few months later. The funding round had also died.

Speaking to TechCrunch in March 2016, Mamedi said Truecaller didn’t need the money as he anticipated it would be cash-flow positive by the end of the year. The trigger, as he explained, would be the introduction of “targeted advertising.”

Truecaller’s advertising ambitions, which Mamedi once hung his hopes on, haven’t quite worked out. Of the nearly $2 billion that brands spend on digital advertising, nearly 80% of a brand’s budget is spent on Google and Facebook properties. The rest is spent on content apps like Hotstar and Tiktok, with less than 2% spent on Truecaller, estimate digital agencies.

“Truecaller has about Rs 250 crore ($36 million) of available inventory in a year. The advertising market is pegged to be at Rs 14,000 crore ($2 billion) in 2019. So, even if Truecaller does the impossible task of selling out all of its inventory for all 365 days (which is highly unlikely), still they will not be able to have a share of 2% of the total ad spends,” says Sahil Shah. He is the executive vice president of operations and media at WATConsult, a digital marketing agency owned by Dentsu Aegis Network. “My best guess is that they will be around 0.75-0.95% of a brand’s spend,” Shah adds.

The payments priority

Fast forward to 2019, however, and Truecaller hasn’t managed to break-even. 

The product, too, has evolved significantly. Gone is the utility app focus—which provides a great experience but is hard to monetise. Today’s Truecaller aspires to be a mobile platform. It offers free chat messages and voice calling between users—much like WhatsApp. In India, it is also aggressively pushing payments, which is another feature Facebook is preparing to add to WhatsApp.

But it’s the effort to push its fintech services—converting low-revenue utility app users into platform app users that generate significant revenue—that seems to have triggered last month’s bug.

At the height of the 2017 payments frenzy in India, Truecaller jumped into payments much like its fellow overseas tech firms such as Google and Facebook.

As UPI volumes soared, the fight for number one was hotly contested between locally grown wallet companies Paytm and PhonePe, government-backed BHIM and Google Pay. Truecaller was nowhere on the payments scene. And now, 28 months since its launch, it has an insignificant presence. Truecaller has about 10 million bank accounts linked, said the company earlier this year. Competitor PhonePe—which is focused solely on payments—has over 100 million users, meanwhile.

Blip on the radar

Over the last three months, Truecaller has handled 1.5% of all UPI volumes processed by Razorpay, which accepts payments from nearly 350,000 online merchants. Official estimates are not available

At the same time, younger companies are shaking trees, too. Merchant-focused payments app BharatPe, which is barely a year old, is powering close to 10% of UPI merchant volumes. It does about 9 million transactions a month. 

Truecaller’s enviable 100 million active user base, however, hasn’t been able to supercharge its payments dream. What it needed was a growth hack. A hack that could have maybe connected all its 100 million users to, say, their bank accounts. 

Bug turns bugbear

When it comes to Truecaller, one privacy breach swallow does not a summer make. Truecaller’s strong desire to make its payments strategy succeed has seen it run with other unscrupulous tactics. One talking point that arose from public scrutiny of the bug is exactly what actions and activities Truecaller’s app handles in the background without the knowledge of users.

Abhay Rana, a software developer at payment gateway Razorpay, found that Truecaller’s app was embedded with numerous data-hungry software development kits (SDKs). SDKs allow one piece of software to talk to another. 

Now, SDKs on their own are no indicator of ethicality. On average, an app has as many as 18.5 SDKs, according to a SafeDK report. Most apps use advertising and analytics SDKs as standard. 

The SDKs Truecaller used, however, granted a credit scoring service MessAI and expense management service Walnut access to user data. The former could trawl messages to profile users. Walnut—which was acquired by fintech lender Capital Float—enjoyed similar access. 

This approach could help Truecaller, which has ambitions to lend, identify which users to target for lending. Rana also checked other payment apps, such as PhonePe and Cred, for the SDKs they used. These didn’t include credit scoring SDKs, he said. 

While lending apps like MoneyTap also have credit scoring SDKs, users expressly download them for the purpose of taking loans. Given its focus on caller ID, few people downloading Truecaller would expect their messages to be trawled to assess their creditworthiness. 

Sony Joy, head of payments at Truecaller and the former CEO of Chillr, defended the company’s practices. Joy claims that credit scoring—which is part of a pilot—happens only for a specific set of users who wish to apply for credit and explicitly grant permission to assess transactional messages. He added that the app asks for consent even though users might have already given messaging permission earlier. 

Joy’s claims appear to be at odds with Truecaller’s own FAQ detailing its credit services. It says Truecaller does not show all of its users this option. “If you are eligible for the offer, it will be seen on the landing page under the banking tab of Truecaller app,” it states. This indicates that Truecaller already identifies which users are eligible for its lending services.

Hours after Rana’s findings were published on Twitter, Walnut founder Amit Bhor said the SDK for Walnut found in Truecaller had been discontinued altogether. It also emerged, after Rana’s finding that Truecaller acquired MessAI in April 2019.

Too close to the sun

Truecaller is reflective of the era in which it grew. Back when Android was a developer haven. App developers flocked to Google’s mobile operating system as it allowed apps to use user data freely and build products with few constraints. As a result, Truecaller has access to call logs, permission to read and create messages, location, and contacts. That’s in stark contrast to Apple’s iOS operating system, which forbids apps built around users’ message inboxes or call logs.

