Posted by christiemasters on 30 September, 2010
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.