Thanks to everyone who read and commented on the first part of this series. I really appreciate your encouragement and reflections. 🙏🏾 In this second part, I will attempt the daunting task of distilling 10 years of learnings and lessons from building Jeeon on the frontlines of rural health in Bangladesh.

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As I wrote in the last post, our journey started with an anthropological immersion in rural Bangladesh that opened my eyes for the first time to the day-to-day sufferings of people that are often unaccounted for in global health, but also to the tremendous opportunity of over 200,000 small drug shops and pharmacies littered across the country who account for more than two-thirds of primary care interactions and out-of-pocket health expenditures in the country. That’s up to 4M primary care encounters, EACH DAY! Not only do these drug shops (often called chemists or druggists in other contexts) dispense all forms of medicines (thanks to a highly competitive and aggressive pharma industry in the country), they are also often the descendents of “local healers” and “herbalists” who have served these communities for millenia, and hence are the closest thing to a primary care physician for a vast majority of the population, despite their lack of credentials or formal clinical training.

We posited that by leveraging this existing ecosystem that has deeply rooted trust and a vast number of footfalls cutting across every possible health condition, we could perhaps get closer to our mission than was possible through the public and NGO infrastructure alone.

Nearly 10 years and numerous wrong turns and dead ends later, we still believe strongly that this infrastructure can be a huge asset to any health system — depending on whether we understand, recognize and leverage it effectively. Indeed, many organizations, most notably mPharma in Africa and SwypeRx (formerly mClinica) in East Asia, are proving this hypothesis correct. Jeeon still continues to exist as a non-profit for that very reason, and this is also why Endless Health believes in upgrading, connecting and mainstreaming informal providers of care everywhere (more on that in the next post).

A chronological history

Phase 1: Telemedicine (2014-2016)

Excited with these revelations, we jumped headfirst into our first product — a telemedicine platform — within months of that original immersion. The idea was to connect these disconnected pharmacies with urban doctors to bridge the clinical knowledge gap, helping the former provide more accurate care for a wider range of conditions, while enabling the latter to increase their reach to remote areas from the comfort of their bedrooms.

The Doctor-in-a-tab service in a promo video

Not only did we launch a pretty sophisticated telemedicine service for its time, we attempted to do it (too idealistically and naively so, if I might add!) in some of the remotest and poorest areas in the North of the country which were submerged under water for half the year. Our rationale, simply, was that the need for a telemedicine solution was greatest in those areas that had the least access to formal health infrastructure.

We also had an elaborate vision of how this would form the nucleus of a broader strategy to link pharmacies to the rest of the healthcare ecosystem, unlocking other revenue streams for us in the process:

But as we found out the hard way, elaborate plans seldom pan out the way you expect! Despite some early traction and positive feedback from both pharmacies and patients (we had 84% positive patient reported outcomes and a consistent 70%+ net promoter score), we failed to eventually scale the model. Main among the reasons was that delivering positive outcomes requires the coming together of many discrete elements - medicine supply chains, clinical knowledge, diagnostic equipment, referral linkages, patient’s own health awareness, etc. - which were all more or less broken in the rural and remote environments we chose for our intervention. We found ourselves scrambling to solve too many problems at once, which drove up our costs significantly. On the other hand, rural Bangladeshis had very slim health wallets, and just recovering our costs would require charging prices that would keep the service out of reach for the vast majority (I wrote a ~50 page report on our learnings from telemedicine for a funder, which I encourage anyone to read to dig deeper into these and many other learnings).

This was a major turning point in our journey, because we had already spent most of our seed investment in perfecting and fine-tuning this model, and were forced to go back to the drawing board and start from scratch. In hindsight, the fact that we were structured as a for-profit also introduced undue pressures to figure out a business model quickly, which caused us to scramble for the next year or so without a clear vision of how to move forward. Many team members were also highly emotionally invested in and attached to the telemedicine model, so we lost some key people and morale dropped significantly.