Focus Pocus

Truecaller is also focused on Nigeria, Kenya and South Africa—all countries where the need for the service exists, but also have a lax permission architecture when it comes to user data. In Europe, where the EU has introduced strict privacy rules, it has altered its trademark reverse lookup feature to ensure consumers opt in to be included in Truecaller’s database

It’s this unbridled access to data that also saw Truecaller almost breach the inviolable principle of digital payments in India. Just as Airtel Payments Bank and Paytm Payments Bank showed how electronic KYC (know-your-customer) processes can be used to sign unwitting people up for bank accounts, Truecaller’s UPI bug shows how apps could be similarly misused.

Truecaller, with its bug, came close to breaching the all-important fail-safe of Indian digital payments—two-factor authentication (2FA). The combination of the three-digit Card Verification Value (CVV number) on the back of a debit/credit card and a one-time password sent via messaging is a mechanism the central bank, the Reserve Bank of India, holds on to dearly. Much to the unadmitted annoyance of digital companies who see the two steps as a point of friction.

When UPI burst onto the scene, it found instant acceptance, because even with 2FA, it practically worked out to be a single-step process. That’s because the first factor is the phone number and device itself, which didn’t need authentication every time one made a payment. But as Truecaller showed, this can also be a vulnerability.

Normally, any UPI app would have access to the device details only when a user installs the app and starts the registration process, but not Truecaller. It had the device details by virtue of already having message permissions as a caller ID app. This let it auto-register. As much as the company would like to call this as an anomaly, it was also something of an eventuality. If not at the hands of Truecaller, then perhaps through some other app with similar fintech ambitions.

Facebook has continued to march on despite significant privacy blunders and this incident too may blow over for Truecaller, like many tech outrages of the past. But there are some worrying signs. Like the upcoming data protection bill, which is expected to be tabled in the parliament in the ongoing budget session, and the bruising competition among fintech and non-fintech companies to lend. 

Even though Truecaller in May, appointed Sandeep Patil, a former Flipkart director as its Indian managing director, its focus on the India market is complicated because the company remains anchored in Sweden (where Mamadi, Zarringhalam and its heads of engineering and product are based). Even Truecaller’s board has just one Indian representative—Sequoia’s Shailesh Lakhani. The Chillr acquisition built out Truecaller’s on-the-ground presence in India, but the incidents of the past week may give it cause to rethink its approach. WhatsApp is poised to explode on to India’s fintech landscape, where will that leave the also-rans?

Clarification: The article was updated to reflect the correct number of transactions BharatPe does in a month. It has also been edited to highlight that message-access is enough for Truecaller to link user bank accounts.

Doubts Doctrine: Users flock but questions linger over Doubtnut, Brainly

“If you have a math question, I’m 99% sure it exists in our database,” says Tanushree Nagori. We’re inside a giant boardroom, with off-white walls and rows of tables, which double up as writing surfaces. Nagori draws on the table between us, explaining where her fledgling online venture—Doubtnut—lies within India’s edtech landscape, which is projected to be worth $1.96 billion by 2021.

“I guess you’d put us in this quadrant,” she says, pointing to a white space between “local language” and “concepts + doubts”. 

Nagori’s visual explanation of India’s edtech landscape (Picture credit: Olina Banerji/The Ken)

Nagori founded Doubtnut with husband Aditya Shankar in late 2016. Offered as an app, a website and even a WhatsApp helpline as of 2019, Doubtnut is an online platform which primarily offers students 24×7 help with math doubts. It caters to students all the way from class 6 to aspiring engineers sitting for public exams, allowing them to upload pictures of questions from books and receive a video solution within minutes. Like a Google for math queries.

“No one was paying attention to the urgency of doubts. We wanted to resolve doubts in a way that would break the Byju’s price point,” says Nagori. Byju’s—which offers online videos and course material on tablets—charges upto Rs 2.5 lakh ($3500) a year, which makes it financially unviable for a large section of the Indian population. Doubtnut, while yet to arrive at an exact price point, is experimenting with granular pricing for modular products. Say, Rs 399 ($5.6)to unlock a month’s worth of doubt-solving videos.

Of all the use cases to build edtech products, doubts are perhaps the stickiest and most compelling. If not tackled on the spot, they fester into what Nagori labels ‘learning gaps’. While Byju’s prides itself on creating a multi-step, learning journey, Doubtnut’s approach is to provide the necessary pit-stops. But has spinning an engagement model of just solving doubts really taken off?

Like a rocketship, Nagori claims. 

Doubtnut says it receives 200,000 mathematics doubts every day. It has 7 million monthly active users, with over a quarter of these using the platform daily. Till date, Doubtnut has raised around $3.3 million from marquee investors such as WaterBridge, Sequoia and Omidyar Network*.

But Doubtnut isn’t alone. Its main competitor in India—Brainly—fields questions from over 15 million users every month. Unlike Doubtnut, which is programmed to send pre-recorded explainer videos to students, Brainly is an international peer-to-peer question-answer platform, a la Quora.

“We realised that students turn to their community of friends, parents and teachers if they’re stuck on a question,” says Michal Borkowski, Brainly’s Poland-born co-founder. This is the experience, he adds, that Brainly’s trying to replicate online. 

