Paying Indians to be Healthy, Play-to-Earn and the Hybrid HealthTech/FinTech Model

In India you have a very small government sector. I can't remember the exact figure, but I think only 6 or 7% of the entire healthcare spend is government — the rest is private. And 80 to 85% of that spend is out-of-pocket. So it's cash, or electronic money, being exchanged for medications, for services, for lab diagnostics.

It's totally different to the UK. Here we're fortunate enough not to pay for service — you go in for an appointment, it's all free, right through to the end. In India, at every single stage there's a different transaction: your pharmaceuticals, your lab diagnostics, your consultation.

You can't get admitted until you deposit some money. You could be having a heart attack, but you still have to give a deposit before you can be admitted. These are real situations that happen out in India. So there's a lot to be solved there. I always admire the NHS — how it started, and the fact that it's free at the point of care is absolutely amazing. There's scope to take some of that and put it into practice in countries like India, or insurance-based systems like the US and the UAE.

But there's very little evidence-based medicine in India. During COVID, in the UK we had clear guidelines — these are the medicines that help, prone the patient, when saturations drop between 92 and 95 do this, below that do that, steroids at this point. Very clear. In India, I must have seen 35 to 40 different people's prescriptions during COVID, and I don't blame the doctors — they just didn't have the guidance. So everyone was getting 40 to 60 milligrams of steroids from day one, despite their saturations being 97, 98%. Everyone got a CT scan — everyone I knew. Imagine the radiation exposure from that.

So these are some of the challenges. Again, being able to take a lot of the NHS's evidence-based practice and implement it in countries like India, Bangladesh, Pakistan — there's so much scope to do something awesome out there.

A hundred percent. If I'm a clinician, how am I making money in India? If I'm working at a corporate, I make money by keeping the corporate's beds full — it's that simple. If I'm running my own private practice, I make money when people come to me sick. And probably more than that, I make money from the referrals I make to diagnostics and to pharmaceuticals. How is that in the best interest of the public? It's probably not even in the best interest of why these clinicians went into medicine in the first place. But they have to do it, because that's how the system works.

Health is a real behaviour-change problem. It's not that someone doesn't want to be healthy — the mindset is, "I'll tackle it when it happens." But by the time it happens, it's too late. If you get diabetes and then get the complications, it's too late — and at that point you wish you'd done things 20, 15, 10 years ago.

So we're trying to incentivise people. We talked to tens of thousands of them and asked, "What would make you change your behaviour?" And they said, "Well, if we could see some monetary benefit." So we've partnered with about 12,000 brands in India now, including big ones like Swiggy, Myntra — one of the biggest online fashion stores — Flipkart, which is the Amazon of India, Uber, and many others. If people do the activities — hitting 10,000 steps a day, staying hydrated and logging their water intake, logging their moods, logging their nutrition — then they get rewarded with Bytecoins, a virtual currency they can redeem across that portfolio of brands.

We're adding more and more things to measure. One thing we're really excited to release in about two or three weeks is measuring what people have actually spent on their health and wellbeing over the last year, and rewarding them for it. So if they've got a gym membership — at Anytime Fitness, Cult.fit, wherever — we'd reward them for that intent. Or if they've gone and got a Headspace subscription. Because realising "I might have some anxiety or stress, and meditation might help" is a great first step. We don't know their progress on it yet, but combined with the mood tracking, hopefully we will.

We'll also integrate with companies like Swiggy — the food delivery, like Deliveroo. They've got a separate health section, so if people buy from that health section, we'll reward them for the healthy eating. That's how you get paid to be healthy.

I can tell you a bit about the roadmap too. We'll soon open up a debit account for individuals. As I said, 55 to 60 million people fall into poverty every year in India because they can't cover out-of-pocket costs. So we're encouraging people to save capital for that rainy day, should it ever come. As they hit certain savings milestones in that account, we give them added benefits — a gym membership, health insurance, or our care service — with different tiers depending on how much they've saved. We're showing them that being healthier isn't just rewarding health-wise, it's better financially. Because that's what Indians really understand — their back pocket.

There's no point trying to hammer home that it's better to be healthier — they know it. It's not that they don't know it. It's how much they want to do it, and what makes them change. So we thought: if they can see that financially this is much more beneficial — that they're saving 5,000 or 10,000 rupees a year — that might trigger some behaviour change.

