HealthManagement, Volume 21 - Issue 3, 2021

Despite recent progress, female labour participation in Pakistan stands at 25%. This is markedly lower than those of countries with similar gross national income per capita. While 80–85% of the students in medical colleges in Pakistan are girls, only 44% registered with the Pakistan Medical and Dental Council (PMDC) are female. Why is this so, and what is behind this phenomenon of doctor brides? discusses this with two Pakistani female doctors and entrepreneurs behind Sehat Kahani, a health tech social impact enterprise in Pakistan aiming to democratise access to quality and affordable healthcare services in Pakistan implemented by a network of qualified female health professionals.

Tell us something about Sehat Kahani - why did you start this initiative, and what was your inspiration?

Sara Khalid: Sehat Kahani is a health tech social impact enterprise in Pakistan that aims to democratise access to quality and affordable healthcare services through user-focused ICT solutions implemented by a network of qualified female health professionals. We have created a network of e-clinics that use telemedicine to connect users to qualified women doctors online, while qualified nurses or health workers act as intermediaries. We have also launched a mHealth app that allows a patient to avail an audio/video consultation with an available network of qualified doctors. Our solution is recently being implemented in ICUs across Pakistan, and these tele-ICUs are catering to people severely affected due to COVID-19.

The story began when I was growing up as a child and my father wanted me to become a doctor. As I grew up and went to medical school, I realised many females join the medical field just to get better hands at marriage - a phenomenon called the doctor bride phenomenon in Pakistan. After graduating, I worked in the radiology segment for quite some time but had to quit work as I soon became pregnant. I resumed my work as a clinical doctor in a low-income community in Karachi. However, owing to my husband’s transfer, I had to move cities. After having my first child, I fell into post-partum depression and in discussion with an ex-partner, I started doing audio calls to that clinic only. These audio calls converted into a video consultation, and this is how we initiated the concept of female doctors providing access to communities using telemedicine.

Iffat Zafar: The need for a supportive environment was something we felt was essential to bring female doctors back into the health workforce and into the economy. I am a doctor by profession and worked in the pharma sector where there was substantial travelling and long working hours. My husband and I suffered the loss of our child in premature birth, and hence when I conceived again, I ended up quitting my job because of the social pressure that I felt. When I joined Dr Sara in her journey for this initiative, I had resumed work after a one-year break since the birth of my daughter; hence I felt the need for flexible work options for women who did not want to give up their career but at the same time felt they needed more time off from work. Thus, with the support of several mentors, Sehat Kahani was established to bring about such services in Pakistan to facilitate both the patients and the human resource issues related to healthcare.

The name ‘Sehat Kahani - the Story of Health’ was inspired by the fact that health problems do not only occur to those who can’t access it but also to those resources that play a role in shaping the health status of the country. Thus, the story of health is the story of a patient suffering from a disease, the story of the nurse who works hard to ensure the care and welfare of her patient, the story of the female health worker who strives hard to uplift the health conditions of her community and the story of the female doctor who struggles to be an integral part of the health workforce while tending to her family.

What are the primary goals of Sehat Kahani?

SK/IZ: Our primary goals are threefold:

  1. Reintegration of female health workforce through the provision of gender-inclusive employment platform using technology while providing them opportunities for capacity building and training skill set.
  2. Reducing healthcare cost; improving healthcare efficiency by providing access to affordable and equitable healthcare while reducing travelling expenses both for patients and clinical staff and increasing female health workforce productivity.
  3. Enhancing healthcare utilisation by improving early diagnosis and fostering access to new technologies and interventional strategies through telemedicine.

You have been working on this for the last five years. What has been the response? What has been the impact on female doctors in particular and on delivering care in general?

SK: Broadly, we have segmented our customers into two groups: our users (demand side) and our female doctors and health care workers (supply-side). At a social level, we benefit our doctors by allowing them to practice medicine remotely from the comfort of their homes. The inclusion of these unemployed human health resources plays a major role in managing the healthcare sector challenges while mitigating cultural and social sensitivities. We currently have more than 5000 female doctors and specialists in Pakistan who are utilising our telemedicine solution to deliver health care services to their patients. Additionally, these doctors and frontline health workers gain financial inclusion, access to virtual continuing medical education sessions, recognition on social media, a chance to attain additional certifications and most importantly, a whistle-blower initiating behavioural change for telemedicine in Pakistan. By facilitating information collection and making it transparent, our model strives to protect and empower end users/beneficiaries as well as contribute to the socio-economic development of SMEs.

IZ: Our other group of customers is our users, who can benefit from our solution through increased access to quality healthcare solutions. Through our e-health clinical model, we are reaching out to beneficiaries who are barely able to afford health services, and it has only worsened after COVID-19. This is partly due to the costs of seeking health care, including out-of-pocket spending on care (such as consultations, tests and medicine) and transportation costs and any informal payments to providers. Collectively we have reached 3.1 million users who have utilised our solution to avail health services. Through our mobile health application, we deliver health services round the clock and have increased sensitisation towards the importance of availing health care.

