Business

While I’m perusing the magazines at an O’Hare bookstore, waiting for my final flight back to Cleveland, I come across this week’s issue of The Economist. Ironically, the cover is about India. I open the magazine to the article focusing on how private companies & small businesses are the drivers behind India’s economic growth. The article reflects on the problems facing India’s economy, but also remarks on private industry’s ability to create  “novel ways to make management more responsive to customers”. This statement is apropos for our last clinical visit at a LifeSpring hospital.

LifeSpring hospitals (LSH) are a group of private hospitals utilizing effective business practices to

LifeSpring Hospital Street Sign

provide quality women’s health care to low-income populations. Much like HMRI, I find learning about LSH exciting, as “it is serving the poor through business”. LSH is also one of the best examples of minimizing cost while maximizing quality and access in health care delivery (indeed, multiple case studies have been written on the LifeSpring model, including one by Columbia Business School; check out the web site http://www.lifespring.in/). It achieves this maximization through its mission and focus, which creates a unique health care company culture in India and requires meticulous planning. The major areas of focus, in order of importance at LSH, are quality, price, and growth.

In addition to the quoted line in the previous paragraph, “never compromise quality” is one of the comments made to us by Priya, a young, vibrant, & knowledgeable assistant manager at LSH, as well as our hostess for the visit. She gives us a tour of one of the hospitals where the corporate office is also located. Quality, as well as transparency and terminology, are what

Transparent pricing

define the company culture at LSH.  We see this at the beginning of our tour, where Priya shows us the equivalent of a patients’ bill of rights. On one long corridor, posters line the walls explaining the quality, services, and prices customers can expect. Nowhere else have we seen such transparency. Nor have we heard of patients referred to as customers. Priya explains, “pregnancy is a condition, not a disease.” Not surprisingly, providers have the most difficultly in using this word. However, according to Priya, staff and patients don’t notice the difference in terminology. Instead, customers appreciate the difference in care and quality. With the patient as a customer, the staff has a customer-first mentality that puts the needs of patients first, a concept that is not as evident at other institutions. Furthermore, as customers pay for services, this model avoids the potential for moral hazard that can be associated with free services.

Like HMRI, LifeSpring also monitors its quality. The head of clinical quality, Dr. Rama, spoke with us about the international guidelines (NICE > ACOG) and quality measures

Quality Policy

(IHI) that LSH uses to establish its best practices. In addition to surveying customers via the call center, its top quality indicators include infant and maternal morbidity/mortality (in absolute numbers, India has the highest maternal mortality rate), postpartum infection, overstay, and primary cesarean section. It’s important to keep in mind that LSH specializes in vaginal deliveries and cesarean sections; it refers IVF, high risk, VBAC, & HIV cases and currently does not provide gynecological or preventive health care (ie yearly well woman’s exam).

The second major focus of LSH is affordable pricing. The target market is women who earn US$3-5 daily. LSH defines affordability as one month’s income. I found it interesting that although government hospitals are “free”, patients are expected to pay tips to staff (housekeeping, nursing, clerks, etc). The costs of these tips can reach INR 3000 and quality, sometimes even a bed, is not guaranteed. At LSH, the cost of delivery is INR 4000. Priya notes that pregnancy is an assumed family cost in

LifeSpring's Promise

Indian culture given the emphasis on childbearing. As such, customers typically prepare for this cost. Because of its cultural and general importance, Priya says, “women want a quality delivery”. At LSH, customers have a three-tier choice for delivery: first tier is the general ward (lowest cost, 80% of customers choose this tier); second tier is a semi-private room (double occupancy), third tier is a private room (most expensive). Each hospital has at least 20 beds, with 30 beds available at the original facilities. Operations are based on a high throughput model. Length stay is typically 3 days for a vaginal delivery and 5 days for a cesarean. Like other facilities, fees are collected before services are rendered, but an option exists (on a case by case basis) for payment afterwards. A fund is also available for women who deliver, but are unable to pay. As of yet, no woman has been turned away. Maintaining such quality while charging low prices keeps the margins low. Priya notes that management must be innovative to keep the company sustainable. With 50% market share, the organizational mission to help those in need, and quality and sustainability as top goals, it’s easy to understand why innovation is crucial.

Group photo (with Luis taking the pic)

To keep up with demand, LSH plans on developing 6 more hospitals this year. Priya refers to this growth as bulk expansion. LSH performs market analysis through its community outreach program prior to selecting new hospital sites. Each hospital serves no more than a 5 km radius in a densely populated area. Extending the parameter would increase opportunity costs to its customers (ie increased travel costs) and would not support its mission.

On the growth-share matrix, LSH is a star given its high growth rate and high market share. It’s not surprising that margins are low, as by definition, a star’s income is used to support its growth and meet its mission. LSH not only identified a new market, it created one and is set up to eventually become a cash cow. When the organization reaches this stage where growth slows and market share (hopefully) remains the same, its margins will likely increase. At that time, perhaps the company can expand to other women’s health areas, such as gynecological exams or preventive health. For now, they are filling a tremendous need by keeping a sharp focus on deliveries.