Market Potential

One in every four Indian students are enrolled in private, after-school tuitions. That’s 26% of the total student population, or 71 million students. Of these, 89% use tuitions to augment their basic education

The surge of students towards doubt solving platforms is indicative of what the next wave of learners—millions of whom are from tier-2 and -3 cities, many just discovering online learning—needs. The immediate gratification of solutions. According to a 2016 report by the Indira Gandhi Institute of Development Research, Indian households spend up to 18% of their income on higher education—one of the highest in the world. But as the demographics change—from users who can spend Rs 15,000-30,000 ($210-420) a month on supplementary education, to those unable to spend more than Rs 200-300 ($2.8-4.2)—product parameters must evolve. Be mobile-friendly, more focused on regional languages and state education board content. They must also be priced significantly lower. 

Both Brainly and Doubtnut have understood this. “Doubts is a smart entry point. These apps are targeting the segment that primarily interacts online through Tiktok, Whatsapp and Youtube,” says Akshay Saxena, co-founder of Avanti, a chain of affordable coaching centres. Consequently, the two are winning over the elusive tier-2 and -3 audience that everyone—from e-commerce platforms to payment apps—is trying to monetise.

Neither company is worried about monetising for the moment. That can wait till they grab more market share from the established players. But is doubt solving a sustainable business? “Can you really build a Rs 1,000 crore ($140 million) company on the back of doubts?” asks a senior edtech investor. He wished not to be named because his firm chose not to invest in Doubtnut. More importantly, if and when these companies do monetise, there’s no telling whether students will stay the course or abandon ship.

Gurugram to Gaya

Doubtnut’s office in Gurugram could easily pass for a call centre. Flanked on both sides by open cubicles, Nagori leads us to a backroom that houses a floating team of 20-30 young engineering graduates who build Doubtnut’s content. The cubicles are partitioned and quiet because these “tutors” need to record audio explanations for the solutions they’re writing.

“It’s just like if a teacher was solving the question in person,” explains Nagori, in a hushed voice.

Since its launch in 2016, Doubtnut has hired interns every summer to belt out a huge number of the most common math solutions. They currently have 400,000 solutions in the database. And that’s just math. The team is also building content for both physics and chemistry, which recently launched on the platform. At last count, they were adding 4,000 solutions everyday. “We expect the number of incoming queries to double,” adds Nagori.

The USP of how these questions are solved—in a mix of Hindi and English, step-by-step—and how long they are—usually 4-5 minutes—resonates with a market untapped by full-stack edtechs such as Byju’s, Toppr or Unacademy. Doubtnut’s videos target users looking for solutions on YouTube or Google, who have little access to quality tutoring near their homes. Rakhi Kumari, an IIT aspirant from Gaya, Bihar, is a case in point. 

“Doubtnut gives me the solution on the spot. 80% of the time, I’m able to source the exact question I’ve been stuck on,” says Kumari. The eleven other students from 9 cities The Ken interviewed told a similar story. 80%, they agreed. When they can’t find something, they submit their doubts and wait for a response. 

New-age apps like Doubtnut represent the third wave in the edtech product line. They eschew the sophistication and design frameworks of their full-stack predecessors. Instead, Doubtnut’s interface is a mishmash of video tutorials, pop-up quizzes and test paper solutions. There’s even a poorly integrated chat function to boot, crammed with ‘good morning’ messages. There’s little typing involved, since questions can be sent via uploaded pictures—a boon for the test prep population and those not fluent in English.

“You can break down the concept all you want. But it’s application in a test setting that really counts,”

Aditya Shankar, co-founder, Doubtnut

On Brainly, on the other hand, users submit questions across a variety of subjects, with the community answering them. The top answers—the ones with the most upvotes—genuinely do a decent job of answering doubts, even if there is also a glut of non-serious answers.

Compared to a Byju’s, Doubtnut is thin on conceptual videos with fancy three-dimensional graphics and drawn-out explanations. Brainly, currently doesn’t have any videos, though it does allow students to upload pictures of their doubts. Both models are a definite structural departure from the more premium products in edtech.

The reason, says Shankar, is that Doubtnut doesn’t bother itself with conceptual clarity if a learner can’t really apply it in a test situation. Their videos are no-nonsense: a phantom hand solving a sum on a smartboard, while explaining the steps. “You can break down the concept all you want. But it’s application in a test setting that really counts,” he adds.

Despite their lean, sparse and patchy look, or rather because of it, the platforms have rapidly gained traction. Doubtnut has gone from 1,000 monthly active users in 2016 to over 7 million within three years. Brainly too, says Borkowski, has been getting traction from learners across India. It even allows for questions in vernacular languages such as Marathi, Telugu, Bengali and Tamil.

Different strokes

The numbers alone can hollow any arguments against their efficacy. Local tuition teachers who use Doubtnut, however, are less enthusiastic about its pedagogy. “It’s a great resource for us. We find different ways to explain sums to our students. But I’m not sure if students would understand this on their own,” says Neelam Sirshat, a tuition class owner from Vikhroli, Mumbai.