Since the launch of our mobile health app in 2020, we currently have 250,000 active users on the app who are availing Sehat Kahani healthcare solutions. Our users have reported an increased convenience in accessing medical services and encountering a variety of connection services platforms, choosing the modality they prefer based on their own unique characteristics as beneficiaries. In contrast to traditional, clinic-based services, our users are able to access medical services in an “on-demand” fashion, engaging in instant message exchanges, video chats, and remote exams.

Why do you think trained female doctors in Pakistan choose to give up their careers? Is it primarily due to cultural and social pressures? Or are there other factors involved?

SK: Research on working women in Pakistan shows that despite some progress in recent years, female labour force participation in Pakistan stands at 25%. This participation rate is markedly lower than those of countries with similar gross national income per capita. There are a number of constraints that hinder women’s entry into the labour market. Household work, including cooking, cleaning, caregiving and child rearing, is still considered a woman’s primary role in Pakistan. Based on data from the Pakistan Bureau of Statistics, 40% of women who are not working report that they do not have permission from the male members of the household. A woman’s decision to work is mostly not her own but is determined by other household members. In Pakistan, while 80–85% of the students in medical colleges are girls, only 44% (58,789 of 132,988 doctors) registered with the Pakistan Medical and Dental Council (PMDC) are female. This is where the term ‘doctor brides’ originates as it refers to female doctors getting married and quitting practice in favour of a fulltime role in the family.

IZ: Furthermore, society members, cultural values, religious practices and caste system of Pakistan mostly discourage not only the employment of women but for a woman, even going to a healthcare provider is often a challenge. It is ironic that although society members discourage women’s employment, at the same time, they give more respect to employed women than unemployed men and women. In addition, working women are often not satisfied with their workplace and environment. To them, there are many security issues while working with men or under male bosses. Male bosses and colleagues sometimes treat women as inferior, and there are also cases of harassment. Because of these issues, parents and family members oppose women in their families to work.

What are the consequences of this for these women?

SK: The personal and social costs of unemployment include severe financial hardship and poverty, and housing stress, family tensions and breakdown, boredom, alienation, shame and stigma, increased social isolation, erosion of confidence and self-esteem, the atrophying of work skills and ill-health. Most of these increase with the duration of unemployment. Also, these women bear disproportionate responsibility for unpaid care and domestic work. Additionally, their unemployment can also be associated with poor mental health as a result of the absence of nonfinancial benefits provided by one’s job, such as social status, self-esteem, physical and mental activity, and use of one’s skills.

IZ: These women also lose their ability to participate equally in existing markets; their access to and control over productive resources, access to decent work, control over their own time, lives and bodies. They also do not have any meaningful participation in economic decision-making at all levels, from the household to international institutions. Ultimately, many of these women end up losing their confidence over a period of time.

What were the key challenges you faced when launching and promoting this initiative?

SK: Leading an innovative start-up in a patriarchal society such as Pakistan required a lot of integrity, effort and commitment. Each step, from the first launch of the e-clinic to the expansion of our operations, while sustaining organisation growth was challenging. There were also financial challenges as women entrepreneurs are perceived as low risk-takers, and it is assumed that they would not be able to attain the desired success for their venture. This affects their ability to obtain external funding. Additionally, there were no telemedicine guidelines in Pakistan on a national policy level that would enable us to regulate our business model or integrate it smoothly into the traditional health care system. However, along with my co-founder, I realised that it was necessary to create an all-inclusive platform where women felt empowered to practice medicine and women in the communities felt safe to access affordable quality health service.

IZ: We faced societal pressures of being a mother and a housewife while trying to launch a solution that was both innovative and much needed. In addition, male chauvinism is still prevalent in Pakistan and not restricted to rural areas alone. This made it even more challenging for us to stabilise our footing in the health tech sector. However, we remained resilient, and this enabled us to co-create Sehat Kahani that literally translates into a story of health. With the help of community stakeholders, partners and our team, we were able to launch a platform that gave women opportunities to voice out their health needs. Today, my co-founder and I lead a team of more than 120+ members, overseeing a network of 5000 doctors utilising our solutions and impacting more than 3.1 million lives collectively by making quality healthcare accessible, affordable and achievable for them.

Are there any similar programmes implemented elsewhere in the world? Was Sehat Kahani inspired by something, or did your team come up with this based on the situation of female doctors in Pakistan?

SK: Sehat Kahani was co-founded in 2017 by myself and Dr Iffat Zafar because we both faced the socio-cultural barriers of not being able to have a supportive environment to fulfill our career ambitions. We realised that we live in a patriarchal society where women from all backgrounds are endured with several obstacles that prevent them from being able to work while looking after their families. The backlash faced by female doctors in prioritising their families over their careers is disheartening along with the additional guilt of not being able to improve the health status of the community. We felt that it was time a solution was found so that female doctors could prioritise both their family and careers and serve humanity without the criticism of their male peers and family members.

IZ: At a previous workplace, I met Dr Sara, who was working on this concept with another ex-partner, and I fell in love with it. We felt that it was time a solution evolved to address the increasing health and work inequalities, so that female doctors could prioritise both their family and careers and serve humanity without criticism from their male peers and family members. In addition, the poor health conditions of people living in low-income communities and lack of feasible, innovative health solutions for middle to upper-income beneficiaries encouraged us to explore options of telemedicine commonly used in developed countries.

