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

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.

How did you like India?

Its been nearly (now over) two weeks since I have come back from India.  The very first question my family and friends have asked me from the moment I stepped off of the plane has been, “How was India?”   Every single time I’ve struggled to find an answer.  To give a simple response like it was good or it was bad did not give justice to the experience at all.  But more fundamentally, I didn’t know what make of the trip.  I signed up for the trip to learn more about India, particularly to get exposed to the culture, people and situations I’d only see fleetingly from  a car window when traveling with my parents.  However, it was impossible to anticipate to the impact of meeting with and hearing the stories of Indians seeking health-care.

The theme that tied the government hospitals, the Good Shepherd, and the SRH was that its clientèle were almost entirely poor.  In fact, all those infectious diseases that we studied in India predominantly affect these people.  We learned that the foundation of the health-care these people received was the government hospital, established in fact to make sure this population received some health-care.  However, ignoring the disparity between private hospitals and government hospitals, we learned from reading White Tiger and speaking to Dr. Beryl that there were institutional barriers for these people receiving health-care, ranging from discrimination over their economic status, the stigma associated with their disease, and merely their class.  Much of India’s health-care problems result from lack of education about these diseases and cultural and religious bias towards diseases and the people who suffer from them.  The value of life I heard many people say in India was not very high there compared to places like the US (incidentally the value of life here in the US is estimated by economists to be between 3 million to 7 million dollars).  This situation was made concrete to me when I talked to an individual suffering from leprosy who’d been living on the streets for six months after his family had thrown him out of the house and when I saw the living conditions of people of the Dalit class.

My initial reaction to this trip was to invoke Siddharta Gautama’s experience of stepping outside of his palace walls for the first time.  I’d never seen such living conditions as those of the dalits up close, only while driving through the outskirts of a city.  But regarding health-care, these people lacked any education on proper health practice as well as any knowledge of their health-care rights in institutions like the government hospital.  But the most striking experience was talking to the young man with leprosy.  As the man began to cry about his devastating situation, my inability right the injustice or to offer him any real aid made me feel powerless.  His pain reached beyond the pathologies of his illness (the disfigurement of his face due to the loss of his nose). What hurt him the most was to tell us that he was living on the streets due to the ignorance of his family.  While it’s true that the rates of leprosy are coming down in India and people are becoming better educated about the disease, this situation still exists, to the point where none of the patients if they could hide that they had the disease admitted to the community that they had suffered from it.

So how does one change an entire society?  Education. At first glance, it seems to be a problem associated with lower class families.  To a great extent it is, but even upper and middle class families suffer from ignorance over a more modern disease such as HIV.  The orphans at SRH have to attend schools secretive of their HIV status, due to the danger of their being kicked out of school if the larger community finds out.  Education about the disease cannot truly take place because sex education does not take place in any serious manner in the Indian public education system.  Part of the stigma lies with the Indian’s Victorian sensibilities regarding sex and talking about it in the open.  However, if one tracks of Bollywood cinemas over the decades, India’s sexual mores have been liberalizing if ever slowly.  Perhaps this liberalization will continue to a point where sex education and education about STDS can take place in an Indian classroom in earnest.

But this stigma about sex does not change the fact that the majority of people who suffer from HIV are actually of the lower class.  Likewise, as mentioned earlier most of these infectious diseases are diseases contracted mostly by people of the lower classes.  Many of these people do not have unrestricted access to education or in the case of the Dalits face discrimination at these places (~27% ) to the point of making education untenable.  Furthermore where a cultural practice of the caste system is that one’s occupation is what one’s father did, a cycle of poverty and lack of education develops.  It was obvious from visiting the Dalit neighborhoods that India does not enforce many if any at all of its rules protect the Dalit population’s rights.  With the lack of education, the Dalit population cannot truly advocate for themselves.  It’s here that a lack of education hinders this population, and really all poor, uneducated persons in India.  And the prospects of educating every one in this population with in a generation does not fill me with hope.  Media campaigns (and some of these may have already run) regarding this disease need to be waged by the government and advocacy groups.  TV, billboards, posters, and fliers need to be made to educate people about each of these diseases for more immediate relief.

