The dabbawala approach to healthcare delivery

A 127-year-old system for delivering lunches in Mumbai could hold the answer for healthcare efficiency in the U.S.

The dabbawalas of Mumbai, India, preserve a tradition that started over a century ago by Mahadeo Havaji Bachche of Pune, India: picking up lunchboxes from houses and delivering them to workplaces. Whether we're talking about delivering lunches or providing medical care, it sounds simple. It’s not.

The dabbawala difference

We look outside our business for answers. Our exploration typically looks for answers within technologically advanced industries. Today, we’ll explore a less advanced industry, 7,786 miles from New York City — the system of the dabbawalas in Mumbai. The dabbawalas are a world leader in efficiency without technological luxuries. Healthcare can learn a thing or two from the dabbawalas.

Translated literally, the Hindi word dabbawala means “one who carries a box,” according to the official website of Mumbai Dabbawala, which explains that dabba means box — usually a cylindrical tin or aluminium container — and that the closest meaning of dabbawala in English would be “lunchbox delivery man.” A network of 5,000 dabbawalas delivers 350,000 lunches every day to commuters across Mumbai, home to a population of 22 million. The preference for home-cooked food (ghar ka khana) has fueled the demand for dabbawalas. Diverse dietary preferences — Muslims, Hindus, Parsis, Jains, Buddhists and dieters — reinforce the need for home-cooked meals.

An exploding population creates a chaotic environment when boarding trains, making it impractical to carry a dabba. Instead of taking their own lunches to work, people pay dabbawalas to transport the dabbas to and from their offices. And the dabbas aren’t just used to carry lunches these days. Messages, cellphone chargers and others things that people might have forgotten at home also make their way into the containers.

Efficiency without technology

The dabbawalas pick up the dabbas at commuters' homes and then transport them by train, bus and bicycle and deliver them to workplaces across the city. This entire process all occurs before lunchtime. After lunch, the dabbawalas retrieve the empty dabbas from thousands of delivery points and return the lunchboxes to their owners' homes — all in a daily cycle.

How is efficiency achieved in this supply chain? Teamwork. The dabbawalas are not overpaid, and all dabbawalas are equal. The cost for this service is the equivalent of $7 to $14 (U.S.) a month, depending on the time and distance required to travel for pickup and delivery. Also, dabbawalas are paid the same regardless of tenure: about $180 per month. Job security and respect are earned privileges for many dabbawalas, who typically have limited education.

In the United States, lean supply chains rely heavily on technology advancements, as in the reinvention of Domino's Pizza. The unmatched record for speed and accuracy makes them different. The dabbawalas have a near perfect delivery rate — one error per 6 million deliveries, which is better than Six Sigma (3.4 errors per 1 million opportunities). Companies inside and outside of India have been extremely curious about how this efficiency is possible without technology.

Simplified precision with networks

The dabbawalas have to negotiate time-bound trains and maneuver through dense urban communities to complete the round-trip deliveries. The dabbas are picked up around 9 or 10 a.m. and travel an average of 25 miles using a hub-and-spoke distribution system. Railway stations (hubs) are used as sorting facilities, and each hub has delivery routes (spokes) that connect to distribution points. Without the use of technology, teamwork becomes essential.

The dabbawalas, or “warriors of the road,” do not write down customers’ home addresses. However, they do use a code of delivery featuring colors, numbers and letters to help with sorting and distribution logistics. These codes are painted on the lids of the dabbas. For example, a code of delivery might look like “11LBNO5 LALIT,” with the LLBN05 LALIT in light blue, the ones in green and the whole sequence underlined in light blue. Collectively, this symbol is circular and represents the pickup destination, the code of the originating dabbawala, the delivery destination, floor and customer name, and the source station.

The level of precision might lead you to believe that the dabbawalas carefully track the 5,000 dabbawala employees and accurately maintain a list of customers. But there is no list of dabbawalas, and no list of customers. The network cohesion maintains order.

