The CEO and Founder of Praava Health on Reimagining Care in an Emerging Market

My obsession with health care in Bangladesh started with my mother’s appendicitis.

It was 2011, and I had come from my home in New York City to Dhaka, Bangladesh’s capital city, to attend a cousin’s wedding. When my mom complained of a debilitating pain in her side, my family rushed her to the hospital. However, the care she received—and the care we witnessed other patients getting (or not)—was awful. We had to chase doctors to get them to examine her, and even then none gave us straight answers. Scans and tests took ages, nursing was downright lackadaisical, and most terrifying, her surgery was delayed and then botched. Eventually, after her condition worsened, we took her to Bangkok, where doctors ordered a second surgery. A year later she needed a third, in Virginia, owing to complications from the original procedure.

Even as I pursued my career in law and foreign policy back in the United States, the experience stuck with me. After visiting a top Bangladeshi hospital, in one of the world’s fastest-growing economies, we had to leave the country to get quality care. Why?

I soon realized that this was not just a problem but an opportunity: to build a new and better system of health care for Bangladesh that would be grounded in international best practices, patient-centric, and affordable. I threw myself into learning about the industry and the country, which, as a Bangladeshi born and raised in America, I’d visited but never lived in. In 2015 I drew up a business plan and began to court investors, jump through regulatory hoops, hire a founding team, and work to outline a clear mission, a set of values, and a corporate culture. In 2018 we opened our first state-of-the-art medical center in Dhaka. We called the company Praava Health—combining the words pran (“life”) and aava (“beam”) to suggest the beam of life.

Today more than 600,000 patients trust Praava Health for their care, making it larger than most U.S. health care systems. We are a household name in one of the world’s megacities. Through our “click-and-brick” platform, we guarantee 15-minute appointments in a country where 48 seconds is the average for a consultation. Our Net Promoter Score is consistently over 80, higher than that of most Fortune 500 companies. We are nearly cash-flow positive on a corporate basis, and MBA students and health care practitioners around the world study our business model. We owe this success to all the members of the Praava team, who bring our vision to life and earn the trust of our community, one patient at a time.

Foundations

I’m not the first entrepreneur in my family. In 1954, when Bangladesh was still East Pakistan, my paternal grandfather, Hamidur Rahman Sinha, founded a pharmaceutical company that is now the country’s oldest and one of its most successful. Like me, he wasn’t a scientist or a doctor or a pharmacist, but he had a vision. At the time, 80% of the drugs on the regional market were counterfeit. He built a business that manufactured quality medicines, constantly warning, “If we ever cheat the consumer, it will be the end of us.” He died when I was 16; I have often wished he were still around to advise me.

His son, my father, grew up in what is now Bangladesh but came to the United States in 1964 as a scholarship student. He expected to study chemistry and then return home to help run the family business. However, after the war for Bangladeshi independence broke out, he decided to stay in America and become a professor. On a visit back to Bangladesh he met my mother, and they soon married. They settled in Roanoke, Virginia, where my brother, sister, and I spent our childhood. Occasionally our family traveled to Bangladesh when we were young, and those visits sparked my interest in economic development.

Health care was a big part of our lives from early on, because my brother was quite sick from birth, needing surgery within hours of his delivery and then suffering from inexplicable skin issues, asthma, and seizures for the first years of his life. Doctors didn’t always take my mother’s concerns seriously, but she finally found a pediatric immunologist at Johns Hopkins who could help. That was an early lesson in the power of patient-centered health care—and the perseverance required to find it.

After graduating from Wellesley College, in 1999, I worked as a consultant at PwC before pursuing a joint graduate degree at Columbia Law School for a JD and at Harvard Kennedy School for a master’s in international development. My education solidified my belief that the private sector is the most sustainable form of development. I spent five years at a New York law firm, and in 2007 I joined the Obama campaign as an external foreign-policy adviser. I felt strongly that the people setting U.S. policy regarding other parts of the world should experience them, so instead of joining the president’s administration when he won the 2008 election, I moved to Afghanistan with the World Bank, then to Thailand with the United Nations, then to Qatar with BCG, and finally back to Afghanistan with the U.S. Institute of Peace. I had some extraordinary experiences, but I missed the accountability and the pace of the private sector, so I returned to my legal career in the United States.

