Ziqitza Healthcare Limited Challenge of Scaling Up Emergency Medical

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Asian Journal of Management Cases
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DOI: 10.1177/0972820113520207
2014 11: 5 Asian Journal of Management Cases
Rakesh Gupta and Sriparna Basu
(EMS) in India using Public-Private Partnership (PPP) Mode
Ziqitza Healthcare Limited: Challenge of Scaling up Emergency Medical Services
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Editors Introduction 5
Ziqitza Healthcare Limited:
Challenge of Scaling up Emergency
Medical Services (EMS) in India using
Public-Private Partnership (PPP) Mode
Rakesh Gupta
Sriparna Basu
Abstract
Ziqitza Healthcare Limited (ZHL) launched Dial 1298 ambulance services in Mumbai (India) in 2005
to provide quality and timely emergency medical services (EMS). They adopted tiered pricing strategy
based on cross-subsidy model to make their services widely available to all sections of society and make
the venture financially sustainable. With funding support from Acumen Fund, ZHL quickly expanded
its operations within Mumbai but wanted to expand their reach across India to make a larger social
impact. Recognizing the commitment and work of ZHL and the pressing need for quality and affordable
emergency medical services, many state governments showed interest in partnering with ZHL. Experts
suggested Public-Private Partnership (PPP) mode as a way forward to improve the quality and expand
the reach of these services. It was in this back drop that ZHL was awarded a three year contract by the
Rajasthan Government in 2010 to operate their fleet of more than 300 medical ambulances. ZHL saw
it as an opportunity to fulfil its social mission and expand its footprints. However, the founders were
apprehensive of working with the government and unsure whether this should be the next step to
expand the reach of EMS across India at an affordable price.
Keywords
Emergency medical services, cross-subsidy, Public-Private Partnership, tiered pricing, scaling-up
Introduction
Shweta Mangal, CEO of Ziqitza Healthcare Limited (ZHL) was returning home when she received a
phone call from her senior manager in Jaipur (Rajasthan) in May, 2013. The manager informed her about
the decision taken by the Health and Family Welfare department of the Rajasthan government to take

Asian Journal of Management Cases
11(1) 521
2014 Lahore University of
Management Sciences
SAGE Publications
Los Angeles, London,
New Delhi, Singapore,
Washington DC
DOI: 10.1177/0972820113520207
http://ajc.sagepub.com
This case was written by Associate Professor Dr Rakesh Gupta (rgupta@imt.edu) from Institute of Management
Technology, Ghaziabad, India and Associate Professor Dr Sriparna Basu (sriparna.basu@imi.edu) from International
Management Institute, New Delhi, India, to serve as basis for class discussion rather than to illustrate either
effective or ineffective handling of an administrative situation. This material may not be quoted, photocopied or
reproduced in any form without the prior written consent of the Lahore University of Management Sciences.
Case
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6 Rakesh Gupta and Sriparna Basu
Asian Journal of Management Cases, 11, 1 (2014): 521
over the operations of running medical ambulances from ZHL. Shweta could not understand the
reason behind such an extreme step, just a few days ahead of the scheduled meeting between ZHL
team and health department officials to resolve all major issues. The Rajasthan government had signed
a three-year agreement in 2010 with ZHL under Public-Private Partnership (PPP) mode allowing ZHL
to operate more than 300 state ambulances to provide emergency medical services (EMS). Though
this agreement allowed ZHL to provide EMS to a wider segment of population and scale-up their
operations but the relationship between the two parties had been rocky despite a promising start. While
looking out from her car window at the rush hour traffic in Mumbai, Shweta kept thinking about the
ups and downs of this partnership, the initial euphoria generated by this agreement and the doubts and
concerns of the ZHL founding team at the time this agreement was signed.
She clearly remembered the celebratory mood at the ZHL office when this contract was awarded
to them by the Rajasthan government in 2010. This partnership was going to quadruple the number
of medical ambulances operated by ZHL and increase the population served by them to 100 million
(Alex 2010). The company was awarded this contract on the strength of its commitment to EMS, its
track record and the fact that it had emerged as the lowest cost bidder. This move was seen by experts as
a major step towards providing quality, timely and affordable EMS to a wider segment of the Indian
population. The term EMS had evolved over time to reflect a change from ambulance service to a system
in which actual medical care was provided in addition to transportation. India, by virtue of its demo-
graphics and number of people needing these services required high-quality, affordable and timely EMS
and a successful PPP could expand the reach of these services while saving countless precious lives.
With experts hailing this agreement and the entire staff celebrating, the founding team was aware
of the operational challenges that this agreement presented. They had to maintain current high-quality
service standards while adjusting to the ambulance infrastructure provided by the government and
scale-up their operations to make these services widely accessible within the state. Though they were
confident of meeting this challenge, the major issue bothering them was the challenge of working
with the government, which shared the same social objective with ZHL but had little experience of
partnering with private service providers. The work culture, operating procedures and decision making
processes of the government were very different from that of a private organization and the founding
team was apprehensive about these issues.