Many undergraduate students in the US choose medicine with the desire to help people. While I was making this decision, I had physicians tell me not to pursue medicine as it is now a business. They’re right. Even if heavily regulated by a government, the delivery of medicine is a business. NGOs, governments, private institutions all have to manage their assets, debts, and expenditures in order to remain sustainable and reach their mission (which is hopefully to help people). But this necessity shouldn’t keep one from pursuing the practice of medicine; instead, one should at least be aware of how business influences the practice of medicine before making the dedication inherent to medical training. I believe it is important to realize that personal and organizational success in helping people is largely due to the environment and systems in which we work, in addition to one’s personal work ethic and determination. The efficiency, innovation, mission & culture of HMRI and LSH in delivering health care to the poor and underserved are what make them so exciting to me. These are also reasons why they perfectly fit the description provided by The Economist. Seeing the success of these private institutions “using business to help the poor” obtain quality health care is invigorating to me. As a result, I’ll take what I’ve seen and learned during this trip and adapt it to the environments where I practice … which I believe is the purpose of such international medical electives.

Overall, this has been an incredible, well-rounded, educational, fun experience that allowed us to

christie masters, amanda gomes, sapna shah, neena auntie, luis barcena, peter coakley

intensely evaluate health care delivery in India and experience Indian culture. As Gomes pointed out during our final day, we were in India during the Festival of Ganesha, the Ayodhya verdict, the national holiday celebrating Gandhi’s birthday, and the beginning of the Commonwealth Games. These events, in addition to our clinical experiences, provided a wide range of experiences, emotions, and discussions. What truly defined this experience are the people who were part of it. I value most my friends and the people that we met, including Shobha, Neena Auntie, Kumar, and all the amazing providers, leaders, patients and children. I’ll miss being able to walk out of a room and having someone to talk with who had the same experience that day, but presents a different perspective. I’ll miss our family-style dinners and their associated discussions and shenanigans (don’t make Gomes laugh while she’s eating). I’ll miss learning daily about the small things that make my friends great. I’m so happy to have been part of this experience and to be able to share it with people at home through this blog and other social networks. I recommend similar traveling to anyone who is willing to get out of his or her comfort zone and keep an open mind, especially if they’re able to travel with friends.

gomes & sapna dancing

puja

shobha

luis, sapna, peter with students at sivananda

peter & luis patiently waiting in the sari shop

peter dancing

Gomes seeing a patient

hanging out

Kovalam!!

CIT4b

after our leprosy lecture

birla mandir

gulistan social welfare society

Dedicated to Christoo, Peteroo, Luisoo, and Amandoo.

I’m sitting in my uncle’s living room watching a Bollywood movie (only one mustache so far), waiting for my aunt to get back from her clinic. My next 10 days will be full of visiting family, shopping, and eating.  I’ll finally get the chance to enjoy India as per usual. When I started this trip, I was thrown off by the fact that instead of my family I would be surrounded by my fellow residents, but when I left them, I was sad to be traveling alone. These last few days I’ve seen them everywhere. Most notably, I visited an ashram that my family patrons, Muni Seva Ashram. It’s similar to Sivananda in its general purpose (to serve the poor), but has a different focus. Muni Seva Ashram was started in 1978 by one woman, Anuben, who felt that it was her mission from God to go to this jungle in Gujarat and help the surrounding largely agrarian community. She began with a daycare where families could send their children. She taught them and provided them with one meal a day. This grew into an orphanage largely for abandoned girls, a home for mentally handicapped adults, homes for the aged (a very new concept in this country), a primary school, then a high school, and in the last 10 years a nursing school. A general hospital was opened in 1991 and in 2001 a state-of-the-art Cancer hospital was inaugurated. It is complete with full biochemistry and pathology lab 16 slice CT, MRI, PET, full chemotherapy, simulator and linear accelerator, 4 operating
theaters, a 90 bed general ward, and full outpatient facilities for almost every subspecialty. Further, they are considered pioneers in this country for research on alternative energy sources. They grow their own biofuel and use solar energy for many things including heating water, cooking, and to power about 1/8th of the air conditioning for the massive compound. Local farmers are taught about sustainable agriculture and dairy farming.

Anyways, without getting too carried away you can see I love this place and my experiences over this elective helped me to understand it better. I knew what questions to ask and had some basis for comparison. My visits to the ashram from now on will be through a new lens. The only thing that would have made it better would have been to have my CIT4b compadres along for the ride.  I kept thinking, what questions would Luis ask? What insightful comments would Peter make?  What would Amanda think of the dialysis center? And I know Christie would have had lots to add given the ashram’s focus on promoting the advancement of women in this community.  You guys would have loved it and been as inspired as I am by it. 

These last few weeks have afforded me a unique platform on which to experience healthcare delivery in a developing country in many ways.  First, I was able to truly witness a cross section of healthcare in this country in terms of quality of care, location, economic, religious and educational background of patients and all that in a resource limited setting. Second, I was able to witness it not just through my own eyes, but through the eyes of 6 other incredible people. They asked pertinent questions and made perceptive comments.  They were courageous in accepting the variety of food, culture, customs, and unfortunately illnesses this country has to offer. They were with me when I met people who changed and inspired me, like Dr. Raghu and Dr. Mercy. They were with me when certain images were burned into my brain: the little boy at the cancer hospital, the little girl on the banks of the river in Kerala, the craziness of Ganesh Chatraputri, at the Ashram when the children sang, “We shall overcome”, and most traumatically the anencephalic baby.  They felt as guilty as I did when our cook took it personally if we elected to eat out instead of at home.  By their side, I experienced the history of Hyderabad, the chaotic traffic, Charmy and Tollywood, the trip of a lifetime to Kerala, and quite possibly the worst driver ever. Lastly, we got to know a lovely woman, Neena Desai. She is truly an incredible person. She enjoys life to the fullest, both socially and intellectually. She has more energy in one little finger than I have in my whole body and she will tell you! She took care of us when we were sick, taught us in her clinic, shared her views on feminism, and enjoyed Hyderabad’s nightlife with us too! She took us to all her favorite shops and restaurants, to her beloved club, and told some of the funniest stories I’ve ever heard. We were truly blessed to have her as the official MVP of CIT4b.