Shirshat’s misgivings are echoed by Adarsh Gautam, a school teacher from Kakori, Uttar Pradesh. Gautam uses Doubtnut to teach difficult sums to his class, most of whom belong to low-income backgrounds. However, he clarifies, Doubtnut may work because of the easy, vernacular explanations in the videos. Besides, he adds, you have to pay for other apps.

Videos help Doubtnut in distribution, claims Nagori. It’s because Google indexes videos over texts, she says. So while the top results for a math question on Google might still show older edtech sites like Meritnation, Nagori claims Doubtnut is rising rapidly. “We spend a nominal amount on YouTube marketing, but most of our traffic comes from organic search results,” she explains. One possible explanation is that Doubtnut builds for search terms like “p2 + q2 is equal to ?”, making their videos easier to find through web searches.

Sachet pricing

“We work on monthly mobile top-ups.
Most students won’t have the means to attend a coaching class,” says Gautam, the school teacher from Kakori, Uttar Pradesh. Access to mobiles is restricted to students in grades 11 and 12, he adds

Brainly is also growing. Since its India launch in 2016, the company claims, it has grown 200% year-on-year. Brainly raised a total of $68.5 million, with almost $30 million in its most recent Naspers-led round. Unlike Doubtnut, it’s currently text-based.

Unlike Doubtnut, whose users need prompt and exact answers to textbook questions, test prep is only a sliver of Brainly’s target market. It ropes in a more diverse set of students looking for help in a range of subjects.

“Our messaging to students between 13 and 19 is very clear. Brainly is the place to ask any homework or exam questions you’re stuck with,” says Borkowski, on a video call from New York, where Brainly is headquartered.

Complete with leaderboards and a daily points register, Brainly gamifies the asking and clearing of doubts. The platform also has tutors, but, as Borkowski explains, “Our tutor intervention has more to do with predicting which questions are going to be the most popular and most difficult to solve, within a particular subject.” Brainly currently employs 140 people worldwide, and content curators—or tutors—make up a chunk of that. 

Despite their differences though, Borkowski and Nagori have one thing in common—they’ve started at the other end of the tunnel from the likes of edtech giants like Byju’s, Toppr and Unacademy. Their whole focus—and model—is centered around doubt-resolution, unlike the more established edtech players, who offer it as one of many products. 

Online coaching platform Vedantu, for instance, includes doubt-solving as part of its larger, paid-for live tutoring package. Byju’s doesn’t even have a hotline for doubts, let alone a 24×7 doubt solving service.

Doubtnut and Brainly understand the urgency of a doubt. While doing homework. While taking a mock test. They’ve replicated offline behaviour like consulting peers and teachers for quick explanations. They also have a common goal: to shore up as many active learners as possible before they shift to paid models. But can this mix of ingredients cook up a profitable business model?

School of hard knocks

Learning is alchemic. It’s almost impossible to bottle into one composite paid-for product.

That’s why, says Vamsi Krishna, co-founder at Vedantu, even though doubts are atomic to learning, they differ in shape, size, urgency, and hence treatment. 

“If a doubt needs explanation, video is the best form. If it’s steps a student wants to learn, then even a PDF or image would do. But a follow up on a solution requires one-on-one interaction with the tutor,” says Krishna, slotting Vedantu into that final category.

There were a few among the first edtech movers who went out on a limb and tried to build a business model by isolating and charging for doubts.

Edtech platforms Toppr and Hashlearn, launched in 2013 and 2016, respectively, both tinkered with monetising a 24×7 doubts helpline. A direct, one-on-one doubts consultation with a tutor, via chat. According to its website, Toppr currently charges Rs 99 ($1.4) for 5 doubts in a month. Hashlearn has monthly packages costing between Rs 8,000-10,000 ($112-140) for an unlimited number of doubts across 3 to 4 subjects.

These models were forward-looking but not particularly lucrative, says the edtech investor mentioned above. “They couldn’t monetise doubts as a stand-alone product. They had to add layers,” he says. Toppr added free videos to charge for doubts and test paper practice. Hashlearn, as of two months ago, added live tuitions and digitised course material to its doubts-only product. “It allows for better ARPU (average revenue per user). We still have doubts at the center of all our products,” says Hashlearn founder and chief operating officer Jayadev Gopalakrishnan. Their new subscription product—Passport—is now an all-access pass, priced at Rs 14,999 ($210) for the year. Students can access live classes, study material and tutors 24×7, to clear doubts.

“We might do away with our standalone doubts model completely,” says Gopalakrishnan.

While both Toppr and Hashlearn have added valuable layers to their core doubt product, Nagori believes that 24×7, one-on-one access to tutors is the Achilles Heel in their operations. “How are you going to handle 200,000 queries a day if each question has to be connected to live tutors via chat? That’s approximately 6 million questions a month,” she says. 

While Doubtnut relies on artificial intelligence to match questions with answers, Hashlearn has a team of 6,000 tutors across India who spend close to 12 minutes per chat session. 

Gopalakrishnan—who prioritises a human touch over impersonal videos— offers a counter argument to Nagori. Doubtnut, he claims, is interested in pushing a solution out, whereas Hashlearn turns every doubt-solving chat into a real-time micro-tutoring session. “People don’t expect to get that kind of service for free. So we’ve always been a paid model,” he says.