As I’ve tried to organize everything I’ve seen on this trip (and writing this has helped tremendously), I finally reach the actually assigned part of this post.  Having had this experience, what will I do with it as someone who’s trying to become a physician-scientist?  I initially think of the summer reading for my entering class at Case Western, Mountains Beyond Mountains, a story about Dr. Paul Farmer’s Partners in Health.  Such an organization would be able to provide care without the social hangups and stigmas common in India.  However, I believe these problems and injustices are something the Indian nation needs to discuss and solve for itself.  An army of American doctors would not be able to patch this health-care system of 1 billion people, although the SRH and Good Shepherd make an argument this stance.  What I think would be of true benefit from a western and incidentally interests me more would be to do research oriented towards these infectious diseases, like the research that Pardis Sabeti conducts in West Afric on malaria and other diseases(who partially inspired my interest in an md/phd).  One of my initial interests in medicine was HIV.  In a mathematical modelling class I chose to reproduce a model of competition between two HIV strains of varying drug resistance under ART.  This experience in India has reawakened an possible interest in HIV research.

Third Week craziness

We spent the third week of our trip at the Operation Mercy India (OMIndia) site of the Good Shepherd Community clinic.  One major bioethical issue we considered was access to health care.  Generally in India, the poor we have learned are shunted to government hospitals or to cheaper but illegitimate services of unqualified people like the local compounder.  While we never visited a private hospital, several sources (Adiga’s description in his novel White tiger and fellow CITers) indicated that there is a wide disparity between the two types of hospitals in health care.  Two groups that are systemically susceptible to this discrimination are the dalits and the joginis.  It was these two populations that we visited in our third week.

When visiting Dalit “villages,” I mostly focused on their circumstances and lifestyles.  In the vast majority of their houses, one could not readily stand up.  All the villages we visited were situated near the places they worked.  One of the stark contrasts I drew was at a village near a resort the villagers were building.  While the resort was magnificent and served the wealthy of Hyderabad, the children in the village were studying in a windowless, unlit shack that served as a Good Shepherd School.  Many of them were migratory, traveling from some rural hometown to the city “village” based on availability of work and religious holidays.

One thing I did not pay much heed to but was brought to my attention in a recent discussion with Dr. Yadavalli was the significance of a church that had been built by another arm of the organization.   Originally I did not believe it was a very big deal since this was a Christian organization, the health workers insisted that they did not preferentially treat Christians over people of other religions, and there were also two temples in the village that made me believe that their was still an adherence to and tolerance of Hinduism.  In fact, many of the students at another Good Shepherd school that we visited drew pictures of a Hindu god just as others had drawn Jesus.

However, the implications of this church being built by the same organization as the one providing the health care were far subtler than the above considerations.  Even if the providers make no attempt to proselytize their faith, the association of this church with the health care workers who treats this patient is not lost on the patient.  This combined with the authority and power the doctor has in his relationship with a patient as we have seen in the previous week may create an impulse in the patient to please his/her doctor and adopt the religion.  So this creates  a situation where the health care this organization is providing is not just a matter of service but also a tool to convert the Dalit population.  After having understood this, I started to suspect the motives of OMIndia organization was not just to provide health care to an underprivileged population but also to convert them of the motives of the individual health care workers.

The joginis were a baffling lot.  Armed with the narratives in the AIDS Sutra, we marched in expecting former ritual temple prostitutes ready to share their tales of subjugation and essentially sexual trafficking.  However, what we got was a group of 40 year old women all talking at once (the fact that none of them was young made me hopeful that the ritual had in fact been abandoned).  Our translator would frequently get into conversations with a subset of these women and forget to translate what they or she was saying.  In fact, I doubted whether our facilitator was natively Telugu since she often used the English word for things like the word loan.  For me as someone who was raised in a Telugu household, it was difficult to understand the dialect of these women.  Needless to say, the true backgrounds of these women remained very murky.  Instead of asking questions about their past and details about the ritual and how society treated them and health implications, the translator instead chose to focus on asking how OM India could help them.  We learned from our facilitator that joginis (or at least these former joginis) were more like concubines who made livings dancing at weddings and other auspicious events rather than actual temple prostitutes.  But this was neither corroborated or denied by the former joginis as we understood it.  In fact, it appeared as if the women had come because they expected lunch and money for the day.  All in all this day was a lesson in how not learn about a stigmatized practice and population, much less unique health care situations regarding them.