As I end my final blog, I just want to say thanks again to all my companions. To our fearless leaders Puja, who could always make us laugh, and Shobha, who fell in line seamlessly with our motley crew. To my fellow residents, I really do miss you already and see you everywhere here. Luis, I see you in the man openly defecating. Peter, I saw you when I was bit by a mosquito at 45 degrees last night (uh oh). My courageous Amanda, I see you in every pharmacy I pass. Dear Christie when I saw a child on rounds with my aunt who truly had a hemoglobin of 1.9, I couldn’t help by think of your beautiful peaked face. And to all of you, I hope you take this in the best possible way when I say, when I see leprosy… I think of you. 

This has been one of the most rewarding and thrilling experiences of my life. It was too rapidoo.

Our last day

Our last day in Hyderabad was one interesting day that basically seemed to extend until Christie and I made it back to the U.S. on Sunday afternoon.  We started Friday morning in the car ensconced with concern that we may not make it to our final site visit at Life Spring given our “driver’s” poor ability to follow directions and the loss of our chief Hindi correspondent, Shobha.  Despite our concern, during our ride over we discussed some maternal fetal medicine issues that truthfully I haven’t ever given much thought about.  What is the major cause of maternal death? Where is the infant mortality rate the highest? How common is Down’s syndrome and what about metabolic disorders in India? We even discussed circumcision practices.  Armed with our questions we (again by sheer luck) made it to Life Spring. We waited in the small clean lobby under a prominently placed sign that displayed the costs of deliveries, hysterectomies, tubal ligations, all of which seemed quite affordable, for our tour guide.  Our Life Spring ambassador was a lovely, young, civically minded, American trained, Indian business woman who after a self-proclaimed identity crisis found her niche at Life Spring.  She gave us a thorough tour of her small hospital that embraced the idea of low income patients being called and, more importantly, treated as customers.  We understood this concept easily enough, but using the word customers instead of patients did not roll very easily off our tongues.  Afterwards a physician joined us to answer more of our medical questions.   Life Spring was clearly a haven for our MBA trained and women’s health minded colleague but we all left impressed and pleasantly surprised to have experienced yet another unique innovation in Indian health care delivery.

We spent our afternoon completing some last minute shopping.  Our tasks: petticoats for our beautiful (if I do say so myself) saris and more pearls!  Not surprisingly this took a lot longer than expected but we are nothing if not task oriented.  We made it home for one last Kumar lunch of our favorite chicken before heading out for one last evening with our Hyderabadi guardian angel, Neena Auntie. Next thing I know we are saying our goodbyes to Luis and Peter; it is 3:30 Saturday morning and Christie, Sapna and I are off the airport. Christie and I spent a fabulous day sightseeing and shopping in Delhi but quickly notice the difference in travelling without the rest of our CIT4b family. 

To steal a line from Luis’ blogging, dhanyavad (thank you) to the faithful blog readers (special shout out to KBA) and for all the support and encouragement from everyone at home when things got kinda scary.   Most of all I must give a heartfelt thank you to Shobha, Luis, Peter, Sapna, Puja and Christie for their sound medical judgment, for the thought provoking (and loud!) debates and discussions and for all the laughter.

HMRI

In Hyderabad we had an amazing presentation on HMRI. They started by showing us a call center, where the objective is to reach to the rural population, improving the access to health care. The idea is that many of the people that live far from the city can schedule appointments and make sure that they will have their health needs taken care a priori showing up to the city, that way they don’t waste time. It is also useful as a triage for the urgency of consults. It is a state of the art building with >200 employees answering phones with high tech computers. Initially I thought of it more of a luxury rather than a necessity, but then after an amazing presentation they showed us the 2nd part of HMRI which I think is the more helpful one: mobile HMRI. It is a van with 7 people that includes nurses, which go to the villages in the state once a month. To put into perspective the amount of coverage, let me start by explaining that the rural population of the state of Andra Pradesh is approximately 40 million people, and currently they are covering close to 39 million, which is Colombia’s population. When I heard those numbers it hit me. My whole country could be covered with the HMRI center. As you might have read before we where fortunate to follow one of the HMRI van’s to a village. They arrive to the town and they set up their center in the town’s Sarpanch‘s house. A line quickly starts to form. In less than 15 min they set up 6 tables, which are numerated, and each one has a specific purpose. The town let us feel like we where movie stars, they let us visit the school, people where taking pictures with us, they where happy, nice respectful and grateful that we where there.

The amazing thing about HMRI is that it answers a question I have been asking myself throughout this trip: who follows the patient? A patient gets a diagnosis and a plan in a 2-minute visit and is then sent back home which in some instances is 7-8 hours away. I have wondered who follows the patient and who makes sure the plan gets executed. Mobile HMRI reads the MD’s plan and makes sure the patient gets the medications and follow-up needed.