After a few years, however, I found myself longing for more-creative work and a more direct impact on people’s lives. The experience of my mother’s appendicitis still haunted me. And because of my connection to Bangladesh, a country of 170 million, I knew it was making tremendous progress. Described as a “basket case” by Henry Kissinger when it gained independence in 1971, it had by the early 2010s become one of the world’s fastest-growing economies and had reduced the share of citizens living below the poverty line from 40% in 2005 to less than 30% by 2010, all while creating a dynamic, growing middle class of 40 million plus and progressing to “middle income” status according to the World Bank, leading the World Economic Forum to call it “the next Asian tiger.” Bangladesh was growing at a faster pace over a longer period of time than even China. It boasted a GDP per capita higher than India’s and a GDP of more than $300 billion, putting it on track to be one of the world’s 30 largest national economies by 2030.

This was a market that needed quality health care. In August 2014 I decided to see whether I could build something to tackle that challenge.

Investigating the Problem

I had a lot to learn about the country, its health care system, the business and systems of the industry around the world, and entrepreneurship. At first my research was self-funded. I went on a global listening tour, meeting Bangladeshi patients and practitioners and leveraging networks across Asia, the United States, Europe, Latin America, and beyond to study health care business models. I met anyone who was willing to teach me something.

Over the years, I had heard other health-care horror stories from my Bangladeshi relatives. Once my aunt and her daughter had gone together to a private Dhaka hospital for routine mammograms, and the clinicians told my cousin they’d found a concerning spot requiring investigation. But when she went for a follow-up in Bangkok, her scans were clear, and she realized that the Bangladeshi mammographers had mixed up her and her mother’s results. My aunt had breast cancer that demanded a full mastectomy. Some time later, when the same aunt was cancer-free but suffering from joint pain, doctors in Dhaka scanned her bones, determined that they were full of tumors, and prescribed intensive radiation. But when she sought a second opinion abroad, the true diagnosis proved to be osteoporosis, requiring a course of treatment very different from radiation, which would only have made matters worse.

As I talked with more people in Bangladesh, I found that such stories were all too common. People consistently told me that they didn’t trust the health care system. I discovered two primary reasons. First, the quality of care in both the public and private systems varied greatly, partly because the government lacked the capacity to regulate it. In fact, across low- and middle-income countries like Bangladesh, the leading cause of mortality is not lack of access to care but inadequate care. Second, demand exceeded supply. As in other emerging markets, health spending in Bangladesh was growing at an annual compound rate of 10%, outpacing the economy. With the public system understaffed and overstretched, private facilities were left to fill the gap, but they were costly, focused on episodic care, and driven by incentives that pushed doctors to hospitalize patients and order unnecessary tests and drugs.

The opportunity to have an impact was compelling. Access to trustworthy health care is a human right and something Bangladesh’s citizens deserved. The financial opportunity was also evident: Across Asia entrepreneurs in other growing economies with similar supply-demand imbalances had scaled up thriving systems with two to three times the market valuations of similar businesses in the United States. I became increasingly convinced that I could develop a better alternative for Bangladesh—one that would create more accountability in the system and challenge all the country’s providers to do better.

Imagining a New Model

By the spring of 2015 I had a 100-page business plan and a financial model for a vertically integrated health-care system that would be centered on high-quality primary care and family medicine—the bedrock for patient trust—while including secondary and specialist care; outpatient procedures; in-house, world-class lab and imaging diagnostics; and a pharmacy that procured only directly from manufacturers. It would be supported by Bangladesh’s first fully integrated hospital information system, its first patient app, and tools such as telemedicine and an e-pharmacy to improve accountability, quality control, efficiency, and access. The idea was to be the first call and most trusted resource for any medical issue and to help patients manage their health in a way that would prevent hospitalizations.

We raised $1.4 million in our first round of funding, at the end of 2015, and have secured more than $15 million since, all from angel investors. I began to build a global advisory council to bring lessons learned in health care and emerging-market entrepreneurship to Bangladesh. This group now includes Omar Ishrak, MD (Intel, Medtronic); Esther Dyson (23andMe, Wellville); David Petraeus (retired U.S. Army general, KKR); Rushika Fernandopulle, MD (Iora Health, One Medical); and Jeremy Lim, MD (Oliver Wyman, Amili).