Phase 2: Prototypes (2017-2018)

Over the next two years, we did what we probably should have started with in the very beginning, i.e. prototype a variety of different products and services to systematically explore the “design space” and find product-market fit. We did this in part through a “skunkworks” like team of our most enthusiastic, creative and energetic people with the mandate of identifying nuggets of opportunity based on our learnings to date, and trying out rapid prototypes of those ideas. Most of these ideas seemed promising initially, but to our utter dismay, turned out to be dead-ends for various reasons:

• A clinical decision support system for “village doctors” to use during patient encounters: They did not want to look at a screen during patient interactions, which they considered detrimental to the eye-contact, warmth and natural flow of the encounter.

• A debt and cashflow tracker for drug shops (“Haal Khata”): We noticed that many pharmacies maintained paper credit-books, and we thought this might be an interesting problem we could solve. Turns out credit recovery was never their aim; they write off most of this debt (often amounting to ~2 months worth of income) at the end of the year anyway, through a festive celebration during the Bengali new year, as a way of building goodwill in the community. The cashflow and accounts management feature failed because the transaction sizes were too small for the users to key it in for each patient.

• A e-learning app for “village doctors” to build clinical skills and knowledge: During our telemedicine model, we had curiously observed that pharmacies would secretly xerox doctor’s prescriptions and study them later to learn treatment approaches. Indeed, when we launched this prototype, we quickly reached about 5000 users within a month. Many users used the platform for hours a day, thanks to its built-in Duolingo-like leaderboards and practical case-solving games simulating real patients. However, the engagement dropped off a cliff after the second month once the novelty wore off, likely due to lack of an end goal (e.g. certification or accreditation), preventing us from monetizing the platform through sponsored content or product recommendations as we had initially planned.

• Non-pharma product sales and associated services: We started off with eye-care, successfully piloting with VisionSpring a model to screen for common eye problems and selling reading glasses (for near-vision disorders) in the process. We quickly reached 35,000 screenings and 15,000+ pairs of glasses sold with only ~150 pharmacies, but the supply chain was too complicated (due to the high number of SKUs of prefab glasses) and expensive to set up (buying vehicles, etc.) in the absence of reliable third-party logistics partners, and the pipeline of additional products that would fit this market was also too dry.

• Referrals to surgeries and other procedures: We successfully demonstrated the potential of using pharmacies to identify and refer cases that required tertiary care, such as cataract and cleft deformities. This also had some revenue potential, but did not generate enough volume and flow to justify investments in building out the nationwide referral network.

Phase 3: E-commerce (2019-March 2020)

Ultimately (and to our great relief!), we found a prototype that started showing traction, which was an ordering solution (branded “JeeonConnect”) for small and hard-to-reach pharmacies to procure quality drugs directly from manufacturers. We decided to double down on this e-commerce approach, had a couple of successful trials connecting ~3000 pharmacies with a renowned pharma company, and by early 2020, secured a contract with the company to aggressively scale up the platform to 20,000 pharmacies by the end of the year. We were energized after a long time because this model not only had a direct revenue model (a commission on every order, compared to the indirect business models of all the other prototypes), tapped into the core business of pharmacies and hence had a relatively large addressable market, relied on the pharma company’s own distribution and hence was not capital intensive, and would get us to a meaningful enough scale to hopefully attract other pharma company partners, raise our Series A and layer on other patient-focused services (the vision for how this would all come together was represented in the 2019 promo video below). Not to say all was a bed of roses with this model (there certainly were thorns!), but it was certainly the closest we had ever been to a scalable business model that could get us to break even.

Phase 4: COVID Response (March 2020 - 2022)

In an ironic twist of fate, just as we were ramping up the roll-out of JeeonConnect, the first cases of COVID were identified in the country, and within a few days, the entire country went on lockdown.

Although we anticipated an increase in sales on our digital platform due to the restricted movement of pharma sales reps, this hardly materialized. Apparently, sales reps were unable to reach doctors for their usual marketing promotions, so they went all-out trying to push sales with pharmacies directly, regularly visiting even the smallest and hardest-to-reach shops that were JeeonConnect’s staple client base.