Overall AMAZING experience, which could be easily, implemented elsewhere (for example Colombia)

This is one of the examples of India’s Intelligence. It is a country that has a lot of problems but comes up with Brilliant solutions.

closing remarks

While I was in India I found myself comparing a lot of things to Vietnam, another 3rd world country that I had visited the previous year. They were a lot of similarities and even more differences. One of the major aspects I noted was the extreme poverty to extreme wealth differences. When we were in the nicer areas it was like we were back in the U.S. Going to the really nice shopping malls and the neighborhood where Abi lived were to examples of this. It was like we were in a bubble escaping reality. Even going into the slums was so different than being on the streets. They are a community of people that are literally living in trash and starving right in front of everyone’s eyes and nothing is being done. When we went outside of these areas there was a sudden need for acclimation back into the reality of India. The last 3 weeks in India showed me so many things that I had never learned before. One of the most amazing things was that many people within the city did not know where Good Shepherd or Sivananda were. They were two extraordinary centers helping change people’s lives and combat major diseases within the country and very few people knew where they were. It goes to show the level of ignorance some people have about diseases that exist within their countries. The centers were located on the outside of the major cities, almost like they were in their own world. It was almost metaphoric about how people with diseases are treated, put somewhere else, away from everyone. Another focus on health care that was a true testament to the statistics we heard about was the government hospitals we saw. Some of them looked like you would get sicker going into them than just staying home untreated. Even the way medical records are done is a testament to how poor areas of the country really are. At Sivananda they kept really important records on construction paper, in huge stacks. It was pre WWII type filing. Another thing that I noticed throughout the trip was the lack of religion we saw throughout the later weeks. The first week we learned a lot about the sacred texts that are supposed to guide people in their journey to reach Karma. I feel like the only people who actually follow these texts are the monks who live by them and have devoted their lives to them. Besides that, there didn’t seem to be as much interaction with the religion and general society. I guess there was a lot of vegetarian restaurants around the cities that were a testament to the surrounding religion but a lot of the morals we learned about were not noticeable in general society.

Innovation

This week we went on a field trip with the 104 van to provide health care to a rural community. The 104 van is one of the four major services provided by the Health Management and Research Institute (HMRI) designed to remove inequity in health care. The van focuses on treating acute minor ailments and providing antenatal, chronic, and child’s health care to the extremely poor in rural environments. Most health centers and physicians are located in urban areas. According to management at the HMRI office, it’s quite expensive for a rural person to seek health services given the loss of daily income, cost of travel, and unpredictability of provider availability, etc. A rural household out-of-pocket cost is ~ 5 times what an urban household spends. Moreover, health care in India is only 1.25% of GDP. 70% of health expenditures are paid out-of-pocket, and, from what we’ve seen, the patient pays for the service before it is performed. Therefore, when given an opportunity to see the 104 van in action providing free health care to this underserved community, we quickly took it.

The rural site visit was a nice and interesting trip away from the city. In addition to learning that Coakley finds odd women attractive and that Gomes can’t stand Celine Dion, I was amazed at the amount of greenery surrounding us. Besides

the random shack with its unique features or a group of women in saris, the scenery looks like we could be driving through the fields and farmland in the midwest (the old highways surrounding I-70 in Southern Illinois come to mind, especially with the various crops growing on each side of the road).  There’s even the occasional smell of “fertilizer” as we roll down the window to snap a few photos. Overall, though, the air smells and feels incredible. It’s nice to be out of the city’s smog.

As soon as we arrive at the location, the HMRI folk start setting up shop in what appears to be a community building. I notice a little girl in the doorway with a DEFCON stare aimed directly at me. As Coakley mentioned before we exited our vehicle, some people in the community might never have seen a white person before. I start smiling at the little girl. Her eyes soften and the corners of her mouth start to rise into a wide smile. She then shyly turns back inside the room. I also turn around to absorb the scenery and notice a little boy in the road behind me; a similar staring-into-smile demonstration unfolds. His stance softens with a smile and a version of peek-a-boo. Similar responses occur with a few women; a smile and namaste turns stares into friendly smiles.

These exchanges are a lovely introduction to the portable clinic. As the morning continues, the experience supports my initial thought that HMRI is a brilliant, innovative  operation. Earlier in the week we toured the office in Hyderabad and learned about HMRI’s services and operations. I found the organization impressive then, and the rural site visit was awesome to see theory and words in action.

So, I reflected on what makes the organization appear successful and conclude the general elements of its success are the result of innovative leadership, incredible operations management, the regulatory environment (or lack of one), and buy-in from the community. The effective, top-down, innovative leadership began with the previous chief minister of the state identifying the need for better health care delivery for the rural population. I think it’s also helpful that he was a physician, as he had experience being an integral component of the direct provider-to-patient delivery of health care. The CEO of HMRI is also a physician, who additionally has training in business (reportedly a PhD in management). I believe this combination of medicine and business, as well as all of the technological aspects in the organization, fuel the innovation. Furthermore, I was impressed with every manager we met and the information they provided, especially the operations manager. Listening to her review the quality control, forecasting, and efficiency associated with the call center, I couldn’t help but wonder about other divisions and leaders of the company … like in HR … how did this company find, hire, motivate and retain such impressive people like the ones we met? The development of HMRI seems like a great case study for business school. It is a private-public partnership that combines the scale and resources of government with the management and efficiency of a private corporation.

