The Grand Finale: Where Do We Go From Here?

It has been a week since the Indian Health Field Seminar ended. Between the struggles of dealing with jet lag and the sometimes echoing question, “Did all of that just happen?” I found myself reminiscing, wincing, and missing the following things about India:

1. The amazing maneuvering capabilities of tuk tuks (auto-rickshaws).
2. The sometimes overwhelming smells (you have to experience them to truly understand what I mean).
3. Amazing hospitality.
4. Unique perspectives on american food.
5. The rich culture and sites like the Taj Mahal.

But, more importantly, this trip also gave me a new perspective on not just how we live here in the US, but also how much we may take for granted. And, as we see healthcare systems like that seen in India, it will be our ability to apply some of what we experienced and learned about the Indian Healthcare System to our own U.S system that will be paramount to our success. I know that it will take a collaborative effort across a spectrum of industries and disciplines.

From what I learned at our last visit with GE Healthcare, many instances of wiping the “slate clean,”“building from the bottom up,”and building products specific to the market and the market’s needs have allowed GE to create products in the Indian market at 1/6 the cost seen in the U.S. For some, that may sound too easy, or too “big picture.” But, maybe not. Right now, our healthcare system is not tailored to the needs of the market, resulting in inefficiencies and wasteful spending. I do believe that we can deliver a substantially lower priced and more efficient system; it can surely be done. It’s just a matter of when? And, if we can arrive at those changes sooner, rather than later, will be the ultimate question with an answer that will dictates our fate.


As a first year MBA student in the Health Sector management program, this was an invaluable professional and cultural experience to have early in the program, and I am so excited to build upon this experience in the upcoming semesters.

Jobs in India

There were many things to adjust to during our trip to India – many were things that I had anticipated: the lack of Western toilets (or “squatters”, as we so fondly dubbed them), the spicy food, the crowds…but one of the things I didn’t expect to witness was the intense level of service and number of employees (both official and unofficial) assigned to one particular job or task.

When I first landed In Kolkata, a boy who couldn’t have been more than fifteen years old insisted on carrying my bag and helping me find my pre-paid taxi. And when leaving Bangalore, Jim, Rachel and I experienced something similar where an airport employee trailed us throughout
our entire check-in process, leading us to the airline desk, the security line, and ultimately asking for a tip. Later in Kolkata, I went to a salon to get my hair cut for the wedding I was attending and was surprised to see that I had not just one but two (or sometimes three) stylists working on my hair.

Three weeks ago, I would have not accepted this kind of assistance, insisting that I am comfortable carrying my own things and finding the taxi myself, or I would have balked at the number of people tugging at my hair in the salon. But in India, I had to look beyond this and just give in to letting someone else (or in some cases, several others) do certain things for me, of which I am completely capable myself and would normally prefer to not burden someone else
with. But this is not an exercise in etiquette. Rather, it’s acknowledging that those who are insisting on helping me are doing so because they really do need the [tip] money, and that it doesn’t help either party to deny their assistance.

We’ve seen how excessive the service can be in India and we have seen many instances where there appears to be at least two people doing the job of one person; this seems to be at least one of the ways in which India has chosen to respond to its massive population and the jobs that such a large number demands.

In Kolkata, the sidewalks were being dug up to lay piping that ran straight up and down one of the city’s biggest avenues. The road work evidently provided jobs for dozens of workers that dug through bricks night and day. These workers were doing the job that one backhoe could have quickly done in a few hours. Again and again during the seminar, we recognized that India is extremely tech-savvy and has a lot of talent, but hindered by its lack of infrastructure. The flip side of this, I’m thinking, is that while the lack of infrastructure seems to prevent or delay the creation of more “sophisticated” positions (and consequently filling them), it does create jobs
that require less education, less skills (road work, digging, the high number of street food stalls, etc.). I am therefore wondering about how deep of an effect will technology-advancement, increased automation and improved infrastructure – when and if achieved – will have on
job availability and unemployment rates in India, particularly to this one very large part of the population that depends on this type of labor for work.

Revisiting India

Between fighting jet-lag and trying to keep up with the reading for my public health classes, I've been revisiting pictures from India. I'm glad I had a really great time on this trip because I left for India feeling rather anxious. It might have been the post-finals daze or the relentless reminders to avoid the tap water, dairy products, fresh fruits, meat, the street children, mosquitoes...the list goes on. Honestly, I think I managed to break all the rules within the first week, with the exception of avoiding tap water.

