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Naluri embraces mental health aspects of chronic disease treatment: Startup Stories

Naluri believes it can be a unicorn with 150,000 users.

Azran Osman-Rani of Naluri.

In the burgeoning health tech space, Naluri Hidup (local Malay for “life instinct”) focuses on helping people with chronic diseases take charge of their lives with early intervention and daily coaching.

Serial intrapreneur Azran Osman-Rani was still helming the Malaysian offices of video on-demand app iflix in 2015 when a gathering of Stanford University alumni brought him into contact with a co-founder of San Francisco-based digital therapeutics startup Omada Health.

Azran had made a name for building new business divisions for broadcaster Astro, long-haul low-cost airline AirAsia X and then iflix, all through hyper-localization. An Ironman triathlete himself, Azran was drawn to Omada’s focus on human behavior as a path to becoming and staying healthy.

He said: “I realized that diagnostics, wearable tech, DNA analysis, doctor booking platforms, digital prescriptions—those sorts of tech you can use anywhere worldwide.

“However, influencing human behavior to become healthy requires deep localization and an understanding of local languages, cultures, foods, and stress triggers. You can’t replicate the US model of behavior change, where being healthy is about eating kale or quinoa, or practising yoga and meditation,” he remarked.

Omada’s focus on the mental health aspect of living with chronic conditions also hit a personal note with Azran, who lost his father to diabetes and cancer in 2011.

“Hospitals and doctors are focused primarily on physiological care such as medication or chemo treatment, not so much on addressing mental health pressures such as depression and anxiety, which my father wrestled with because of his life-threatening conditions,” he recounted.

Starting from scratch

In August 2017, after iflix sealed a USD 133 million Series C round, Azran left iflix and revisited the Omada idea.

“I wasn’t getting any younger. I wanted to build something from scratch, and something that was more meaningful and personal to me,” Azran said.

There he was, wanting to disrupt the healthcare industry, but not knowing anything about it. Leveraging his industry ties, Azran took a crash course in learning and spent three months talking to CEOs of insurers, and C-suites of large Malaysian corporates about their worries and pain points.

His journey took him back to his former colleagues at McKinsey, who directed him to Dr. Jeremy Ting, a medical doctor heading the consultancy’s healthcare practice in Southeast Asia.

Another industry friend led Azran to Dr. Hariyati Shahrima, a specialist who was a consultant psychologist for the Biggest Loser Asia.

“Dr. Hari has a PhD in health psychology, a very rare field focused on people dealing with heart conditions and cancer. At the time she was only seeing patients one at a time. By going digital, she could reach 100 patients,” Azran said.

Naluri had its core team, but no minimum viable product. The team first tested if people were willing to use instant messaging to talk to a psychologist.

“I asked around Facebook for volunteers, and we got 30 to 40 people talking to Dr. Hari. The first version of a module was a series of questions designed on PowerPoint with multiple-choice answers. An intern would take a screenshot and send it as an image, people would reply, and the intern would send the next picture. That’s how crude it was.

“Once it was clear people were willing to try it, we hired our first engineer to build the app. By April 2018, we had launched version one of Naluri,” Azran said.

Screen early, intervene quickly

Ninety-five percent of Naluri’s 5,000 users since its launch have come through its corporate programmes, where its team of 50 doctors, psychologists, coaches, dietitians, and nutritionists help insurers and corporates screen employees and policyholders for early health risks.

“In an organization of 1,000 employees, fewer than 100 are causing more than 50% of all corporate medical expenses and sick leave. We help corporates identify these 100 with early screening instead of waiting for them to get sick. Then we enroll them in a four-month Naluri programme sponsored by employers or insurers.

“That first day, most users spend five to ten minutes with a psychologist talking about their blood results, depression or anxiety. For the next four months, everything is online, but that first interaction is still face-to-face,” he said.

Naluri now has 30 corporate clients, including three insurers (one of which is AXA) and expects a few hospitals to come on board by year-end. Users are sponsored for four-month periods, and Naluri currently has 1,500 active users, with many employers sponsoring new batches of employees. On average, corporate clients pay about USD 25 per employee per month.

Despite its dual focus, Naluri starts by addressing the physical condition first, as mental health stigma is still prevalent in Malaysia.

“Those few companies who do offer mental health services utilize the standard employee assistance program (EAP) where you call a hotline and book a session with a therapist. Your company sponsors maybe five sessions a year, if you want more you have to pay for it.

“With EAP, only 4% of employees are reaching out for help—companies we spoke to are even seeing rates as low as 2%. But our own data points and Ministry of Health studies show that 30–50% of working adults experience mental health pressures. Clearly, the EAP model is broken,” Azran said.

Naluri disrupts EAP with early screening. A typical distribution of employees would see 40% having depression, 60% experiencing anxiety, and 30% dealing with stress.

“Out of that 40%, maybe 8% are undergoing very severe depression, 12% severe, and 6% moderately severe. For many companies, it’s the first time seeing quantifiable data, so they sponsor employees with elevated stress levels into Naluri.

“These users start chatting with our coaches about simple stuff. But because it builds a rapport, when they suddenly feel overwhelmed or have a panic attack, they feel they have someone they to talk to. We hope to get better at early detection and prevention before someone is borderline suicidal,” he said.

Actionable results

Naluri uses Amazon Web Services, with the United States HIPAA (Health Insurance Portability and Accountability Act of 1996) standards with private servers and end-to-end encryption. It does  not share individual user data with insurers or employers—only aggregates and percentages.

Even aggregate data has been enough to influence some workplace practices, as Naluri experienced with an oil and gas client.

“We can estimate people’s emotions just from chatting. For this client, there was a ‘down’ point where all the enrolled employees were experiencing stress. It coincided with a plant shutdown, which entails staff having to work 24 to 48 hours straight to bring it back online.

“The employees were under a lot of stress, worried over who would take care of the kids and send them to school. Now, companies can think about providing a certain level of support during the next plant shutdown.”

“The single biggest policy change is the willingness for companies to create support for mental health and make digital solutions available to employees,” Azran added.

Going regional

Naluri has undergone two seed rounds so far, raising USD 233,000 in January 2018 from Biomark and 500 Startups, and a further US$1.5 million from Global Founders Capital in July 2019.

Azran is now eyeing a Series A round of around USD 5 million in 2020, which he expects to fund Naluri’s expansion to Indonesia, Singapore, Thailand, and the Philippines. Naluri is planning to get Indonesian operations up by end-2019.

Azran says investors must view digital therapeutics through a different lens, since the business model does not revolve around racking up millions of users.

“Livongo was the first digital therapeutics company to IPO in the US in July, at a valuation of USD 3 billion, which makes it a unicorn. Before Livongo listed it only had 164,000 users and in its second year, there were 6,000 users from 30 clients — that’s about where Naluri is at now.

“Our goal is to get to 150,000 active users in seven years, as we focus on getting a targeted at-risk segment healthier. We can be a unicorn with 150,000 users,” Azran said.

This article is part of KrASIA’s “Startup Stories” series, where the writers of KrASIA speak with founders of tech companies in Southeast Asia.