The private-government connection made me think of government regulations in general in India. From our experiences, the regulations seem few if present. During a trip to Apollo Health City, a private hospital, I asked if any government regulations apply to private hospitals (because we’ve seen and heard what would be considered multiple violations of HIPAA and EMTALA if they occurred in the US). The physician at Apollo confirmed my suspicion that few government regulations exist. In her response, she states that the hospital instead follows Joint Commission International (JCI) accreditation, the international subsidiary of JCAHO. During that conversation, the physician also referred to the fact that India doesn’t have the same medico-legal environment that is present in the US. No doubt, regulations have their place, as they develop in response to previous wrongdoings or shortcomings. However, limited regulations allow for innovation, which can be contributing to the success of HMRI.

Ultimately HMRI is providing a service/product: health care with the goal to treat patients and prevent disease. For its service to succeed, the end-user must accept and value it. In business, one can say developing this acceptance and trust is building consumer confidence; in medicine, this process is called relationship building … and it can take some time. According to management at HMRI, it takes 3-4 months for HMRI to win the confidence of the people. Within this timeframe, HMRI demonstrates that its services are constant and regular. Hearing this testimony made me think of my favorite management/sociological theory du jour: diffusion of innovation (which is studied in HIV prevention). The theory postulates that innovation will take off once the early adopters of a new idea/product accept it in their community; once a certain number of people accept the innovation, the rest of the community will follow. Within a few months, the people in the rural communities are relying on the 104 van for certain health care. Therefore, this theory and community support seem applicable to the success of HMRI.

So much can be written on the various aspects of HMRI that appear to make it successful, as much could likely be written on the limitations and barriers it faces. The four main reasons I developed in my analysis of its success include innovative leadership, incredible operations management, limited government regulations, and community support. The site visit was exciting for me, as it showed the success that can be achieved when the goals of business and medicine are similar. The translated mission of HMRI is “to provide quality care to the poorest of the poor and further the concerns of the state”. From what I’ve heard and seen, I think this mission is being accomplished.

Reaching the Village

There is quiet literally nowhere that I would rather be than in a village in a developing country, so today for me has been the highlight of the trip. When my mind wanders, which is, let’s face it, pretty frequently, it wanders to rural Uganda. Now it has somewhere else to wander.
The day starts with Luis’ irritating bird tweet alarm which never wakes him but never fails to wake me. 5.30 am. At least today it is actually set for the time we have to get up and not some random time in the middle of the night, probably a coincidence. Christie is in the shower before me but I beat Sapna and Luis. Kumar has made us breakfast and coffee and with eyes burning from the DEET cloud that seems to permanantly exist outside the door I make it to the car. So far so good. The plan is to meet the Health Management Research Institute (HMRI) mobile unit at a small town 60km away and follow them to the village. After a good 30 minutes escaping from the Hyderabad suburbs we emerge with only minor concussion from the fiercely staccato urban drive into the countryside. The sky is blue and the sun is blasting through the windows of the car as we pass out a truck that is passing out a bicycle with another truck coming straight at us. Fortunately the horn protects us, presumably the sheer vigour with which it is employed generates enough sound energy to force both trucks out of our way. The thought of being part buried in Columbia, part in Toronto, part in Ireland, part in Gujarati Ohio, part in San Francisco, part in Saint Louis fades from my mind again and I relax. It’s not the first time on this trip I’ve had this thought. I like to share it with my colleagues at particularly tense moments.
We belt on through the lush tree lined road. What look like Rhesus monkeys are playing on the tarmac, whole families of small light brown red-faced  macaques with their young clinging to them basking lazily in the heat. Apparantly the best way to deal with monkeys is the same way you deal with large trucks- accelerate and drive straight at them with the horn blaring. Shobha intervenes and communicates in Hindi that we would like to leave at least some monkeys alive. Our driver does not seem too impressed, however no monkey is harmed in the making of this blog.

After several stops and phone calls for directions we arrive at a town crossroads. We pull off the road barely avoiding a small shop and its line of customers. Just as we do so the HMRI vans appear in the distance. They are big square vans, two in total. We join the convoy and follow them. We have to remind our driver not to overtake them, he has a tendency to overtake vehicles he is supposed to be following. Habit I suppose. We drive along quiet roads through rice fields and small corn fields, until we arrive in the middle of a small little village. The van stops at a one room concrete building with a porch. This is the focal point of the village, a type of communal hall used for various village functions. We also manage to park although with a lot of horn blaring. Not entirely necessary I think as there is no other car within ten kilometers, and I’m pretty sure everybody in the village has noticed us.

Without a pause the activity begins. The van doors open and almost ten staff emerge. They quickly set up five metal tables. Number 1 has a laptop and web-cam- this is the registration table. Number 2 is the weighing station- it has a standard and infant scales and a measuring tape. Next is the lab.