During my time in India, I managed to place myself in rather uncomfortable situations. For example: being the fourth person in a tuk-tuk ride in the middle of heavy traffic, having to use a squat toilet in Old Delhi, navigating the small alleys of the Dharavi slum, and crossing the traffic-laden streets of Bangalore during rush hour. The discomfort of these situations and many others while on the trip helped me to become a more resilient traveler and less high-maintenance overall.

While I can't say I learned the art of crossing an Indian street, I did learn to love the energy that pulsates all throughout India. Despite the sometimes chaotic conditions of the country, the Indian people are welcoming, highly innovative, and tirelessly entrepreneurial. As I progress through a career in global marketing, I really hope I get the opportunity to live and work in India in the near future.

ASHAs

Of the hundreds of pictures I've taken on this trip, this image of the ASHAs from the National Rural Health Mission is one of my favorites. The ASHAs are Accredited Health Activists who are selected to act as intermediaries between their villages and the public health system. The photo reflects the positivity with which the ASHAs approach their duty of educating and engaging members of the community, despite the dire public health situation that surrounds their village. It is empowering and inspiring to see these women take the health of their community into their hands. As the ASHAs show us around the village they nurture with dedication, the effectiveness of their work becomes more and more evident. They are more than happy to showcase their spirited community, filled with healthy mothers and lively children.

In some ways, these ASHAs represent what we all desire and find difficult to obtain in the US - a personal health advocate, who is culturally competent and sensitive to one's changing needs. While the ASHAs live in a world so drastically different from the one we are familiar with, we can learn a lot about delivering care just by observing their enthusiasm and passion for health in their community.

Dharavi

During our trip in Mumbai, we visited Sion Hospital where we were briefed on their Urban Health Center. The center serves the people of Dharavi - a slum in the heart of Mumbai. We also had the fortune of touring Dharavi to see the conditions of the slum and the people the clinic serves. Although Dharavi is home to a middle class, we only saw extreme poverty. The slum was dirty, unsanitary, overcrowded and there was a lack of clean water. One of the larger homes we saw was a 300-400 sq ft loft that housed a family of at least 6.

Despite the deplorable living conditions, Dharavi is a self sufficient community. Most people make their sole income from the various industries that were set up in the slum such as recycling, pottery, and textiles. We only witnessed the pottery trade, but it was amazing to see how much they could produce and how they could sustain themselves with so little. However, the success of the pottery industry comes at a cost to the community. The kiln sits directly underneath multiple homes and emits toxic smoke into them, further polluting the slum environment.

UHC provides a multitude of services to the community such as an advanced maternal health clinic, STI clinic for men, cancer screening, and they are even making their own version of plumpy'nut to curb malnutrition. I spoke to a doctor at the Urban Health Center and she said that all outreach services are provided for free and medical services cost only 10 rupees (about US $0.20). Medical services include all meds and the ability to use the clinic for 15 days. The government subsidizes the costs since Sion is a public hospital. Regardless, it was surprising to learn that the government covers such a large portion of Dharavi's healthcare costs since so much of India's healthcare is paid for out of pocket. The programs are promising, yet I worry about its funding. Knowing how corrupt the Indian government is, I wouldn't be surprised if corners were cut in the development of the clinic and the services provided. It's a pessimistic view, but often the case in this country.

To Copy or Not To Copy

During our time in India, we saw two different sides of the pharmaceutical battle. On the one hand, we visited Anand and Anand, a law firm specializing in patent law that represents many multinational pharmaceutical companies in India. On the other hand, we visited companies like Cipla and GSK, which produce generics in India, both for local use and exportation.

The battle between the two sides does not really have a good and an evil; rather, each side has its valid points. The multinationals feel that they need patent protection in order to recoup the costs of developing drugs, which takes many years and a large amount of capital investment.

The companies that create generics view their job as to feed affordable pharmaceuticals into the market, allowing those who could not otherwise afford medicine access.

Both sides make good points. The generic companies and the market would not have access to any pharmaceuticals if the multinationals did not spend money developing those drugs, which necessitates them to recoup their costs in order to reinvest. But, at such high costs, the middle- and low-classes in India can not afford access to those drugs.

