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5
Case
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
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.
6 Rakesh Gupta and Sriparna Basu
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.
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 Shaffi’s (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
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 Krishna’s mother had a heart
attack in New York, USA, an ambulance arrived within five minutes and this timely medical intervention
saved her life (D’Souza 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:
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 Shaffi’s 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’.
cardiac diseases and stroke would be a major cause of death and disability for Indians by 20203 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 patient’s 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 rickshaws4 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 didn’t call ambulances to go to hospital.’
‘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 6–8 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 ZHL’s 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 India’s access
to quality emergency medical services at an affordable price. He found ZHL’s 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 India’s 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.
Ambulance Services
Main Services
ZHL’s 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).
Women’s Helpline
ZHL collaborated with Dr Indu Shahani, the Mumbai Sheriff, to bring about 1298 Women’s 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 Sherrif’s office, Akshara Foundation and Times Foundation developed Women’s 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.
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 Shweta’s words:
Saving a life is one of the most rewarding experiences a person can undergo in one’s life. The feeling of creating
something new, something which will not only make money but benefit the society at large is what keeps us going.
social impact. In 2009, Bihar government approached Ziqitza with a unique proposal—the 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.
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 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.
Source: ZHL.
Source: ZHL.
Exhibit 6.
Reasons Family would not call an Ambulance: Survey Responses Conducted by ZHL
Source: ZHL.
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, Master’s 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 continued)
(Exhibit 8 continued)
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.
Sector No. of Projects Upto on ` 100 Cr. Bet. 100–250 Cr. Between 250–500 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.
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.
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