Field Lab

The lab consists of a haemometer which gives a haemoglobin measurement. Blood is mouth pipetted from a pin-prick into a glass tube where it is mixed with some HCL and water, allowed to settle and a reading is taken from the graduated side. There is a glucometer, urinalysis dipstix and some pregnancy test strips. Table 4- blood pressure. Table 5- counselling, nutritional advice. There is also a small dispensary. There are no doctors here but there are nurses and health officers. The drugs have been prescribed by a physician who is several miles away and the vans bring the medications with them on this monthly visit to save the long journey to the pharmacy. The drugs are standard fare. There are folic acid tablets for the pregnant women, metformin, theophylline, phenytoin, paracetemol syrup. The van doubles as a chart store and examination room especially for antenatal checks.

Checking Haemoglobin

Soon there is a buzz about the place. At first there are one or two elderly men and women in their lungis and saris. They have expressive, weatherbeaten faces and their clothes are old and stained but clean. One tall elderly man has a woolen pullover on and is carrying his heavy blanket. It must be about 40 C. I am trying to avoid heat stroke. Just looking at him is making me light-headed. The elderly women bring the infants. I am not sure why, I think it is likely that the young are working. If this was sub-Saharan Africa it would be for different more tragic reasons, but thankfully the HIV epidemic has not yet devastated India in the way it has Africa. The operation is orderly and smooth. We are not party to the health advice, I have forgotten most of the Telegu I learnt as a child, and Sapna’s consists of adding the suffix “doo” to the end of every word (“breadoo”), with only limited success. Shobha is able to make some progress in Hindi. Overall everyone seems happy with the service, a very important component of which is prevention. Antenatal checks like these will flag pregnancies that are not progressing well. Low haemoglobins will be referred for follow up, especially in pregnancy. Child progress in charted on growth charts, blood pressure and urine sugars are checked.

Infant Health Check

Mid-morning we get a chance to wander around the village. This is the standard size village that the HMRI vans will visit for half a day, approximately 1500 people. There is a short main street with some small streets off to the sides. Most houses are brick and concrete or mud with low straw outhouses for the cattle and goats. There is a water pump outside the village hall. There are lots of open drainage and lots of open stagnant water containers, ideal breeding sites for mosquitos. Wandering up the road we some across the village health centre, a tiny single roomed house with a red cross painted on the walll. This is were the village asha (health worker) stays. A little further up there is a little statue with the old men sitting around talking and the school. We are ushered into the school and the head master brings us to see the children. There is great excitement and they all stand up and greet us. Songs are sung, photos taken and of course pandemonium when they see themselves in the pictures. The children use chalkboards to learn to write. There is no furniture, they sit cross-legged on the floor. On the whole they are sweet. happy little things, clean and bright-eyed, full of the same joys that children possess exclusively all over the world. Leaving the school, past the fire with it’s giant cooking pots, some of the smaller ones run past barefoot hitting tyres with sticks. Children’s games are the same everywhere. Or at least they used to be, before Nintendos and 24 hour cartoon networks.

The Barber Shop

Back at the village hall (room would be more accurate, it is an undecorated bare room with piles of rice and pots and pans in the corner) the clinic is in full swing. Patients move from table to table. More infants have appeared and young pregnant women. A barber has set up shop under the shade of one of the straw and mud walled houses and, sitting cross-legged on the ground behind his client he watches the proceedings, his scissors flickering in the sun light. There is also someone who must be the village shaver shaving his clientele with his trusty cut-throat, brush and soap. Every now and then a herd of goats, or cows, or sheep are marched past. The locals are enjoying having their photos taken and seem to be very grateful to be photographed, even when they do not see the results. This perplexes me a little. They are even happier when I show them the pictures, they look approvingly at the camera and smile and shake their heads. I know they don’t expect to receive copies but I hope that I can get somehow get some to them.

The medical care that HMRI provides on these trips is basic but it is organised and systematic. There are different types of mobile clinic services in different parts of the world, even including mobile operating theatres. These are usually run by NGOs. HMRI is a public-private partnership with the Indian Government. What makes their operation particularly impressive, besides it’s integration into the health service, is the sheer scale of the operation. As Shobha has already mentioned there are over 400 (I think the figure was around 475) vans on the go constantly. They service villages over 3 miles from basic health centres (which are usually staffed by a nurse of midwife). Some are many more miles away. They provide care for half a day a month for villages of 1500 people, each van will travel to two villages a day or stay a whole day in the bigger villages where the populations are around 3000. Overall HMRI provides a once monthly visit to 38 million people. The service operates in a hub and spoke manner, the vans return to their hubs at night where they can be serviced, fueled, restocked for the next day. The level of organisation involved is very impressive. I very much admired the systemic approach to the operations. Each van operates in the same manner, is equipped the same and follows the same protocols. The system is computerised but not overly so, each van has a laptop and webcam that can be used to keep track of patient demographics and registration. The service is not overly complicated, instead of providing more complex care for a few they have opted for basic healthcare for many: nutrition, antenatal care, childhood health checks, basic health advice, reassurance, counseling, providing medications, but also facilitating referral to higher level health services, even attempting to provide transport to patients on the visit days if required. If a patient needs a HIV test they can provide the counseling and then try and arrange for the patient to be tested at a government testing site. A woman with complications of pregnancy can be referred to higher level care earlier. Staff can also access a doctor by phone on their own 104 healthcare line. It does not attempt to duplicate services, only to increase access to present services.