But at a monthly average ticket size of Rs 15,000 ($210), both Hashlearn and Toppr are prohibitively expensive to an audience who aren’t yet paid subscribers to any edtech product, lean or full-stack. On the other hand, free doubt solving may build huge traction, but it hardly builds loyalty. 

Muscling up

Of the 11 Doubtnut users The Ken spoke with, only half said they would consider paying for the app. The other half said they would move on to the next best—and free—option.

Admittedly a small sample, these responses point to a challenge that’s brewing right under Doubtnut’s nose. Brainly is somewhat protected by its ad revenue, even though cost-per-clicks in India are far lower compared to other markets like the US. The company refused to divulge any India specific revenue numbers.

While they’ve created immense value and generated high user engagement, converting free users to paid ones is a question Nagori and Borkowski are yet to find solutions to.

For both companies, their lean DNA is bound to resist topping up with too many expensive and clunky value adds. But Borkowski’s willing to incorporate videos, if it proves to be more engaging for students. In fact, he’s already scouting the market for an edtech content partner. “We’re exploring all kinds of options, including joining forces with other edtech firms,” says Borkowski, without revealing the exact nature of such potential partnerships.

“Doubt-solving platforms are painkillers, not vitamins. Older [edtech] platforms are mostly content, without immediate solutions. Students will organically want the painkiller”

Edtech expert from Bengaluru

Doubtnut, for its part, has set up two studios in its office, which may be used to launch one-to-many live classes, says Nagori. The treatment will be markedly different from a Byju’s, and focus only on the pain points students have while answering questions. “We want to go granular with the content. We have data from over 5 million users to figure out what these topics should be,” she adds. In the year ending March 2018, Doubnut’s total loss stood at Rs 24 lakh ($33,600), while it earned revenues of Rs 4.6 lakh ($6,435), according to figures sourced from company research platform Tofler.

Live classes might be a first tentative step towards monetisation. But Doubtnut will now have to tread carefully on its own stomping grounds. “Getting the next 8-10 million students to pay will need sachet pricing, like monthly mobile top-ups. Rs 60-300 ($0.85-4.2) is the bracket,” says the edtech investor mentioned above. 

With the numbers it already has, and at dirt cheap prices, Doubtnut could unlock an extremely lucrative—and untapped—paying market. But in creating an AI-fueled, free engine with high user engagement, both Doubtnut and Brainly have unwittingly turned themselves into prime acquisition targets for larger companies. Paired with the right monetisation model, Doubtnut and Brainly are perfect additions to a full-stack model. What they have cracked with doubt-solving, at a low unit cost, is exactly the value that edtech giants want to add, says Saxena. It could be a win-win for all. 

Except Nagori isn’t particularly interested in building bridges. Unfazed, she’s trained her sights on conquering YouTube. After all, it’s how repeat users like Kumari found Doubnut. “We want to make sure that they’re spending their YouTube time on our videos. And all the time they’re not on YouTube, they spend on our app,” says Nagori.

Indian marketplace unicorns are the new incumbents

A perfect storm is gathering over the country’s most dominant digital platforms.

Over the last decade in India, billions of dollars have been spent by startups, venture capitalists and tech multinationals as they seek to rewrite entire sectors. In the process, they’ve managed market shares that took their “offline” or “old economy” peers decades to achieve. This has left companies like Zomato and Swiggy; MakeMyTrip and OYO; Flipkart and Amazon the “last players standing” in sectors like dining and food delivery; travel and hotels; and e-commerce.

Their venture capital backers have burned billions of dollars in loss-making businesses in the hope that one day when the fires clear, their companies would end up as natural monopolies. Free to increase prices and reduce spends.

Well, that day has come. The fires have cleared, but there’s a new problem at hand.

A slowing economy, widespread and coordinated supplier angst, and a tightening regulatory regime are coming together to target the largest platforms still standing. Yesterday’s scrappy disruptors, now the incumbents in their respective sectors, are in the crosshairs of numerous adversaries.

In late June, the Kerala Hotel and Restaurant Association (KHRA), a local trade chapter of hotel and restaurant associations from the state, called for a two-day boycott of hospitality platform OYO. Independent hoteliers who sold their rooms via OYO’s platform had a litany of charges against the Gurugram-headquartered company. These ranged from hidden commission fees as high as 40-45% of a booking; rampant deep discounting; one-sided contracts loaded against hotel owners and opaque delays in payments.

OYO managed to head that off by first threatening to take legal action against potential boycotters. It then got the Delhi High Court to pass an interim order banning any hotel association from boycotting it.

As a dominant digital platform, OYO correctly foresaw the risk of tens of thousands of fragmented suppliers (independent hotels) organising themselves for better collective bargaining and action. Hence, its extreme response.

But Zomato, one of the two dominant platforms in the food delivery space, misjudged it. Hundreds, then thousands of restaurants came together under a trade body and accused Zomato and its peers of practices similar to those for which OYO was criticised. Aggressive and perpetual discounts; rising commission charges and arbitrary changes to contracts. Restaurateurs also claimed the food aggregators’ ranking and discovery algorithms were rigged towards discounts and their own services.

The resulting boycott is still ongoing and has forced both Zomato and Swiggy to adopt far more conciliatory tones.