Vidyapitham reflections

The visit to the Vidyapitham was an opportunity to get a perspective on health issues in India from classically trained scholars. Their orthodox and conservative lens was to serve as a foil for the other, more familiar, attitudes that students were likely to experience during the trip. In this connection we were able to interview scholars at the Vidyapitham over two days and to witness their theological reflections. They based their positions on passages or examples from sruti (revealed texts) and smrti (authoritative humanly created sources). Our questions revealed two basic principles, in addition to their assumptions about human life and existence (karma, rebirth, moksa etc): first, all decisions about health issues must be linked to enhancing and facilitating devotion to Lord Vishnu; second, that these decisions must also support all aspects of society in so far as they encourage, facilitate, etc, devotion to Vishnu. The panels of scholars included 5 professors who have PhDs and taught at the Vidyapitham and had positions in the research wing of the Vidyapitham as well as the Pejavar swami (bishop) of the Vidyapitham on the second day. Scholars included Prof. A.V. Nagasampige, Prof. Haridasa Bhat, Prof. Kulkarni, Prof. Srinivasa Murthy, and Prof. P. Vinay. These scholars are among the best trained in India and it was a unique opportunity to witness their reflection and to be granted an audience with them. Hopefully students will keep their lens in mind when they observe and interpret for the duration of their trip.

A before B

Flight delays and  ?racial profiling aside…I am jealous of the CIT4a group. Wish I was in India already. Good luck Trevor, Gopi, Neal and Sarena. I hope this trip brings you as much learning, humility, fun and adventure as it brought us last year. In the next few weeks your heart will weep, your tummies will churn, your skin will sweat, you ears will hear and your eyes will feast. Enjoy every single uncomfortable moment. And remember to bring home some of that color, noise, hospitality and simplicity. Good luck to you all.

 P.S: please someone say hello to Suresh for me.

Delay? So soon?

Delayed already? We got on the plane to go from cleveland to chicago, and then were told to de-plane as there was inclement weather in chicago. Here’s hoping we make our connecting flight…. and by the way, I still have no seat assignment from london to hyderabad.

Waiting in the airport

Gopi and I are in Cleveland Hopkins International Airport waiting to head to Chicago–the first step on our way to Hyderabad. The person at the gate knew who I was as soon as I said where I was going. He was like, “you must be Trevor.” Not too many people making the Cleveland-Hyderabad journey today, I suppose. Gopi is upset because they won’t assign her a seat on the last leg of our trip, yet I had no trouble with this. They told her it is because of her name. She says this is racial profiling. She has set her husband on British Airways to try to resolve the matter. She says, “more to come…”

Packing

It is the night before my departure and I am packing. Well, more like looking intently at my suitcase. There isn’t a whole lot to pack, since I try to maintain a wardrobe in Hyderabad, but I will be bringing some updates. The suitcase is really for the loot I will be lugging back in a month. I have called our hosts in Tarnaka to confirm our arrival this week. I have also requested our usual driver, R. I am hopeful that R will pick me up at Shamshabad Thursday morning. And that he will take me directly to my family’s home without unscheduled stops. One of the highlights of CaseIndiaTrips for me each year is my conversations with R every day.

I am also looking forward to my aforementioned Triumphant Return to Bangalore. And to meet the students in the Bioethics course. Especially the one that has chosen the moniker interim17.

Finally, a word about my flight. I am, for the first time, taking a direct flight from the US to the subcontinent. Newark to Mumbai. 15 hours. The longest I have been on a plane before this is 9 hours. Not sure what to expect. Everyone who has told me it will be terrible has reported never doing it. Everyone I have spoken to who has done it has said it is fantastic. Will I, as my friend Federico likes to say, be the exception that proves the rule? I have loaded some books on the iPad and will also have my laptop with me. I am not taking any sedative/hypnotic despite the recommendations of many. Maybe the extended time aloft will spur some inspired blogging.

T-7

One week until CIT4a, when we start our 30-hour trip to Hyderabad where we will meet up with the rest of the CIT4a team.  Still with a lot to do before leaving- I have done no packing as of yet, but did at least fill my prescription for mefloquine and purchased my requisite bug spray.  Thanks to our CIT3 friend (and now CIT4b advisor) Puja for helping us figure out all of our travel essentials, along with hosting a fantastic pre-CIT4 dinner a few weeks ago 🙂  Hoping there are no elephant stampedes or tiger maulings while in Hyderabad, as I have just filled out the all-inclusive pre-trip waiver from our friends in the UH legal department.   Can’t wait to start our trip to Hyderabad, and also excited for our weekend trip to Goa while in India!