Ziqitza Healthcare Limited Dial 1298: Inception
To assist in saving human lives by providing the leading network of fully equipped advanced & basic life
support ambulances across the developing world.
ZHL and Dial 1298, its branded ambulance service, was founded in 2005 in Mumbai (India) to provide
high-quality, timely and reliable EMS at an affordable price. The word Ziqitza comes from Sanskrit
words chikitsa, meaning medical treatment, and zigyasa, meaning quest for knowledge. Ziqitza was
the brainchild of five friends Naresh Jain, Manish Sacheti, Ravi Krishna, Shaffi Mather and Shweta
Mangal, who left their lucrative jobs to start this venture. The genesis of this idea could be traced to the
diametrically opposite experiences of the two founding members of ZHL with EMS in two different
parts of the globe. When Shaffis (founding member) mother choked in her sleep in India, he was clue-
less about medical support facilities like ambulance services and could not obtain suitable transport other
Ziqitza Healthcare Limited 7
than the household car. Krishna (founding member) lost a close friend in a road accident due to lack of
availability of timely medical attention (Desai 2009). In contrast, when Krishnas mother had a heart
attack in New York, USA, an ambulance arrived within five minutes and this timely medical intervention
saved her life (DSouza 2009). These two different experiences left a deep mark on them and subsequent
discussions within friends highlighted their strong desire to improve EMS in India. This was the impetus
behind the initiative of Dial 1298 for Ambulance. In the words of the founders:
We wanted to bring services like 911
1
and 999
2
to India.
They began working on this idea in 2003 with the intention of doing detailed research and presenting
their findings to the government about how these services could be streamlined. They examined various
successful and failed models of EMS across the world to come up with a suitable model for India. They
found that many government-supported medical ambulance services had already failed in developing
countries, but it got them thinking whether this kind of initiative could be undertaken in the private
domain. During this time, Shaffi won a scholarship at London School of Economics (LSE) and there
he got an opportunity to work closely with the London Ambulance Service (LAS). He built a lasting
relationship with them, wherein LAS agreed to help them in launching these services in India. This
turned out to be a big step in the incubation of Dial 1298 for Ambulance. After Shaffis return, the
friends did a pilot run in Mumbai in 2004 by equipping two ambulances as per LAS standards. Finally,
in April 2005, the founders began this venture with ten ambulances and a state-of-the-art call centre in
Mumbai. The ambulances were fitted with advanced life-saving equipment, doctors and paramedics
to administer oxygen and provide emergency medical care. The call centre, operating 24 hours, had
features like a detailed digital mapping of the city, tracking system for ambulances, and advanced
medical priority dispatch software. To start the service, the founders tried to acquire a three-digit
phone number, as used in United States (911) and United Kingdom (999), which patients could call
easily to access these services. After approaching the telecommunications department, they learnt that
three-digit numbers were allocated only for government programmes and they could instead get a
four-digit number beginning with 12. They zeroed in on 1298 and hence the initiative was named
Dial 1298 for Ambulance.
Need for Emergency Medical Services (EMS) in India
A report by the Ministry of Health and Family Welfare, Government of India mentioned injury as one of
the leading cause of deaths in India (Annual Report to the People on Health 2010). It stated that the
global average of road accidents for every 1000 vehicles was 0.75 but in India it was sixteen accidents,
so the ratio of traffic accidents was 21.3 times higher in India than the World average. Furthermore, the
Transport Research Wing, Government of India, mentioned that each year more than 100,000 people die
from road accidents (Transport Research Wing 2011) in the country (see Exhibit 1). World Health
Organization (WHO) has projected that by 2020 road crashes would be a major cause of deaths in India,
accounting for approximately 546,000 deaths annually (WHO 2004a). Around 30 per cent of accident
victims in India die due to delays in transportation or lack of access to timely medical care; 50 per cent
die in hospitals within five days due to infection which may be caused by primitive modes of transporta-
tion and only 20 per cent die on the spot as a result of injuries (Mangal 2010). Research points out that
cardiac diseases and stroke would be a major cause of death and disability for Indians by 2020
3
and these
patients require emergency and timely medical attention.
Even in cities like Mumbai, it was extremely difficult for a patient suffering from a major accident,
heart disease or stroke to reach a doctor within the first hour and hence, most victims would be deprived
of critical medical intervention at the time referred to as the golden hour to save a patients life,
provided that proper medical treatment was be provided. It was the lack of adequate and timely
medical support that made the situation difficult rather than availability of medical facilities. As
per ZHL, Mumbai alone had about 100,000 emergency medical cases per month (see Exhibit 2), out
of which only 10 per cent were serviced by medical ambulances. The majority of people relied heavily
on auto rickshaws
4
or taxis or personal vehicles for emergency transport owing to their perceived
low-cost and easy availability. On the other hand, ambulances run by hospitals and NGOs were not
widely used due to lack of awareness, perception of unreliability and lack of timeliness. A study con-
ducted by ZHL found that only 4 per cent of patients were transported by medical ambulances across
the country and most people often adopted a scoop and run approach of using the nearest available
vehicle to transport the patient.