The connection to healthcare

What is the greater antagonist to patients: the inconvenience associated with science or the breakdown of functional systems? Waiting, scheduling and the distribution of information may be improved by establishing loose networks and cutting down hierarchies weaved through the U.S. healthcare delivery system. Why are dabbawalas able to manage a network of 200,000 lunches delivered to almost as many offices with a rate of failure lower than annual medical errors in the U.S.?

A recent study by John Hopkins Medicine found that out of 35,416,020 hospitalizations, 251,454 deaths stemmed from a medical mistake. Researchers forecast that these mistakes translate to 9.5 percent of all yearly deaths in the U.S. Is the delivery of healthcare that much more complicated than the urban challenges which face the dabbawalas in Mumbai? I’d offer it’s not. Treatment is complicated, but delivery is simply access or care delivery.

We can learn from the dabbawala system and improve healthcare. Nine immediate observations come to mind.

  1. The absence of technology: Limit the dependency on technology in healthcare and build networks of care, not networks of systems.
  2. Regional accountability for issues: Establish groups by geographically designated areas to improve healthcare communication and efficiency.
  3. Salaried to owner/partner model: In 1983, the dabbawalas transitioned from a salary model to an owner/partner system with profit sharing. Healthcare needs a model with shared ownership for outcomes.
  4. Supervisors are hands-on: In the dabbawala system, supervisors (called muqaddams) distribute dabbas while leading. The supervisors resolve disputes, oversee coding, sorting, loading, unloading, collections and payments, and deliver dabbas. Healthcare leadership should have greater participation in healthcare delivery.
  5. Promotion by election: Dabbawalas are voted to leadership by consensus. While not a perfect system, a balanced approach between appointment and election would benefit healthcare leadership and governance.
  6. Commitment matters; qualification doesn’t: Entry-level dabbawalas are slightly underqualified, creating an eagerness to learn. Injecting more nurses, PAs and NPs into the healthcare system will improve access and decrease costs.
  7. Teams calculate profit monthly: At the end of the month, each dabbawalas group independently calculates its profit. Restructuring the financial model for care is a necessity.
  8. The density utilization: The dense population of Mumbai and overcrowded conditions make delivery networks essential. Local knowledge of communities make delivery possible. Regional care delivery locations could be designed to function as hub-and-spoke care networks.
  9. Limited delivery capacity: It's not logistically feasible for dabbawalas to carry more than 30 to 35 dabbas per bicycle. What if we limited visits by clinicians in healthcare? This shift would move the conversation from transactional to transformational, focusing on outcomes. Ending the five-minute doctor consult might result in fewer repeat visits to address similar symptoms.

Healthcare redrawn sitting on a dabbawala bicycle

We would be hard-pressed to remove technology from healthcare. But it might not be a bad idea to reflect on the possibility of decreasing our heavy dependency on technology. We talk about regional healthcare challenges and confined health disparities, yet little action is taken. Incentives inspire action. Incentives also provide a catalyst for change. Healthcare needs new incentives where value, risk and profit are shared.

Peering into the world of the dabbawalas is a fun escape. Imagine an alternate world of healthcare. We can create a new world where healthcare organizations become places where people want to work.

This is not an endorsement for junking existing EMR systems or printing more copies to share information between providers. There is, however, a lesson from the dabbawalas for healthcare. The lesson is that we all have a lot to learn from areas that initially appear insignificant.

Growing from tradition

The system of dabbawalas started in 1885, when a Mumbai banker hired a man to pack and deliver his lunch. The opportunity to leverage the railway system (a new innovation at the time) and provide farmers a consistent income was identified by Bachche, one of the original delivery men. The first 35 farmers were “warriors of the road,” and these simple villagers were descendants of tribal warriors. These entrepreneurs established a flexible delivery system and network. They empowered each dabbawala by creating guidelines, not standards, and establishing shared ownership.

Why do we have monolithic standards in healthcare that push outdated technology into the hands of caregivers, resulting in counterproductive care? It’s time to create a loosely managed network of home care. A new highly networked informal system that capitalizes on differentiation with guidelines, not standards.

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