HMRI is a good example of the benefits of public-private partnerships in health care. As a private albeit not for profit organisation it has efficiencies and freedoms that government organisations do not have. It has more streamlined operations and the flexibility to scale up or scale down or adapt to changing situations more rapidly. It may have to compete with other projects for funding which can reduce costs and encourages innovation and operational research. The government on the other hand is in a better position to provide the large amounts of funding required for the services and to leverage funding. Paradoxically the major disadvantage of this system is that should the government decide not to renew funding then the operation will collapse and as such it’s continued existence is at the whim of a labile political system and could also fall foul of corruption. Finding non-government donors for this scale of operation would be very difficult, especially at short notice. The programme is easily and rapidly reproducible, at least within India and there is interest from other states in providing a similar service. It also has potential as a model of care for other developing countries. It does seem to be particularly suitable in India where road infrastructure, ability of at least the better off states to fund the initiative and the large rural population are conducive to a service of this nature. It is an excellent programme, innovative and well designed and while it remains vulnerable to political decisions and cutbacks it provides very important services to millions of people who have none.

HMRI part 2 , the saga continues

The night before we went on our 104 mobile visit, we had important matters to tend to. Here we were in the city of pearls; we would be remiss if we didn’t do some serious damage. So, Neena Auntie to the rescue, we arrived at an awesome jewelry store where we all had a great time followed by a trip to Neena Auntie’s sailing club (yeah we’re high rollers here). While we were waiting for our pearls to be strung, I naturally was drawn to watching a little girl about 3 years old at the store. She had on a yellow shirt and a floral skirt complimented by two curly pigtails. She was clearly not as interested in pearls as her mother, but was happily entertaining herself. She was watching herself in the mirror, making faces, and playing with the sash from her mom’s salwar-khameez for over an hour. I was in love. She was so well behaved and you could tell this was not her first time out on a long shopping trip with her mother.

I couldn’t help but think about her when we arrived at this remote village and saw a little girl the same age with those same curly pigtails, a black and white dress, and shy smile entertain herself with her 23 year old gravid mother’s sari. I followed them (don’t worry I wasn’t going to steal the child, Amanda) from registration where she and her mother had their photos taken for their EMR, to station 2 where temperature and review of systems was obtained by a nurse and station 3 where they took weights and heights. They bypassed station 4 which was for blood pressure management and patient education about chronic diseases (primarily asthma and diabetes) in favor of station 5 where her mother had her hemoglobin checked via mouth pipetting and a haemometer, and finally on to station 6 for folic acid and multivitamins. Just like the little girl in the pearl shop, this little girl was so well behaved and you could tell this was not her first time through the line. From a young age, she was both receiving basic healthcare monitoring and being exposed to the importance of medical care.

As I fell in love with another indian baby (probably the millionth on this trip), I couldn’t help but think how these two beautiful little girls were from very different families. One had the means to spend an evening buying pearls and the other likely had very little extra comforts at home. However, to a certain extent, 104 mobile is at least able to bridge the gap in healthcare access for them. We have seen a lot in these past three weeks; it’s really been an incredible experience clinically. However, 104 mobile is definitely the program that I think has impressed me most. While they are limited in the services they provide – they only have a staff of 7 per van, their only labs are hemoglobin, accucheck, urine albumin, glucose, and HCG and their dispensary is limited—they have an incredible opportunity for expansion and refinement. Just today, Peter and Luis returned crazy with excitement after a great day with the HIV specialist, Dr. Emmanuel, at Gandhi Hospital. They said he had heard of 104 mobile and they were planning to work with them to expand their ability to diagnose and treat HIV. The program has only been in existence for 15 months and already they are starting to make an impact on both the rural and medical communities. The potential for this endeavor is vast. We have witnessed a lot of discouraging cases, overwhelmed clinics, people unable to afford care, and caring providers often too late to make a difference. I thought visiting this village might be a little depressing. The people there do not have much money. They live in substandard housing. Their school has 110 students in a very small states and only goes up to grade 7. But it turned out, we were welcomed graciously (no surprise here) by some of the happiest people we’ve met so far. If this service can break the poverty-disease cycle, even for a few people, that’s really encouraging.

Big city meets country

Our drive out to “rural India” looked, to some extent, like driving from Toronto to Ottawa or through southern Illinois. There were fields, there were livestock and bright blue skies. The differences: palm trees, monkeys and road blocks secondary to goats. I think our driver (I am being very liberal with the title) got more than he bargained for with this trip. The reason for our trek? To see HMRI (Health Management and Research Institute) mobile provide primary care to villagers in a reliable fashion. Sixty kilometers outside of Hyderabad we met two large vans at the corner of some store across from some lamp post at the correct time by sheer luck. We followed the trucks in our Toyota van (also known as our home away from home) into the village. Once we arrived, the HMRI team of nurses, paramedics, and some logistics members (note: no actual physician was present) quickly and efficiently started setting up the clinic at the local town hall. While this was going on we milled about checking out the roaming chickens and roaming children and I worried about where in god’s name we would find a bathroom. My ears perked up when I heard the familiar chime of windows booting up which they had attached to a web cam to take pictures of the patients when they check in with their health cards. From here they get weighed (babies too!), have their BP checked, can get some labs checked and then on to the pharmacy where they can get free medicines (FYI: phenytoin was one of the drugs they had available). Of the labs they had available I was most intrigued (and concerned) about the haemometer used to check hemoglobin. This method involves mouth pipetting blood (thus my concern) from a capillary stick. Within 20 minutes there was a hemoglobin value with only the use of hydrochloric acid and distilled water and haemometer (no batteries or assembly required); I was impressed.