In India, services provided to transport patients requiring emergency medical attention were either
unavailable or outmoded or unreliable and the response time was simply too high, and communication
between ambulances and hospitals was virtually nonexistant. There was a dire need for a nationwide
EMS and if one projects a requirement of one ambulance per 100,000 population, India roughly required
a fleet of 10,000 ambulances for a population of over a billion people, which would require an estimated
operating cost of US $ 280 million per year with average operating cost of US $ 24,000 to US $ 28,000
per ambulance per year.
5
With the Government planning to raise health care expenditure to 3 per cent of
the GDP,
6
a commitment of US $ 280 million towards EMS was possible. According to Mather:
There were no organized ambulance services across India when we started out as it was micro-fragmented,
individual units. People didnt call ambulances to go to hospital.
ZHL-Initial Growth and Financial Sustainability
In its first full year of operation, ZHL serviced an average of twenty-eight calls a day, of which
20 per cent were emergency calls and the percentage of free calls was around 25 per cent (see Exhibit 3).
The number of ambulances owned and operated by ZHL grew steadily and emergency calls increased
at an impressive rate of 30 per cent to 40 per cent each year. There were a number of early success
indicators for Dial 1298 services; between 2005 and 2007, there were more than 30,000 completed
incoming telephone calls (DSilva 2007). Around 15 per cent to 20 per cent of services provided in
response to the completed calls were free or subsidized, indicating that their services were touching
all social strata within Mumbai. As ZHL began experiencing early success and gathering momentum,
its leadership was charting the five-year plan that would increase their effectiveness within Mumbai
by increasing their reach and reducing response time for EMS and taking the company beyond
Mumbai (ibid.).
We plan to have about 70 ambulances in Mumbai in two years time and cut our response time to about 6 or
8 minutes from the current 15 minutes, said ZHL founders in 2007.
While starting the ZHL, the founders set three goals-1) meet global service delivery standards; 2)
provide services to all regardless of their paying capacity and 3) reach long-term financial sustainability.
In accordance with its mission to provide EMS across India, ZHL developed a long-term plan of
expansion. They were able to expand into Kerala within the cities of Ernakulam and Thrissur by the end
of 2008 starting with five advanced life support (ALS) ambulances. The service area was further
expanded to cover two more cities, Alleppey and Kottayam in June 2009, with addition of five ALS
and ten basic life support (BLS) ambulances, making a total of ten ALS and ten BLS ambulances in
Kerala as the company planned to cover the entire state (Author, 2009).
Right from the inception, ZHL differentiated itself by positioning the organization as a high-quality,
affordable, efficient and reliable EMS service provider. The ZHL team wanted to develop an operating
model that would create a financially viable and scalable EMS platform to expand their geographical
reach and make a larger social impact. They wanted to reach the emergency caller within 15 minutes
initially and later decrease that to an average response time of 68 minutes as in most developing
countries. Looking at the available ambulance infrastructure, traffic conditions and urban infrastructure
of the major cities in India, this was a very challenging goal. The founders were clear from the beginning
that though the venture had been launched in Mumbai, they had to scale-up to make a larger social
impact and make it financially sustainable. For this ZHL needed infusion of capital, clear future growth
strategy and a robust business model. Upon entering their third year of operations in 2008, the founders
set goals for increasing their market reach, improving efficiency and becoming financially sustainable.
This meant close monitoring of key operating metrics, such as number of trips an ambulance makes
per day, average charge per trip, and the ratio of paid to free services. ZHL business model targeted a
ratio of paid to free ambulance trips of 80:20 and put 20 per cent as the upper ceiling for free services.
A hospital outreach team was created to build relationships with various hospitals to refer patients to
them. In 2007, only 20 per cent of the calls coming into their Mumbai Control and Dispatch Centre were
made directly by individuals, and the remaining 80 per cent were transfer or referral calls from hospitals.
Today, Dial 1298 medical ambulance services were available in seven districts of Kerala, fifteen districts
of Orissa, all districts of Rajasthan, Bihar and Punjab along with Mumbai and Chennai in India.