Meanwhile, in the neighbouring world of retail e-commerce, Amazon and Flipkart are under the cosh. The e-commerce leviathans are being targeted by multiple trade associations for the same broad reasons. For their opacity of algorithms, deep discounting, and blatant favouritism towards entities in which they held economic stakes.

If KHRA’s court-stymied boycott of hotels against OYO set the ball rolling against large digital platforms, the National Restaurant Association of India’s (NRAI) successful restaurant boycott of Zomato and its peers was the tipping point.

Almost all of the issues faced by these dominant platforms end up at the door of one of India’s hitherto easygoing regulators: The Competition Commission of India (CCI).

In our story last year on the institution, a competition lawyer who successfully defended a large technology company before it said the CCI was not an alarmist institution. Instead, he said, the CCI preferred to be hands-off given that digital markets were still quite nascent. The CCI will only intervene, he added, if it’s sure that the growing dominance of a company is going to end badly for its competition or the general public.

After ordering a wider probe against Google in April (the news of this was broken by Reuters) for what it saw as prima facie abuse of its dominance, CCI organised a well-attended event last Friday in New Delhi. It brought together a range of industry stakeholders, platforms, trade bodies, media organisations* and individuals to discuss competition issues. The CCI also used the event to reveal the results of its study on the Indian e-commerce market.

It wasn’t pretty.

Food Fight

First up on the day’s menu were food delivery platforms.

The representatives from Swiggy and Zomato sat at the two ends of the table. Sandwiched in between were an increasingly belligerent group of restaurant owners and industry association members.

 Accusations and justifications flew fast and thick. While the industry lobby and restaurateurs were out for blood, the tech giants were in a mood to reconcile. All of it made for a really awkward family dinner between quarrelling relatives.

 Anurag Katriar, a member of the NRAI and executive director of deGustibus Hospitality, minced no words as he underscored the core conflict between the warring aggregators and their restaurant partners. “Every discount kills my bottom line. If you want to give discounts, then please fund it entirely on your own,” said Katriar. As spontaneous applause broke out in the hall, the reps from Zomato and Swiggy shifted uncomfortably in their chairs.

 In fact, all of last month, aggregators like Zomato have been walking on a bed of coals. An escalating pricing war—over Zomato’s flagship subscription scheme Gold—saw over 2,000 restaurants owners (and members of NRAI) threaten to dump the scheme, and ultimately, Zomato’s platform. The antagonism towards Zomato Gold and other “deep discounting” schemes by platforms like magicpin, Dineout, etc., isn’t new. From its very launch in 2017, Gold has been a double-edged sword for its partners. While it promised to increase footfalls, restaurant bottom lines were taking a huge hit with the scheme’s variations of the buy-one-get-one offer.

I appreciate that data was first used by this [restaurant] industry. As a tech player, we are opening new opportunities for them. The sooner we get to “we”, rather than “us and them”, the better. Zomato has been part of this industry and I see this as a temporary speed bump in our relationship

Mohit Gupta, CEO, Food Delivery, Zomato

 Two years of skirmishes, and one #logout campaign later, NRAI has assembled its disparate members into one cohesive action group. And with an e-commerce behemoth Zomato—most recently valued at $3.6 billion—running for cover, they’ve tasted blood.

 “We made our complaints known to CCI almost ten months ago. This meeting is a result of that. It’s a tipping point. We aren’t going to be silent anymore,” said Thomas Fenn, on the sidelines of the conference.

 Fenn, a member of the NRAI and partner at Delhi-based restaurant Mahabelly, had sharp criticism against the aggregators on stage. He laid out a buffet of complaints, chief amongst which was the lack of data sharing between platforms and their restaurant partners. “We’ve been in the data business longer than them. We used to do it through feedback forms,” said Fenn. While analogue methods like forms might seem feeble against mighty data algorithms, Fenn’s larger issue was that by cutting off restaurants’ access to customer data, including masking their numbers, aggregators were culling them out of the food delivery experience. “No one should have exclusive rights to this data,” he said.

 The vast tracts of consumer data, claimed the merchants, have also allowed platforms to morph into suppliers. Restaurant partners cried foul over Swiggy’s three cloud kitchens, built completely from gleaning unmet demand from consumers. Rahul Bothra, chief financial officer at Swiggy, cut a lonely figure on stage as he insisted that cloud kitchens were in the consumers’ best interest. “There is a market for affordable home-cooked meals. Restaurant food is occasion-driven. At the price point of Rs 100-150 ($1.5-2), we’ve opened up a marketplace. We’re inviting our restaurant partners to join it,” said Bothra. His conciliatory tone was swiftly undercut by both Katriar and fellow-panellist Munaf Kapadia, CEO of The Bohri Kitchen.

“Then why don’t you share that data with us, instead of opening up your own kitchens?” Katriar fired back, swivelling his chair in Bothra’s direction.

“If we haven’t been able to fulfil their demand, trust me, neither can you,” he added. The restaurant lobby was particularly agitated about how customer data put both Zomato and Swiggy in a powerful position. The platforms were opaque about this data, they claimed, and used it to their advantage. While Swiggy has capitalised on it by playing both trader and marketplace, Zomato, claim the restaurants, have used it to offer outrageous discounts.