At the same time, however, we were also hearing earnest pleas for help from our pharmacy clients, who felt vulnerable to this unknown virus and deeply anxious without any access to authentic knowledge or protective equipment, despite a rapid uptick of symptomatic patients who they couldn’t turn away.

It was an extremely difficult choice, but one that we made unanimously as a team (and probably the one decision I’m most proud of in all my 10 years of running Jeeon) — to put our commercial operations on hold and invest wholeheartedly in COVID response work, irrespective of the existential threat it represented.

We launched an online certification course on community-based COVID response (which was accredited by the Pharmacy Council of Bangladesh) within 5 days, which ended up certifying over 25,000 community pharmacies nationwide. From our own coffers, we supported over 4000 pharmacies with PPEs. We worked shoulder-to-shoulder with the government and other NGOs and multilaterals in the Risk Communications and Community Engagement (RCCE) pillar of the country’s COVID strategy. Our engineers helped design the standardized national API that centralized millions of COVID-19 case reports from all corners of the country over the next two years. We conducted symptomatic surveillance through pharmacies in partnership with a Yale research group, disseminated behavior change content and up-to-date verified information to communities through our pharmacy network in partnership with BRAC, and helped the Savar health officials (a large industrial suburb of Dhaka) develop and document a highly effective COVID response strategy engaging communities and pharmacies directly. We eventually wrote up this latter experience into an Action Toolkit, which was published by Monash University, and since disseminated to all regional public health officials in the country as a best practice in community engagement during public health emergencies.

In the process of all these activities, we also built a massive database of over 120,000 pharmacies (complete with phone numbers), and over 35,000 pharmacies joined our closed Facebook community for access to authentic COVID related information and educational content.

Although we raised some philanthropic resources for all this work, by 2022 we had exhausted all our capital and without a path back to our commercial trajectory, were left with no choice but to convert to a non-profit, aided in no small part by the supportive generosity from our investors.

Phase 5: Jeeon as a Non-profit (2022 - present)

Today, Jeeon is a non-profit with a small team of part-timers and volunteers, who are keeping alive our large online community of pharmacies through regular virtual learning sessions on timely health topics, knowledge-based discussion forums and exchanges, and collective advocacy efforts for a more conducive regulatory environment. Some conversations with potential partners to leverage this network to roll-out various products and services are also under way.

Key Learnings and Takeaways

It is hard to summarize the thousands of big and small learnings from such a long and intense period of experimentation and discovery, but I have tried to pick the top three below.

Technology solutions must follow a deep understanding of the problem, not precede it

Like many technology-enthusiasts, we often got carried away by the “silver bullet” fallacy. We got excited about the solution before investing deeply in peeling the various layers of the problem to get to the root issues.

For example, with telemedicine, we were trying to solve the pain point people repeatedly emphasized in our focus groups — lack of access to doctors. As we rolled out the service, we started to feel that the underlying need was more about the quality and completeness of the treatment provided, which included the accuracy of the treatment, but also required a stock of quality medicines, access to diagnostics, and more. I did not realize until much later that the actual deepest need was for a quick, inexpensive fix to whatever problems poor people came with. Indeed, as we found through our research, people typically give a pharmacy 72 hours to “fix” the problem before switching to a competitor (and usually there are 10-50 such competitors in any rural bazaar). This was why drug shops as they operate now — delivering the two-day dose of the most potent antibiotic or steroid in their stock, sometimes even on credit — was such a “perfect” solution.

In hindsight, I’m not sure telemedicine would ever solve this particular need, unless you could get people to care about the long-term costs of these quick fixes, set up monitoring mechanisms on providers and impose punitive measures for mistreatment, AND offer an alternative that was just as convenient and inexpensive (cannot even imagine what that might be). In other words, unless you can change poor people’s definition of “quality” or address their desperate need for a “quick fix” in some way, it will be really hard to design a private sector service (technology-based or otherwise) that truly delivers health outcomes.