Funding
ZHL began their operations with ten ambulances and state-of-the-art call centre in Mumbai in 2005. To
make a beginning, the founders pooled their personal savings to the tune of $ 120,000 and Ambulance
Access for All Foundation (AAA Foundation) donated 6 ambulances to ZHL. The founders knew
that ZHL needed to acquire more ambulances to fully leverage the ambulance network and call centre
infrastructure to meet their core objective. However, to expand its operations and reach the goal of
seventy ambulances in Mumbai, ZHL needed an investor (Alex 2010). This was a challenging task
because the investor should value ZHLs compelling mission of a making larger social impact by creat-
ing a financially sustainable venture. They started searching for investors with experience of investing in
social ventures because they realized that traditional investment options might not work in their case. A
ZHL investment advisor suggested that the founders should approach Acumen Fund, which had a reputa-
tion for making social investments. The founding team met with Mr Varun Sahni from Acumen Fund
India office in early 2006. Mr Sahni and his associate, Mr Vikram Raman, thereafter met Brian Trelstad,
Chief Investment Officer of Acumen Fund to discuss potential investment options in ZHL. Brian was
impressed by the focus and commitment of the ZHL team and their passion for improving Indias access
to quality emergency medical services at an affordable price. He found ZHLs social objective compel-
ling and was impressed by the sound financial understanding of the founders and became convinced that
the venture would be sustainable. Acumen recognized that if ZHL experienced growth and success, its
impact on Indias population would be both substantial and demonstrable. After completing due
diligence process, Acumen Fund decided to make a $1.5 million equity investment into ZHL in two
tranches in lieu of 30 per cent equity stake and one board seat. The infusion of capital was used to expand
the fleet of ambulances, increase their awareness campaign and meet working capital requirements.
Tranche 1: $600,000 by the end of 2006
Tranche 2: $900,000 by the middle of 2007
Using Cross-Subsidy Model to Become Financially Sustainable
Keeping their social mission in mind, ZHL initially decided that people would be given the option to pay
depending on their affordability believing that those who could afford would pay for these services. Very
soon they realized that their pricing strategy was flawed and could not be sustained. While considering
various pricing options, the founding team met with Dr Sam Pitroda, who impressed upon them the need
to develop a suitable pricing strategy to scale-up their venture to make a larger social impact. This led to
the development of sliding pricing strategy based on cross-subsidy model in which, people who used
their services for going to private hospitals paid the entire fee, and those who used it for going to govern-
ment hospitals paid a subsidized fee whereas, accident victims and those who declared their inability to
pay were transported free of cost. So the pricing was based on the choice of hospital reflecting their
affordability, where well-off customers selecting expensive hospitals paid the full fee, while the poor
received a discount of up to 50 per cent off or even a free service. Additionally, victims of accidents
and disasters were transferred to government run hospitals, free of charge (Lee 2009). The fee varied
from US $ 6 for basic services to about US $ 12 for cardiac care (DSilva 2007). The founders realized
that this pricing strategy would lead to revenue generation and make the venture financially sustainable
while meeting its social objectives. In addition to providing EMS access to the poor, ZHL created
value proposition by providing high-quality healthcare services in emergency situations in a timely
and cost-effective manner.
ZHL developed two distinct streams of revenue; one through fee associated with EMS and another
through advertisements. For advertising revenue, ZHL, in addition to displaying its 1298 number, placed
large multicolour advertisements on its ambulances, thereby providing a moving billboard facility to
the corporates. In initial years of operation, advertising revenue outpaced EMS revenue, with 1298 gen-
erating advertising revenue of US $ 48,000
7
in 2006 and US $ 200,000 in 2007. The revenue in service
fee grew quickly, from US $ 32,000 (2006) to US $ 145,000 (2007), to US $ 160,000 in 2008, which
touched US $ 240,000 in 2009. This increase in revenue reflected both an increase in ambulance trips as
well as increase (from US $ 6 to US $ 12) in average charge per trip. ZHL leveraged their corporate
relationships such as with Tata AIG, who provided them monetary support in lieu for corporate social
responsibility advertising on 1298 ambulances.
Ambulance Services
Main Services
ZHLs 24/7 control room employed Emergency Medical Dispatcher Software, which was designed to
enable real-time tracking of ambulances through GPS and ensured that the nearest ambulance could
reach an emergency caller at the earliest. Control room staff were trained as Emergency Medical
Dispatchers (EMD) who could carefully question callers to determine the nature of emergency, degree
of damage and give necessary instructions before the ambulance arrived. EMDs stayed in contact with
ambulance staff to coordinate with medical workers at area hospitals (see Exhibit 4). ZHL ambulance
services came with a Life Institute of Health Sciences (LIHS) doctor, a driver and a helper. All ambu-
lances were air-conditioned, had basic soundproofing, and equipped with a collapsible trolley stretcher
and a stair chair on board.
ZHL possessed two kinds of ambulances:
BLS: Ambulances provided transport to patients who did not require extra support or cardiac
monitoring; these ambulances included oxygen administration, splint treatment and cardiopulmo-
nary resuscitation (CPR) capabilities.
ALS: Ambulances provided transport to patients who needed a higher level of care; these ambu-
lances included oxygen administration, splint treatment and CPR capabilities plus defibrillator,
cardiac monitor, portable ventilator, suction machine, resuscitation kit, and electrocardiogram,
emergency medicines and pulse oximeter.
Other Services
BLS Workshops including First Aid
With Life Institute of Health Sciences (LIHS), 1298 started a community initiative to create First
Responders in Mumbai by providing free of cost training to college students. Workshops were held
regularly by LIHS doctors on medical and trauma emergencies ranging from fractures to cardiac arrest.