 Deep discounting, cloud kitchens, data sharing—all key weapons in the arsenal of food delivery platforms—have left the bottom lines of restaurants in shambles. Katriar points to data culled from 40-50 restaurants on the effective discount they’ve had to offer as Gold partners. “It came to 34% of their topline revenue,” claimed Katriar, speaking to The Ken. Zomato and Swiggy have disputed this number in their deliberations with the NRAI. They claim the discounts are closer to 24%, which is still a high number, says Katriar.

 Restaurants’ strength in numbers has paid off. According to a senior member of the NRAI, Swiggy has even promised a time-table for its discounts, instead of running them year-round. There’s also an initial agreement about a uniform commercial contract for all restaurant partners. Most importantly, restaurants and aggregators have begun negotiating a differentiated commission charge for various restaurant tiers, said the NRAI member.

Friends and foes

Even as barbs were exchanged on stage, on the conference sidelines, the restaurant lobby and aggregators posed congenially for a group photo. Hands were shaken, backs slapped and promises were made to meet soon and resolve issues. While it seemed like the quarrelling family members had made up, no one’s holding their breath. The ball is squarely in the platforms’ court.

 This is a tenuous peace though. Even as discussions continue between the two warring factions, the fragile peace is already under threat. Zomato, according to reports, has plans to extend its Gold offers to online delivery.

 “If they insist on it, there can be no further discussion,” says Katriar, signing off. 

No reservations

If the food and beverage industry’s problems with platforms had boiled over into open revolt, things were simmering when it came to the hotel space.

For the past 2-3 years, the relationship between online travel agencies (OTAs) and hotels has been stretched thin. Somewhere around the end of 2016, the bigger hotel brands—the likes of Oberoi and Lemon Tree—were the first ones to realise that power was shifting disproportionately in favour of OTAs like MakeMyTrip (MMT), Yatra, and Goibibo (now owned by MMT).

Deep-pocketed online aggregators were throwing money at users in the form of discounts and cashbacks in their bid to gain market share. As a result, felt the bigger hotels, their brands were being diluted. A year later, smaller, budget hotels joined this chorus. The Federation of Hotel & Restaurant Associations of India (FHRAI) accused OTAs of distorting market prices through their deep discounts while simultaneously charging hotels exorbitant commissions.

Last year, the issue reached a crescendo. Hotels in Ahmedabad, Gujarat, stopped listing on Goibibo and MMT. The boycotts spread to Mysuru in the south and Sikkim in the north-east as well. OYO, the SoftBank-funded hotel aggregator, has also faced similar charges. While OYO was listed on an earlier invitation to the event, no OYO representative was present on the day.

For representatives of other OTAs, however, there was no dodging irate hoteliers at the event. Nirav Gandhi and Gurbaxish Singh Kohli, both from the FHRAI, offered no quarter to executives from MMT and Cleartrip on the panel on “online hotel booking”. Addressing Mohit Kabra, the chief financial officer of MMT, Kohli was blunt in his assessment. “We are not here to pull each other’s collar and ties, but let me tell you, we are not happy with you,” said Kohli, who runs Pritam Hotels in Mumbai. Gandhi, the promoter of Express Hotels in Vadodara, was even more scathing. OTAs, he said, were mainly concerned with valuation gains while fooling people with the word “tech”.

While both Gandhi and Kohli represented hyperlocal hotel chains, Adarsh Manpuria reiterated that even larger, pan-India chains such as Fab Hotels were unhappy with aggregators. While Manpuria, the cofounder of FabHotels, did not go into details, he mentioned that FabHotels no longer works with MMT. According to reports, MMT de-listed FabHotels from its platform after agreeing a deal FabHotels’ much larger competitor, OYO. Manpuria alluded to this when he said platforms must be fair and neutral.

Kabra, for his part, only broke his zen-like silence to say that pricing came from suppliers. “We only provide offers and couponing,” he said.

This hardly satisfied the gathering, as FHRAI members rounded on Kabra with a slew of questions and allegations. These ranged from allegations of false reviews/ratings, OTAs charging commissions as high as 40%, discounting without the consent of suppliers, and a lack of growth in the tourism industry.

“There are only 1,200-1,300 rated hotels. Then, tell us, who has rated the 70,000 hotels on your platform? Most of these are false reviews and ratings”

Nirav Gandhi, owner of Express Hotels, Vadodara

Jimmy Shaw, FHRAI member and managing director of the Waterfront Shaw at Lavasa, Pune, even accused MMT of promoting unregulated “bed and breakfast” properties who do not have the required certifications.

Unsurprisingly, the FHRAI is now banking on the CCI to clamp down on OTAs for their monopolistic practices. But the FHRAI isn’t content to just wait and watch. The association has already started taking steps to find a solution for what it believes to be malpractice. For one, FHRAI is setting up a series of meetings in the coming months with OTAs to sort out points of conflict.

On the sidelines, Kohli informed The Ken that the ministry of commerce has taken an active interest in the matter and has asked for the hoteliers’ issues and suggestions. “We are collating all this information and we will send it to the Department of Industrial Policy & Promotion (DIPP) very soon,” he said. He expects the final suggestions to be part of the broader e-commerce policy the govt is working on.