At the moment, yes. But you make a very good point. Where we're going on the roadmap is: okay, we know you're diabetic when you enter our ecosystem. You've been doing your 10,000 steps — great — but it doesn't mean much if you're also doubling your food intake. So let's look at what you've done with your HbA1c. Has it gone from 8.5 or 9 down to 5 within the last 12 months? We'll monitor that too, and reward for actual outcomes, like you said. But at the moment, this is where we're starting. A hundred percent, we're heading towards an outcomes-based reward mechanism.

I think you have to balance it. We won't get rid of the input rewards at all — those stay. It's about how we tweak the system to bring in outcomes too. And you've got to think about the business modelling. These rewards are essentially cashback to the consumer. So who else is vested with us in that model? The insurance companies — because they want to pay out less for complications of chronic disease and for in-hospital admissions. So the business modelling will be on the outputs.

Because the insurer will subsidise it. Take two newly diagnosed diabetics with the same starting HbA1c. One gets it down to a normal range and comes off insulin, onto just metformin — that's a completely different risk. The other only drops by one point and is still much higher risk for complications. Our payment from the insurance company will be far less for the second person. So that's the part that needs to be worked out: how much can we get from the insurers, and how much actuarial risk do we actually reduce for each individual? That's why we haven't yet figured out exactly how the outcome-based rewards will work.

The modern healthcare system has only been around about 70 years — the NHS was founded 75, 76 years ago. And the disease spectrum has completely changed. Back then it was infectious disease: you got admitted, you went home, you were better. Now it's chronic disease — you get admitted for an acute-on-chronic flare, then you go back out still carrying that chronic condition in the background. As the times change, you have to think of new models of care.

And from a behavioural perspective, why have these conditions arisen? We've got a bit lazier — we're working in front of screens 10, 12 hours a day, our activity levels are low. So how do you motivate people? At the end of the day, the back pocket is the best way. What impacts people financially usually drives really good behaviour change. That's why so much fintech is merging with healthtech. In France, for instance, there's a company that started as an insurtech but is trying to impact people's health and wellbeing — that's the fintech play too.

And the penetration numbers back it up. 85 to 88% of Indians now have some sort of bank account, whereas engagement with digital health is maybe a quarter of that — 20 to 25% at most. Out-of-pocket spend on pharmaceuticals is the highest of any category in India by a long way, and yet only 2% of it is done digitally through e-pharmacies. So 98% is still spent the traditional way.

Whereas on the finance side, everyone's banking online. I don't know if you've come across UPI in India — it's an instant payment system. If you take a rickshaw — an auto rickshaw, or even a cycle rickshaw — the driver will have a phone with a QR code and say, "It's 30 rupees for the ride." You scan it and the money transfers to their account immediately. So the penetration of finance is much, much deeper than healthcare — which makes it a great channel to distribute healthcare services through.

It's huge. Someone on the lower-middle or low end of the economic scale in India will still have online banking through UPI — to download apps, pay for food or grocery delivery, or scan a QR code at their local grocery store to pay for their fruit and veg. But healthcare, despite COVID, just hasn't had that penetration. So as a vehicle, using fintech is genuinely interesting.

I've been meaning to write an article about this with the BMJ, and I liken it to Tesla.

What Tesla has really done isn't just about cars. Tesla's a great car — fine — but that's not why its valuation is where it is. What Tesla is really doing is changing our dependence on fossil fuels and oil. That's the interesting part. Not many people realise it, but a lot of Tesla's IP is in its battery technology and its solar panels. And Tesla realised it couldn't sell cars or change behaviour unless the infrastructure was in place. If there are no charging stations — if you go to your local Shell garage and there's only petrol and diesel — then where are you going to charge your car? It's a chicken-and-egg situation. So Tesla placed charging points every five or ten miles, strategically around the country, and then pushed hard: "Okay, now go and buy your Tesla."

That's how I see this. You're putting an infrastructure in place using the fintech model for the new world of healthcare you want to deliver — value-based healthcare, where you're incentivised to be healthier, where it's outcome-based, and you get paid by the insurer or payer based on the outcomes you deliver as a care service. So if I can keep a person healthier and reduce their diabetes-related admissions compared to the next provider, I should be paid more. That fintech layer is the infrastructure — and the car is the healthcare service.