Students were given basic CPR training as well as automated external defibrillator (AED) utilization
techniques. The whole point was to create public sensitization about first aid and the need for ambu-
lances by involving the youth (Author 2008).

Womens Helpline
ZHL collaborated with Dr Indu Shahani, the Mumbai Sheriff, to bring about 1298 Womens helpline in
January 2008. This helpline assisted women against sexual harassment and violence, and received
around twenty to twenty-five calls every day. To further facilitate this programme, ZHL, along with
the Sherrifs office, Akshara Foundation and Times Foundation developed Womens Resource Directory
in September 2009. This directory comprised contact details of over seventy-five NGOs in Mumbai
who specialized in providing counselling, legal help, interim housing and health support services
to women.
Health Check-Up Camps and Rescue Efforts
ZHL regularly organized health check-up camps at local parks and temples, which offered services
including blood pressure and blood sugar tests. They were involved in various rescue efforts; when Bihar
was devastated by floods in August 2008, they dispatched five ambulances to help in relief efforts.
During the terrorist attack on Mumbai in November 2008, 1298 Ambulances were first to reach the
scene at Taj Hotel and Leopolds Caf devoting over 50 per cent of their ambulances to transport
125 victims to hospitals. ZHL coordinated with the Mumbai Fire Brigade, whereby the fire brigade
informed Dial 1298 control room to respond to an emergency. ZHL had partnerships with ten railway
stations in Mumbai, so that emergency medical aid could be provided to victims of train accidents in
the shortest time possible.
Awareness through Marketing Initiatives
A key focus area for ZHL right from the beginning was to create awareness about its services. Outreach
efforts were planned with a more grass root level, mass appeal programme that had ZHLs phone number
and key messages displayed on local rail pass covers, poster boards and on cinema slides. The company
ran an extensive Hoardings Campaign
8
which involved placement of hoarding and messaging at high
visibility sites throughout the city. Three key messages were printed on 1298 ambulances: 1) Doctor on
Board 2) Free transfer for accident victims and 3) Subsidized rates. Sponsored by corporations, ZHL
ran training programmes in schools and colleges in Mumbai along with various social organizations.
This provided them an opportunity to increase awareness about its free or subsidized services and
need for EMS. It also helped in overcoming some of the earlier held notions about the availability and
services provided by medical ambulances as demonstrated in the ZHL survey (see Exhibits 5, 6 & 7).
For its public relation efforts, Dial 1298 team relied heavily on media coverage, it was typical for any
news story covering them to feature shots of ambulance vehicles with the 1298 number prominently
displayed. Individuals and corporations began to donate ambulances to Dial 1298 since they viewed their
services as a truly efficient way of providing life-saving emergency services to all sections of society.
A bigger challenge however lay in marketing their services to different customer segmentsif the
company became too successful in marketing the high quality of their service, they risked losing their
poorer customers who would perceive it as being too expensive. Alternatively, if the company marketed
a free or subsidized service extensively, it could lose higher income customers whose revenue was
required to cross-subsidize the less well-off segment.
Strategic Partnerships, Awards and Recognitions
Since its establishment, ZHL had developed key partnerships to maintain world-class services. The
founders spent two years researching various ambulance service models that existed across the world,
and finally settled on LAS as partner. To meet the objective of delivering high-quality service,
ZHL developed partnerships with leading service providers like New York Presbyterian Hospital and
American Heart Association (AHA) to meet global service delivery standards. LIHS, Mumbais pre-
miere emergency care training centre, provided medical training to Dial 1298 staff. Over the years, ZHL
expanded its partnerships with University Hospital of Cornell and Columbia Medical Schools, Harvard
Humanitarian Initiative, American Association of Physicians of Indian Origin (AAPI) and AHA.
Recognitions and Awards for Dial 1298 for Ambulance Project came in steadily. Some of the major
awards and accolades that came their way included; Godfrey Philips National Bravery Award for Social
Act of Courage 2007 and Times Foundation Recognition Award for Life Saving Service in Mumbai
2006. In response to all the recognition and glowing accolades, the founding team (see Exhibit 8) stayed
focused on their core objective and their core philosophy come through in Shwetas words:
Saving a life is one of the most rewarding experiences a person can undergo in ones life. The feeling of creating
something new, something which will not only make money but beneft the society at large is what keeps us going.
Scaling up the Venture using Public-Private Partnership (PPP) Mode
Since the onset of economic reforms in 1991, the Government had been encouraging private sector
participation in many areas of public services to overcome the problem of resource constraints and
improve the quality of public services as well (Author 2006). In most cases, participation of private play-
ers came through the Public-Private Partnership (PPP) mode. There was no single accepted definition of
PPP. It generally involved a contract between a private player and government, in which the private
player provided public services and assumed significant risk in the technical, operational and financial
sustainability of the project. In certain PPPs, service cost was borne by the users of the service and not
by the taxpayer, whereas in others, service cost was borne wholly or in part by the government whereas
the private player made financial investments to bring about specific services, or operate these services
efficiently or both (Ministry of Finance 2010a). The government supported the PPP projects by provid-
ing revenue subsidies which included tax breaks, or giving guaranteed annual revenues for a fixed period
of time. Rajasthan was the first state to formulate a policy for build-operate-transfer (BOT) PPP projects
in 1994 (Ministry of Finance 2010b). Rajasthan government encouraged PPPs in urban development
projects related to transportation, waste and information technology (Author 2006). However, there had
been little partnership activity in the healthcare sector beyond providing subsidy for specific medical
tests (see Exhibits 9 and 10). Given the resource constraints faced by the government and state of
healthcare services in the public sector, there was a compelling need for private sector participation in
healthcare services through PPP mode.