As aggregators locked horns with hotel owners on stage, Jimmy Shaw, CEO of Food Marshall Tech Services, could barely contain his contempt towards OTAs like MMT. During the Q&A, Shaw confronted MMT’s Mohit Kabra: “I’ve written to you several times about the illegal hotels on your platform. You still haven’t responded to me.”

As the world’s third largest hotel association, the FHRAI is now using its considerable clout to even out the long-skewed power dynamic between hotels and OTAs. “The government has been very receptive on this matter. Some solution should be in sight in another three months,” he said. 

Not buying what you’re selling

Of all the panels, the one on online retail was by far the loudest. Traders associations were vociferous and vehement in their criticism of ‘predatory pricing’, private labelling and ‘preferential treatment’ of a select few sellers by marketplaces like Amazon and Flipkart.

The government and regulators, too, came under fire as traders charged them with not enforcing changes introduced in the foreign direct investment (FDI) policy for business-to-business e-commerce. See, it isn’t that the government never put in place rules to ensure a level playing field for small traders. It’s just that marketplaces kept finding ways to circumvent these rules.

Take Press Note 3 (PN3), for instance. For the uninitiated, in sectors like telecom and e-commerce, policies are made or clarified via government press releases, called “Press Notes.” Press Note 3, issued in 2016, was of particular importance. It sought to ensure that no one seller or group of companies—ostensibly those favoured by marketplaces—could account for more than 25% of a platform’s total sales. In addition, it also aimed at preventing marketplaces from owning inventory.

The result? A web of retailers, all with one arm’s distance to the marketplaces, ensuring that while PN3 was followed in letter, it wasn’t implemented in spirit.

In 2018, another Press Note—Press Note 2 (PN2)—was issued. Ostensibly to fix the loopholes in PN3. But while the intent was clear, implementation of the new, more detailed rules—more specifically, determining compliance—was practically untenable. Once again, group companies became non-group companies, and it was business as usual for marketplaces.

Little wonder then that brick-and-mortar traders still point to a lack of neutrality among marketplaces—both with regards to sellers and products. Of 500,000 registered sellers on Amazon, claimed Kush Agarwal of the All India Online Vendors Association (AIOVA), 80,000 have received just one order in the last year. 40,000 received at least 10 orders. Only 10,000 sellers have received considerable business, he alleged.

“We need strong regulation. The CCI must address the abuse of dominance in these markets. Even if it’s about domestic companies. Like predatory pricing practices by Reliance Jio”

Arul George Scaria, NLU, Delhi

The interim findings of the CCI study on the e-commerce market showcased these concerns. According to the study, certain sellers are treated preferentially and are more visible. Platforms also channel most of their products through a select few sellers.

Private labels, too, were an issue, raising concerns over conflict of interest. “PN3 is clear that platforms are technology providers who cannot own the inventory,” said Pawan Kaul, head of corporate affairs at e-commerce platform Snapdeal. PN2, he says, was brought in because of how platforms had circumvented the inventory rule. Despite this, marketplaces have still found ways to hold on to their private labels. “Enforcement was an issue then, and it is now,” Kaul concludes.

Rahul Sundaram, senior corporate counsel of Amazon and the sole e-commerce representative on the stage, did his best to hold his own. Pointing to a study by India Brand Equity Foundation, Sundaram reiterated how small online retail is in the overall scheme of things. The study stated that 93% of retail in the country happened offline, with modern trade—large traders or retail chains like Reliance Retail, etc.—accounting for the bulk of the remaining 7%. “E-commerce is a very minuscule percentage of the overall market,” he said.

Of 500,000 registered sellers on Amazon, 80,000 have received just one order in the last year. 40,000 received at least 10 orders. Only 10,000 sellers have received considerable business,

Kush Agarwal, Member, All India Online Vendors Association (AIOVA)

For all the noise and outrage, representatives of retailers associations agreed that e-commerce was the future of Indian commerce. “But,” said Praveen Khandelwal of the Confederation of All India Traders, “no predatory pricing; no deep discounting”. 

Pankaj Mohindroo of the Indian Cellular and Electronics Association (ICEA), however, was quick to remind Khandelwal that the issue of predatory pricing and deep discounting was hardly restricted to just marketplaces. “Reliance Jio sells a phone which is worth Rs 2,500 ($35) for Rs 500 ($7) and destroys 50% of the feature phone market, is that acceptable to you?” he asked Khandelwal.

Even as Khandelwal struggled to justify Reliance Jio’s strategy, the significance of Mohindroo’s question sunk in. This was not a battle between foreign entities and Indian traders. Or between online-only platforms and brick-and-mortar stores. This was about the unceasing, all-consuming creep of big business. A field that would never truly be level. So, what then? Perhaps the day’s hosts—the CCI—could provide some parity.

“There are a few key questions that have come up before the panel. Whether we need regulation? Yes, we need strong regulation. What’s the role of the CCI? Unlike my co-panellists, I feel the CCI must be addressing the abuse of dominance in these particular markets. Even if it’s about domestic companies—for example, predatory pricing practices by Reliance Jio,” says Arul George Scaria, assistant professor at National Law University, Delhi.

After being rather hands-off when it comes to the digital economy, the CCI has finally shown a willingness to act by ordering a wider probe against global search giant Google. Offline businesses will hope the CCI extends this newfound vigour to the platforms that now tower over their respective industries.