Later on we ventured out to the town school (they had a bathroom!) just down the road and created quite a stir just as any visitor would at a primary school. There were giggles, waves and let’s face it, a lot of stares…we may not be the best looking but we are quite the spectacle in Hyderabad let alone a small village. While the school was pretty nice it was hard to imagine learning without desks, with outdoor bathrooms, and an open fire in the school court yard. There were however, textbooks, notebooks and school uniforms, and I surprisingly even saw one little girl pull a cellphone out of the pocket of her pinafore.

I think I started the day with a bit of a negative prejudice about the whole set up. I mean isn’t a clinic without a physician a bit misleading? This of course prompted some serious consultation with team CIT4b; some of the smartest (and most opinionated) people I know. There definitely is not comprehensive care being provided by the mobile clinic, there aren’t vaccinations, it is not possible to start new meds or adjust existing meds. There are free labs, free drugs, reliable follow up and care right at their door step despite their remote location. These people are receiving support from their government in their home town; they don’t have to bear the burden of traveling to a city. I assume that this has to help with compliance. Maybe the PD nurses could get on board with HMRI mobile and patients wouldn’t have to travel 800 km to NIMS for their monthly visits? I wasn’t sure at the outset but seeing the setup in action and after some discussion with some smart cookies I’m convinced this government program is helping fill some large holes in India’s health care delivery.

My day

My teaching topic for the trip has been chronic kidney disease, end stage renal disease and renal replacement therapy in India (likely not a surprise to many of you) and man, today was my day. While Sapna and Christie were off at KIMS with Neena Auntie learning about “the sugars” and women’s health respectively, the rest of us were back at NIMS. Luis, Peter and Shobha had their sight set on a day of microbiology while I would be spending the day with the nephrology department. We met the department head Dr. Dakshinamurty when we arrived; he may rival Dr. Wish for the most smiley nephrologist ever. We sat in his office while I fired questions at him; it bordered on pressured speech, but I really wanted to compare what I had learned in my readings to what was really going on. Dr. Dakshinamurty did confirm that “crash landings”, patients who show up with ESRD secondary to god knows what was still quite common. A lot of the articles that I read while preparing my talk painted a rather dreary picture of renal replacement therapy options in India so I was encouraged when we learned that they did in fact have maintenance hemodialysis available. We discussed access issues and line infections (it seems there is ID everywhere!). Peritoneal dialysis is really much much more common here than hemodialysis here which is a very sharp contrast to the U.S.. The benefit to PD is that people can still work, only need to come into clinic once/month and they don’t take up the very limited number of hemo spots that are available. Doctor visits are a big deal especially if you are a patient living 800 km away in a rural area making the trek to NIMS. Get this, no perma caths only temp lines and fistulas. The fistulas are used after 4-8 weeks. I was unable to figure out what the heck results in the 6 month delay at home.

Their hemodialysis unit has 14 stations with 5 shifts per/day, yes, that is basically 24 hours a day, and yes, some outpatients do come for HD in the middle of the night. Dr. D’s only comment about that was “ya, they hate us sometimes” which he of course said with a smile. The unit itself was really nice and could easily have been found in Cleveland. The exceptions were it was quiet (a pleasant change) and we had to take off our shoes (chappels again), this gave us the opportunity to witness Peter’s pink socks. Later in the morning while team ID was learning about fungus and TB I went on to the outpatient clinic. Dr. Dakshinamurty dropped me off with some of his junior faculty, once they figured out what the heck I was doing there and that I did have some vague knowledge about nephrology they seemed to warm up to me and really tried to explain to me what was going on while they saw a bazillion patients. The clinic set up: a room the size of the DMC, one table, on exam bed, 2 stools, 3 chairs, 1 manual sphygmomanometer and 1 bottle of hand sanitizer (which I am pretty sure was only used by me). I am not kidding; at one time there were 14 people in the room, again making me a little more grateful about my own continuity clinic. We saw one poor young gentleman who was accompanied by his father who looked quite old, and a cousin who looked like he had things somewhat together, who had relapsing MPGN. He was having nose bleeds so his nose was packed, and he looked quite ill and in desperate need of dialysis. Turns out his Cr was 16 and he was uremic as all get out. Plan: intermittent (or temporizing) PD…hmm, well that’s different.

In the afternoon we “rounded”. I use quotes as rounds consisted of the intern (who by the way, looked just as flustered as I felt as an intern) presenting a couple of new patients to the attending at the nurse station while nurses kept handing her labs written on scraps of paper, and patients coming out of their rooms (not in any sort of hospital attire) sometimes with their families asking questions, all at the same the attending was trying to review all the notes that the flustered intern had written that day. Try to picture the secretary’s desk on tower 3 with about 25 people hovering around it and the attending and me sitting in a mountain of charts behind the desk. So, I was encouraged, at least here at NIMS and seems like in Hyderabad in general, l there are treatment options available for patients. There were some discouraging things that were confirmed. The attrition rate from HD is 50% in the first 3 months, if you don’t have a family member to donate a kidney you’re pretty much out of luck (at least at NIMS), there is still no organ procurement program so cadaveric kidneys are not an option, if you do get a transplant the risk of TB or CMV is overwhelmingly high. There are at least options; this is good. What a great day!