Despite the optimism generated, the PPP mode had met with varying degrees of success and
progress had not been very encouraging. There were many examples of PPP mode like Delhi Airport
Metro Express, Gurgaon Toll Plaza, where these partnerships had failed. There were many issues in
PPPs, which needed to be examined to make these partnerships successful for the larger public good.
Since PPP projects operated in public utility services; a supportive operating environment, a harmonious
blend of the organizational culture and operating styles of the government and the private players, and
a sound understanding of the business model to make these projects financially viable was extremely
important for private players to function independently and effectively in PPP mode.
ZHL had expanded its geographic reach at a rapid pace since its inception and was instrumental in
changing the face of EMS in India. Their commitment to the cause of EMS and quality of services had
led many state governments to show willingness to partner with them. Though, ZHL had been apprehen-
sive about working with the government, they understood that this could be the way forward to making
their services available to a larger segment of the population at an affordable price and making a larger
social impact. In 2009, Bihar government approached Ziqitza with a unique proposalthe government
wanted to run a pilot project with them to provide quality medical ambulance services in Patna, the
capital city. ZHL agreed to run the pilot as it was focused on the under-privileged segment, dispatching
five BLS and five ALS ambulances. Emergency callers paid a reduced, flat rate of US $ 6 under
government-subsidized scheme, compared to the market rate of US $ 12 for ALS ambulance transport
(Author Year). ZHL received US $ 20,000 per month from the Health Ministry to operate in Patna, with
the prospect of scaling across the state, based on the success of the city pilot. The big breakthrough
came when the Rajasthan government signed an agreement with ZHL in 2010 allowing them to operate
over 300 medical ambulances of the state government across the state for a period of three years.
This partnership in PPP mode generated a lot of enthusiasm as well as some apprehensions within the
founding team but helped ZHL to scale-up their services and achieve their social objective. From just
10 ambulances in 2005 to 407 by 2010, the number grew to more than 700 ambulances across Mumbai,
Kerala, Bihar, Rajasthan and Punjab by 2012, which ZHL planned to expand to 1,000 ambulances by
2014 (see Exhibit 11). The founding team recognized the importance of PPP mode as a route for growth
and the next step towards making a larger social impact but they were also aware of the challenges
presented by these partnerships. However, Shweta maintained that their biggest achievement was the
total number of calls completed over the seven years of operation till 2012, around 10 per cent of
the calls were emergency calls and over 12 per cent of the calls completed were free or subsidized, thus
fulfilling its core objective of making the service available to the needy irrespective of their ability to pay
(see Exhibit 12). In a span of a few years, ZHL had responded to approximately 250,000 emergencies
and was able to save more than 9,500 lives.
Emerging Dilemma for ZHL
ZHL had signed agreements with a few state governments in PPP mode and these agreements increased
their reach, scaled up the venture, made the venture financially sustainable and met their core objective
of providing quality EMS to all segments of society. They had taken a leap of faith despite certain appre-
hensions and gone ahead with these partnerships. However, Shweta and the founders were aware of the
challenges these partnerships were likely to pose as their experience of working with the Government of
Rajasthan had been a mixed bag. The initial one year of this partnership was smooth but soon wrinkles
started appearing, though the partnership continued with some effort and accommodation on ZHLs part,
problems started cropping up on a regular basis. This agreement ended in April 2013, but since the
Rajasthan government could not finalize the next service provider, they requested ZHL to continue
operating ambulances for another three months, to which the company agreed. ZHL claimed that the
Health department had not paid an outstanding amount of approximately US $ 3.6 million despite
repeated reminders following which the company had to ground some ambulances. This stood in con-
trast to the claims made by the Health department that ZHL was demanding undue payments and it was
in response to ZHL grounding the ambulances, that the Health and Family Welfare department decided
to take over the operations of medical ambulances in May 2013 from ZHL.
A scheduled meeting between ZHL and health department officials was to be held soon to resolve
these issues when this news of taking charge of ambulances came in. Shweta and the founders were
stunned to hear this news and it appeared as if their worst fears about working with the government
had come true. They wondered what lay ahead and whether ZHL should continue to expand through
PPP route or should they reassess their growth options after this incidence. Which direction was likely to
work in the long run, in terms of bringing financial sustainability as well as creating a higher social
impact? These questions haunted Shweta and the founding team as they considered the potential costs
and benefits of working with governments and braced themselves for the stormy meeting that lay ahead
with the Department of Health and Welfare of the Rajasthan government.