Similarly, in our excitement seeing the early traction on our e-learning app, we forgot to ask what was the deeper pain point this was meant to solve, which would keep them coming back in the long term. The lack of good learning content was surely an issue, but the much more urgently felt pain point was a lack of formal recognition from the health system as primary care providers, which would only be solved with some sort of a government-issued accreditation. Then again, a one-time accreditation would not suffice in solving the problem of long-term engagement — you would require regular renewals of the accreditation based on units of learning or requalification exams, similar to CME requirements for doctors in advanced economies. This was not a technological problem but a regulatory one, and hence was way beyond the scope of a 30-person startup.

(As a tangential but important point, it did not help our cause at all that the fundamental technologies we were banking on (particularly rapid diagnostics toolkits) did not materialize on the timelines we needed them to. With today’s price-performance of these kits combined with AI, it may have been a very different story. As they say, success in innovation is as much about timing as it is about the idea or the execution.)

Incentives reign supreme

Having come from the experience of working only with government and NGO health workers, who are salaried employees that tend to do what their managers ask of them, I was completely oblivious to the complex incentive structures private sector players like drug shops operate within. Not only do they have direct financial interests and motives as a micro-business, they also care deeply about their reputation in the community, being perceived and even addressed by the local community as their “doctor”. As a result, for example, they were often reluctant to encourage their own patients to opt for a telemedicine consult, since it made them look less confident in their own skills.

On top of this were the explicit bonuses and pressures from pharma companies to sell the latest branded drugs, the significantly higher margins often associated with poor-quality medicines, and the strong implicit expectation from patients for the drugs that would most swiftly relieve their symptoms and allow them to get back to work. This was indeed the perfect storm of perverse incentives!

This remained a blind spot for us for a long time because with telemedicine, we were initially trying our best to optimize value for patients. We were late to realize that we needed to align with the pharmacists’ incentives more directly and solve their pain points, since they were actually our primary clients, not patients, even though we were trying to ultimately impact patient outcomes. This “aha” moment was partly the result of a really fortuitous 1:1 discussion with Bill Gates in 2016, where he insightfully pointed this out as a key flaw of our telemedicine model. (I wrote a piece reflecting on that meeting and imagining a follow-up conversation below). This was why we tried to address the pharmacy’s pain points more directly in all our subsequent models post- telemedicine.

A (hypothetical) follow-up conversation with Bill Gates about Jeeon’

Rubayat Khan

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April 20, 2022

Read full story

But incentives were at play at not just the pharmacy. Patients had their own unique set of incentives due to their limited health education and the varied pressures on their limited time and resources. Even doctors in our telemedicine model responded strongly to simple patient feedback and satisfaction scores, especially when ranked on a public leaderboard against their peers. It opened my eyes to how much we as humans —experts or otherwise— operate mainly as a function of our surrounding incentive architecture.

As a corollary, it also continues to amaze me how little effort and sophistication we bring to shaping the incentive structures of our providers and systems, and still expect genuine effort and positive outcomes from them.

Aligning the 3 Ms — Mission, Market and Model — is critical

Our for-profit business model was inconsistent with the rural market we were trying to address, and our mission of delivering positive health outcomes at any cost. When we pivoted to e-learning and then e-commerce, however, the market and models were better aligned, but we were straying further from the mission. We felt this deeply in our sagging morale and creeping self-doubt. It was only when we chose to let go of our for-profit orientation and decided to go after COVID response work with a philanthropic mindset, that our mission, market and model were finally completely aligned, allowing us to reach national scale and impact virtually overnight.

If I were to do it again with the benefit of this lesson, I would probably have started as a social business in a peri-urban market or a captive audience such as a factory, where people had more disposable income and greater health awareness, and oriented our mission towards a more narrowly defined problem (like low-cost diagnostics, or integrated diabetes care). If it were successful, it could provide the platform to form a sister non-profit that targeted more rural and difficult markets with a philanthropic approach.

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If you survived till the end of this long post, my sincere thanks. 🙏🏾 Please comment (on the Substack website) or email (replying to this mailer) with your reflections or pointing out blind spots I may still have. I would also appreciate if you shared this with anyone else who might find it interesting.