How would you describe the role of telehealth in Pakistan now?

SK: Telehealth has been an increasingly successful strategy in filling the gap of access and quality in the healthcare system. Through outreach in remote areas, telehealth has played a major role in solving maternal child health issues in the rural population. Though Pakistan’s health indicators have improved in the last two decades, this rate of improvement is relatively slower than the neighbouring countries. Pakistan’s mortality rate for under-five remains the highest among the South Asian (SA) countries. High maternal mortality (deaths) combined with high fertility (birth) results in a ratio of 1:89 women dying from pregnancy-related causes. On the other hand, in Pakistan, the doctor-to-patient ratio is close to 0.83 physicians per 1000 individuals in the population. Digital health interventions are being designed to address various health care needs while making up for the lack of qualified human health resources in our country. Several SMS-based interventions are being used to improve medication compliance in patients with NCDs. Telemedicine tools are being used to educate patients and keep health care professionals abreast of medical advancements.

The challenges typically relate to a lack of national policy and regulatory framework, weak governance structures, low client and provider adoption rates, weak health workforce capacity and digital infrastructure (and digital exclusion), as well as issues relating to service quality, data privacy, and institutional resistance to digital disruption. In addition, the rapidly evolving technology space and the overwhelming diversity of available tools have made it difficult for actors in health systems to identify, adapt or develop solutions that are appropriate to their specific context and needs. However, despite all the challenges, digital health is steadily expanding through the efforts of multiple stakeholders in both the public and private sectors.

IZ: Globally, telemedicine is growing - currently estimated to be a $38 billion market and expected to grow and become $175 billion post-COVID-19. If I talk only about Pakistan, the smartphone and internet penetration is growing day by day, making access to digital interventions possible now more than ever. Beyond the COVID-19 pandemic, telehealth at scale has the potential to significantly improve health equity, especially in countries with low primary healthcare coverage, because it can improve the accessibility for patients who face challenges related to geography or disability. Telehealth can be a powerful solution for improving health outcomes locally and at the grassroots levels. But while telehealth services are now available in many countries around the world, public and private health providers are facing challenges to implement and scale up these services cost-effectively and systematically. However, despite all the challenges, digital health is steadily expanding through the efforts of multiple stakeholders in both the public and private sectors. Telemedicine may be the much-needed tool for improving healthcare in Pakistan. Over the last few years, it has been encouraging to see more doctors using telemedicine tools to deliver services. Telemedicine is a team effort and involves building trust and confidence. The focus on strengthening doctor-patient relationships and building a healthcare network to improve access as a common goal will benefit all partners. This unique experience can create programmes designed for implementation in Pakistan with distinctive cultural, socio-economic and geographical needs.

How do you see Sehat Kahani in five years? What would you like to see added to its scope that is not included now?

SK: Sehat Kahani, like all the other global players in the telemedicine market, intends to grow its current business by expanding its telemedicine platform through e-clinics and mobile applications and not only become a market leader in digital health in Pakistan but also a global player. With the current COVID-19 scenario, the inertia towards telemedicine has already been broken, and the acceptability of seeking a doctor’s opinion over a video call through a smartphone while maintaining social distancing and reducing the risk of exposure has grown tremendously. Sehat Kahani has already built a strong network of corporates and industry magnets (including banks, telecoms and pharmaceutical companies as the key giant players) as early adopters to champion Sehat Kahani’s vision and impact during the current COVID-19 pandemic. They are availing our services for their employees and will continue to do so in future.

IZ: In the next five years, we aim to lock over 50 million active users availing e-health services through the e-health clinics and our mobile application, shifting the trend from physical health towards virtual OPD consultations and other digital diagnostic services. We aim to become the next ‘Uber for Healthcare’ in Pakistan. In these next five years, we would like to integrate advanced AI and VR components in the existing scope of our solution while striving to expand public-private partnership areas to promote the integration of our initiative in the basic health care system at national and international levels.

What is your advice to female doctors who are educated and have professional degrees but do not work?

SK: In a country where half of the population lacks access to a healthcare professional, I would say that you are the greatest asset to the nation, especially in these troubling and uncertain times. With the world going virtual, doctors - especially female doctors, do not need to go out in the field or hospitals to practice. Telemedicine has emerged as a beacon of hope for both patients and doctors to ensure that the help is provided to those in need. Hence, amidst this resurgence of COVID-19, this nation needs more and more doctors willing to serve through any means available to them. Involving the healthcare community will be instrumental in ensuring adherence, monitoring, and liability regarding telemedicine integration in our country. If you were not able to continue your medical practice due to any reason, now is the perfect time to gear up and get back in the field.

IZ: Faced with a common threat that is blind to wealth, gender and social status, we can create the equity in healthcare we have craved. This is the time to educate patients, doctors and the community. This “once-in-a-century pandemic” is our chance to change the healthcare delivery model in Pakistan. This is the time when we, as healthcare professionals, can face our vulnerabilities head-on and choose to be compassionate catalysts for a better tomorrow.

Conflict of Interest