Appendix
Exhibit 1. No. of Casualties in Road Traffic Accidents in India (20052010)
Year 2005 2006 2007 2008 2009 2010
No. of Deaths 98,254 1,05,725 1,14,590 1,18,239 1,26,896 1,31,622
No. of Injured 4,47,900 4,52,900 4,65,300 4,66,600 4,69,100 4,71,300
Source: Transport Research Wing, Ministry of Road Transport and Highways, Govt. of India.
Exhibit 2. Mumbai Market Share Analysis of Emergency Medical Services
2005 2006 2007 2008 2009 2010 2011 2012
Emergency Cases/
Month
60,000 63,000 69,300 76,230 83,853 92,238 101,462 1,09,587
Emergency
Cases/Day
2000 2100 2310 2541 2795 3075 3382 3652
Cases Handled by
Ambulances/Day
200 210 231 254 280 307 338 365
No. of 1298
Ambulances
10 10 19 37 50 70 70 70
No. of calls/day
by 1298
34 60 143 526 664 731 767 805
No. of Emergency
Calls/day by 1298
7 12 36 132 166 183 192 207
Mkt. Share of 1298
of Emergency Cases
.34% .57% 1.54% 5.18% 5.94% 5.92% 5.67% 5.86%
Source: ZHL.
Exhibit 3. ZHL Call Summary Details of Mumbai (Ist Year 2005)
Month Calls Attended Free Calls Percentage of Free Calls
April 225 13 5.78
May 529 52 9.83
June 571 77 13.49
(Exhibit 3 continued)
Month Calls Attended Free Calls Percentage of Free Calls
July 519 160 30.83
August 659 165 25.04
September 638 190 29.78
October 853 230 26.96
November 1193 346 29.00
December 1110 320 28.83
January 1213 345 28.44
February 1265 285 22.53
March 1193 322 26.99
Total 9968 2505 25.13
Source: ZHL.
Exhibit 4. ZHL Process Flow Chart
Source: ZHL.
Insights from Individual Interviews & Consumer Insights
Neighbors provide important help in Medical Emergencies
Extensive use of Auto-Rickshaws/Taxis to take the person to hospital
Most people dont want to go to government hospitals because of poor service and long waits there
There is lack of awareness of ambulance use in an emergency
There is limited understanding about the relevance and nature of services provided by medical
ambulances
Perceived high cost of using a well-equipped ambulance is another primary concern
Source: ZHL.
Exhibit 5. ZHL Survey
Source: ZHL.
Exhibit 6.
Reasons Family would not call an Ambulance: Survey Responses Conducted by ZHL
Exhibit 7. When Someone Needs Help, What Do You Do?
Source: ZHL.
Shaffi Mather
Vice President & Head, Retail Roll-out/Start-up, Reliance Webworld/Infocomm
Chief Officer & Vice President, Retail & Games, Essel/Zee TV Group
CEO, Esplanade Shopping Mall/Mather Projects Ltd.
Senior Scholar in Leadership and Excellence, London School of Economics
MBA, University of Pittsburgh, Masters in Finance, University of Bridgeport
Member, CII CEO Forum on Retailing & CII Committee on Young Business & Entrepreneurs
Naresh Jain
Promoter Director, Suncity Synthetics Limited
Director, Salawas Metals Pvt. Ltd.
MBA, University of Maryland
Exhibit 8. Profile of Founding Team Members
Exhibit 9. Sector-Wise Breakdown of No. of Public-Private Partnerships
Sector No. of Projects Upto on ` 100 Cr. Bet. 100250 Cr. Between 250500 Cr. More than 500 Cr.
Airport 5 0 0 303 18808
Education 1 93.32 0 0 0
Energy 24 175.59 558 2669 13708
Ports 43 96 970 2440 62992.95
Railways 4 0 102.22 905 594.34
Roads 271 3162.5 5526.49 32,861.87 60453.92
Tourism 29 742.56 674.52 0 1050
Urban Dev. 73 1283.86 1468.7 2403.91 10132
Total 450 5638.83 9299.93 41,582.78 167739.21
Source: Department of Economic Affairs, Government of India.
Manish Sacheti
Portfolio Manager, NRI Investors (South East Asia), Partner, Anuradha International Logistics
Finance Director, Oxy Metals Industries Pvt. Ltd., Mumbai
MBA, University of Pittsburgh, BS, Illinois Institute of Technology, Chicago
Ravi Krishna
Director, IT, Legal & Corporate Affairs, EMPEE Group, Madras
Associate, M. Ratna Singh & Associates, Cochin
LLM, University of Pennsylvania
Sweta Mangal
Chief Manager TATA-AIG Life Insurance Company
CEO of Ziqitza Healthcare & Dial 1298
Board Member ZEE Entertainment Ltd.
MBA Rochester Institute of Technology
Source: ZHL.
Exhibit 10. PPP Projects Process Management
Source: Ministry of Finance, Govt. of India.