I started recruiting seasoned professionals to Praava before I could even afford to hire them. Among them were Mahbubur Rahman, a clinical biochemist with deep experience running world-class labs, who became our laboratory director, and Zaheed Husain, an eminent cancer immunologist who had spent 30 years at Beth Israel Hospital and Harvard Medical School and would set up Bangladesh’s first molecular cancer diagnostics PCR lab at Praava. Simeen Akhtar, a Bangladeshi physician and an expert in quality management who had practiced medicine all over the world, agreed to come out of retirement to be our chief medical officer, while Sabrina Imam, a software engineer with more than a dozen years of experience at IBM and recent stints in health tech, signed on as our IT director. Sawsan Eskander, one of a handful of trained actuaries in Bangladesh with extensive experience in health insurance, joined as our chief innovation officer. Kutub Uddin Kamal, a former journalist who had never previously worked in health care but is now our head of patient experience, joined because of a passion for changing the system. All were frustrated with the current state of medicine in Bangladesh and wanted to be part of making Praava a reality.

Success would require more than just a business plan, capital, and a team, however. So in August 2015 I took the biggest leap: permanently relocating to Dhaka. I was all in.

I knew the transition would be challenging, because I was neither an insider nor a total outsider; I was a “third culture kid.” Even today I’m the only American-born Bangladeshi I know in Dhaka who moved there for any reason other than marriage. But my vision was so clear that I wasn’t worried. I surrounded myself with a strong local team and a global army of supporters to build the bridges we needed.

As I met with potential investors, prospective hires, and government officials, they peppered me with understandable questions. What were my motives? Was I in it for the long haul? Why did I—a 37-year-old Bangladeshi American—think I could solve this big problem? No one said, “Who do you think you are?” but some were certainly suspicious and occasionally ageist, sexist, and anti-foreigner. Still, being underestimated and flying under the radar allowed me to focus on the work. To those who were open to it, I patiently explained my vision, my intentions, and the kind of company I wanted to build, and I won over everyone I needed to. I’m also grateful to the people who challenged me, because facing their questions better prepared me for what was ahead.

About a dozen city and national government agencies would regulate the sort of health care company we were creating, and we had to build relationships to ensure that we could secure the numerous permits and licenses required to operate. The processes were transparent but tedious. Later we developed a strict code of conduct and anti-corruption, antibribery, and whistleblowing policies to protect our team and investors.

Coalescing Around Values and Culture

In the spring of 2017 I convened Praava’s fledgling team of 20 to define our organizational purpose, values, and culture. A spirited brainstorming session produced our vision (“We envision a world-class health care system that puts patients first”), mission (“We aspire to be your trusted partner in health”), and core values: service, my Praava, integrity, listening, and excellence.

SMILE: Praava’s Five Values

Service

Praava is a safe place that offers a warm welcome and personalized services.

• I am respectful and ready to work together to create the best care.

• I practice safe behaviors in everything I do and take action to always put safety first.

• I project a positive image and energy.

My Praava

I am accountable for an important part of Praava, no matter how big or small.

• I am engaged and dedicated to making Praava the best it can be.

• I am constantly learning and improving.

• I am always challenging myself and my team members to do better.

• I speak up to ensure that Praava lives up to our promises.

Integrity

Praava means care that I and my patients can trust.

• In every interaction—with my team members, patients, and community—I am honest, trustworthy, and transparent.

• I respect the privacy of my team members and patients.

• I use my time and resources wisely.

Listening

Compassionate care starts with listening to our patients and each other.

• I listen with empathy so that I can act effectively.

• I am courteous and respectful to all.

Excellence

Praava is setting a whole new standard for patient-centered care.

• I perform my role efficiently so that patients get the most out of their visits.

• I go above and beyond to exceed patients’ expectations.

For us, investing in culture is more than a feel-good activity; it is a business strategy. As we mapped out patient journeys, renovated what would become our flagship Dhaka clinic, drafted our brand guidelines, and readied ourselves for patients, we also developed an intensive hospitality-training program to connect everyone to the patient experience we were imagining. Every one of our first 65 Praava employees—from security guards to doctors to software engineers—attended the first training session, in August 2017. We shared health experiences and sometimes emotional stories about loved ones who had died owing to misdiagnosis, personal suffering and pain, and unethical practices condoned by other management teams.

That was a powerful reminder of why we were launching Praava. Our job was to treat people coming into our facilities as we would want to be treated in the same circumstances. We ended that day with an inspiring video on empathy. On the second day we watched a TED Talk on patient experience and then broke into smaller groups to brainstorm how each of us might bring Praava’s five values to life in our various roles. Then, on the third day, each group performed skits illustrating both a poor health care experience and how it could have been improved—a nice way to encourage creative collaboration and relationship building among colleagues from different departments. (Six years later I still conduct these sessions once a quarter as a core part of employee onboarding.)