A hundred percent. It's on the roadmap. We're trying to understand this play-to-earn model — where you reward people for healthy actions. With NFTs and crypto there's a play-to-earn model there, and I've seen some succeeding in that world. Right now I don't understand the crypto space well enough, and I'm also trying to understand where it's going from a regulatory standpoint — India has said it will ban crypto. Do I really think that'll happen? No. I don't understand how you'd even ban crypto. But the markets have also taken a turn for the worse recently, so I'm trying to analyse where the space is going. It's on our roadmap for the next year to 18 months.

For crypto and play-to-earn to work, you first have to build a very strong community — people who want to play with the model. So initially we're doing that with our traditional rewards and partners. But absolutely, we're trying to work out how to move into that crypto and NFT space.

Yeah, for sure. There's recent news about a Chinese city being tracked on every level, including people's interactions. And there was that Black Mirror episode where a girl goes around the city and gets a star rating from everyone she interacts with — she goes into a coffee shop and the barista gives her four out of five, which drops her ranking enough that she can't get a mortgage. It's also like car insurance and the black box — install it and it monitors your acceleration, your braking, your speeds, and you get incentivised. When will that black box become connected over wifi and just run your car exactly how it wants to? We don't know.

I definitely see that this data could be used against people in the long run, so we're mindful of that, Musty. Maybe you won't be able to get health insurance at all if you're not engaging with something like this. But that's not what we want. We want health to be equitable — we want everyone to be able to access it. That's our fundamental belief. The aim isn't to eliminate the 10% who aren't doing the right things; it's to educate and motivate even that 10% to do the right thing for their health.

I'm humble enough to realise I'm not the smartest person on the planet, and humble enough to reach out to people who are — to get the advice of people much smarter than me, whether on my board, in the operational team, or just generally. Before starting this venture I was fortunate enough to get access to a board member of Wipro and the CEO of Airtel — big, top-20 CEOs in India. I got to ask them what they thought of the idea and how they'd do it differently.

It doesn't have to be names like that, but it's got to be people who've been there and done it. Professor Bruce Keogh, for example, has been a friend and mentor for a long time; Professor Shafi Ahmed too. I've gone to them and asked, "Prof Keogh, you were National Medical Director for the country for four or five years — what would you do if you were setting up the NHS now? What would you do differently?" To me, it's 100% about who you surround yourself with.

It's not easy. You've just got to be persistent — show them your grit, show them how determined you are. Most of these people are actually very humble and want to give their time, but they're time-poor; they've probably got thousands of people asking. If you show some persistence — and typically, if you've already interacted with one or two key people they know and have worked closely with — that's always a good lead-in. It's social proof. It's the same as selling your services to a company: if you can show them one or two other companies you're working with, especially in their space, it's so much easier to get in the door and pitch. You've got to be a good salesperson at the end of the day.

Exactly — to engage people at that level, you're showing them why you're worth their time, and how their time, if they give it to you, will be meaningful for the world. I think that's what your show is for them too.

Running Medic Bleep has become a bit more automated for me now — I've got the team in place, built out over the last four or five years, so it doesn't actually take up too much of my time, if I'm honest. Maybe a day and a half to two days a week. Meanwhile I'm building out Carebyte and testing the waters — it's still very much in testing mode. My hope is that once it reaches its scaling or tipping point, Medic Bleep will be at its exit point anyway. That's what I'm setting that company up for.

As we touched on before we started recording, I see Medic Bleep sitting nicely in a portfolio — either for a unified-comms company, like a Mitel or something similar, or an electronic health record company. Because no one's going to be procuring just a pager replacement. People will be procuring: how do we communicate across the entire ICS — GP surgeries, community staff, social care, the trust? Medic Bleep would be part of that whole solution. Or, if you're creating a shared care record across a region, you need a communication solution you can message within, contextualised around the patient. Those are the two areas where I think Medic Bleep goes further — and where the acquirers might come from.

Zero to One by Peter Thiel is a really good book. And one of the best tutorials, if you're new to forming a company and looking to start up, is Y Combinator's Startup School — without even getting into YC itself, just going onto that free resource. It's great. There are plenty of startup books I could mention, but Peter Thiel and the YC startup videos take you through the whole course — it's great.