Notes
1. Name of Emergency Medical Services in United States of America (U.S.A). http://www.wjem.org/upload/admin/
201203/96ac491c02b55bef396335e9d126b0c5.pdf.
2. Name of Emergency Medical Services in United Kingdom (U.K). https://sites.google.com/site/healthcarezz
99/home/emergency-medical-services-in-the-united-kingdom.
3. http://apps.who.int/iris/bitstream/10665/41864/1/0965546608_eng.pdf
4. These are small three-wheeled passenger vehicles, used in parts of Asia. Similar vehicles with three wheels also
come with pedal facilities.
5. Report of Working Group studying emergency medical services in India by Ministry of Road Transport &
Highways, Government of India. http://morth.nic.in/tenderdetailsarch.asp?lang=1&tid=197 and http://bmjopen.
bmj.com/content/3/8/e002621.full.
6. Ministry of Finance, Government of India. http://www.finmin.nic.in/
7. 1 US Dollar= 62.50 India Rupee at the time this case was written.
8. A hoarding is the British term for billboard.
Exhibit 11. Ziqitza Healthcare Limited (ZHL) Ambulance Growth
S. No. Year No. of Ambulances
1. 2006 10
2. 2007 19
3. 2008 61
4. 2009 90
5. 2010 430
6. 2011 480
7. 2012 700
Source: ZHL.
Exhibit 12. Ziqitza Healthcare Limited (ZHL) Call Growth
Year No. of Calls Percentage of Subsidized Calls
2005 10763 23
2006 14265 18
2007 18649 19
2008 26886 16
2009 37392 15
2010 52678 14
2011 74253 12
2012 96476 12
Source: ZHL.
References
2006, Facilitating Public Private Partnership for Accelerated Infrastructure Development in India. Asian
Development Bank. December. http://www.adb.org/projects/documents/facilitating-public-private-partnership-
accelerated-infrastructure-development-in
Alex, Amit 2010. Business Development Manager of Ziqitza Healthcare Limited. Interview, 23 April, cited in
http://acumen.org/wp-content/uploads/2013/03/ZHL-Scaling-Emergency-Services-Across-India-case-study.
pdf.
Annual Report to the People on Health 2010: Ministry of Health and Family Welfare, Government of India.
http://mohfw.nic.in/index.php
Chidambaram owned company to operate ambulances in Patna. http://acumen.org/wp-content/uploads/2013/03/
ZHL-Scaling-Emergency-Services-Across-India-case-study.pdf
Desai, Shivani 2009. Business of benevolence, Bombay Times, August 20, cited in http://acumen.org/wp-content/
uploads/2013/03/1298-Ambulance-Columbia-B-School.pdf.
Dial 1298 for Ambulance Newsletter. 1298. October 2008. http://www.scribd.com/doc/8559861/Dial-1298-for-
Ambulance- Newsletter-129802
DSilva, Jeetha. 2007. India Wakes Up to the Need for Ambulances, HT Media Ltd., August 30. Available at http://
www.livemint.com/Politics/gtepwiztAHkk3CAVHzylUJ/India-wakes-up-to-the-need-for-ambulances.html
DSouza, Maria, 2009. Dial L for life, Outlook Business, May, 2.
India: Building Capacities for Public Private Partnerships. June 2006. The World Bank. http://www.un.org/esa/
coordination/ Alliance/Ex-PPP%20in%20India.pdf.
Lee, Moses 2009. Subsidies in Base-of-Pyramid Venture Development, William Davidson Institute, March. http://
acumen.org/wp-content/uploads/2013/03/1298-Ambulance-Columbia-B-School.pdf.
Public Private Partnerships in India. April 2010. Ministry of Finance, Government of India. http://www.pppinindia.
com/
Rajasthan. April 2010. Ministry of Finance, Government of India. http://www.pppinindia.com/introduction-
rajasthan.php.
Transport Research Wing, Ministry of Road Transport and Highways. Road Accidents in India 2011. New Delhi:
Ministry of Road Transport and Highways, Government of India, http://in.tool-alfa.com/LinkClick.aspx?filetic
ket=wHv699P0VXs%3D&tabid=72&mid=486.
WHO. 2004a. in M. Peden, R. Scurfield, D. Sleet, D. Mohan, A.A. Hyder, E. Jarawan, et al (eds). World report
on road traffic injury prevention. Geneva: WHO. http://whqlibdoc.who.int/publications/2004/9241562609.pdf.
WHO. 2006. in M Dutz, C Harris, I S. Dhingra and Chris Shugart. India: Building Capacities for Public Private
Partnerships. June 2006. Energy and Infrastructure Unit and Finance and Private Sector Development Unit
http://www.un.org/esa/coordination/ Alliance/Ex-PPP%20in%20India.pdf.
Mangal, Sweta 2010. Chief Executive Officer of Ziqitza Healthcare Limited. Interview. 15 January. http://www.
youtube.com/watch?v=8cCsIu28heg.

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