In February 2018 we officially opened Praava’s medical center in Dhaka—a one-stop shop for outpatient health care, with 19 consultation rooms, an advanced laboratory setup, basic to advanced imaging services, and a pharmacy. Within a few months our patient app—Bangladesh’s first—was live. For the most part we got our product-market fit exactly right from the start. We were offering trustworthy, integrated, tech-enabled health care that the country hadn’t seen before.

From day one we asked patients, Did our medical professionals listen to you? Did they answer your questions? Were they empathetic? Praava managers and team leaders meet weekly to review all patient feedback. We spend about five minutes on the positive comments and the rest of an hour on the ambivalent or negative ones, trying to learn and adapt and improve our work accordingly. Science is not perfect, and neither are the doctors and the staff at Praava, but when we make a mistake, we hold ourselves accountable and try to prevent similar incidents in the future.

In the early days we spent very little on marketing. Each patient we served became an ambassador and a word-of-mouth marketer, and the patients kept flowing in. In November 2018, in our 10th month of full-fledged operations, our flagship unit broke even.

However, with aspirations to build smaller clinics as spokes around Dhaka and eventually scale up a similar model in cities across the country, we still had work to do. I knew that staying focused on values and culture would position us best for expansion. In 2019 we embarked on a formal initiative to create a culture deck. First we surveyed 30 culture documents from companies around the world that had frameworks we admired. Then we talked with employees across all our groups to understand how their work aligned with our corporate goals and culture and what they loved about working at Praava. Simultaneously we launched a companywide survey. All those learnings plus details of our five values went into the culture deck that we now use alongside the hospitality training to onboard hires and refresh existing teams.

This might seem like a lot of energy for a start-up to invest in culture. But I believe it helps us ensure that all who work at Praava are on the same page about who we are and, as a result, can be trusted to act in line with our values no matter what decisions they need to make. That’s especially important for frontline workers, who constantly face unpredictable scenarios and personalities.

Our response to the Covid-19 pandemic was a case in point. Our team rose to the moment largely thanks to our investments in culture, and I couldn’t have been prouder. Initially we faced a terrible cash crunch: We couldn’t pay anyone for two months. But by the end of March 2020 we were the first private facility to partner with the government on telemedicine and offer it to our patients, and by May 2020 we had launched our e-pharmacy. That same month we were entrusted with being one of the first private providers to process Covid tests, and in June we received a public grant for a remote-care management tool that resulted in a two-thirds reduction in hospitalization rates. Like health care systems everywhere, we were initially stretched thin and had long wait times for our call center and care. But everyone worked tirelessly around the clock to serve every patient who needed us.

The Road Ahead

Over the past few years we have harnessed the goodwill we earned during the pandemic and continued to grow. We have stayed true to our vision and values and are excited about the future. Data from the more than half a million patients we’ve served shows that they are less likely to be hospitalized than those treated elsewhere. Among our in-house doctors, we have a 0% attrition rate: Once physicians come to work at Praava, they don’t leave. Our lab is one of only seven in the country that meet international standards, and it also processes samples collected from hospitals and doctors across more than half of Bangladesh’s 64 districts. We have more than 2,000 corporate clients who offer Praava access to their employees. They include local conglomerates; multinationals such as Unilever, Mastercard, and Chevron; and institutions such as the World Bank, the U.S. embassy, and a dozen UN agencies, and they account for more than 20% of our revenue. We’re seeking capital for expansion into more areas of Dhaka and then the rest of the country and beyond. We have seen larger players, such as BRAC (the Bangladesh Rural Advancement Committee, now known as Building Resources Across Communities) and private hospitals, start to copy our model in Dhaka—competition we welcome if it helps more Bangladeshi patients get access to high-quality health care.

Launching a start-up in an emerging market is the hardest thing I’ve ever done, but it’s also undeniably my greatest privilege. In founding Praava, I was able to leverage my experiences and networks to bring health care to Bangladesh in a way that I was uniquely committed to. I am proud that we’ve built a company with rock-solid values, a cohesive culture, and a dedicated team, and that we never brought in investors who would push us away from our initial mission and vision. We want Praava to be available to all of Bangladesh’s 170 million people. We also hope to see our model deployed in the many other emerging markets where high-quality health care is desperately needed.

Strangers frequently approach members of our team in Dhaka to thank us for building the company. That only fuels our impatience to bring quality care to more patients. We are just getting started.

Copyright 2024 Harvard Business School Publishing Corporation. Distributed by The New York Times Syndicate.

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