One option which was discussed during several of our visits was the system of licensing patents. Generic companies would pay fees to multinational developers in order to have access to the patents for specific drugs, allowing the multinationals to recoup some of their costs while paving the way for generics to send low-price drugs into the market. However, this system would naturally raise the price for drugs coming from the generics - though likely not as high as those from multinationals with monopolies on the market.

No system is perfect. Heavy patent controls make pharmaceutical costs too high, low patent controls eliminate margins for multinational developers and would eventual eliminate innovation. India must find some middle ground in order to provide access for its people while still making pharmaceutical development worthwhile for multinationals without placing the burden of cost on other nations.

Coming into focus

This view of the beach in Goa is a perfect example of India's perspective problem. From afar, it looks pristine and idyllic. However, as you get closer and closer to the action, the picture gets less rosy. Sitting on the beach you'd observe a decent amount of trash and general debris. You might be lucky (or unlucky) enough to see the people in charge of cleaning the beach burying all the trash the collected in the sand.

As we toured the wide array of healthcare facilities in India, I was constantly reminded of this example. Even at the high end hospitals (e.g. Max Healthcare), things looked great until you got up close and personal. Solely looking at infrastructure, its easy to see the lack of attention to detail in the construction. While the challenges to the Indian healthcare are many, a focus on and commitment to quality throughout the system seems to be one of the keys to improving the system. Many of our hosts (e.g. Narayana) espoused a consistency in purpose and values, which was encouraging. Hopefully this is a trend that continues with a renewed focused on quality.

India's Progress

I read an article in the Wall Street Journal today lamenting that many American companies are moving more and more R&D spending to Asia.  Read: China and India.  The article's tone was somewhat negative, and regretful of the movement of high skill jobs and R&D money out of the United States.  The aricle fails to take into account 3 major points we can infer from this increased investment abroad. 

1) U.S. corporations realize that they can earn a better return from investing in projects in these countries.  Economic theory is based upon the assumption that capital will flow to where it gets the greatest return.  In most of the recent globalization, this has perversely not been the case.  Instead capital from emerging markets has been flowing towards the rich world, and particularly into U.S. treasuries.  The WSJ (of all publications) should be lauding this (small) return to normal economic conditions.  In addition, since when are greater profits for American companies a bad thing?

2) Investment in and development of Asia, particularly India and China, is not a zero-sum game.  As we saw during our visit to GE, R&D for a large multinational is often done at a global scale with 3 or 4 centers.  Breakthroughs in any of these encourage breakthroughs throughout and the more money that is invested in each area, the better off they all will be.  Progress requires adequate investment throughout the R&D chain.  India in particular, with its legions of world-class engineers ought to be bringing in even more R&D money.  Further integration of worldwide R&D and greater investment in all areas will produce more and more rapid economic growth throughout the world.  

3) Following from the lest point, and perhaps the most important take-away from this article, is the signal that increased R&D expenditure in India sends.  For a company to increase its R&D budget for a particular office, it should first be comfortable broadly speaking with government protection of intellectual property created.  As we saw at the law firm we visited, even just in the past year, IP protection has increased by leaps and bounds.  What began at the behest of the increasingly IP reliant pharmaceutical industry is now spreading throughout the Indian economy, with the judiciary increasingly hawkish on IP matters.  Greater R&D budget allocation is a further symptom of this new maturity of the Indian economy.  It is clear that companies are taking the cue from the central government that their innovations will be protected and therefore pumping much needed dollars into the Indian economy.

Far from being a cause for concern, the WSJ and all Americans should see this R&D shift as further evidence of India's emergence into the global economy as well as the increased maturity of the government of India to foster economic prosperity at home.

Learning from the tumultuous history of microcredit in India

Arogya Parivar, the rural healthcare initiative created by Novartis, uses a unique approach to equip rural healthcare facilities with the machines they need to serve their cliente. AP partners with local microfinance institutions (MFIs) to create microcredit facilities used to finance the purchase of new equipment. This is a well worn idea in the world of development: provide banking services to un-banked population to help them work their way out of poverty (or ill health, in this case). While India has been fertile ground of MFIs, it also was the setting for an ugly evolution of the practice only a couple years ago.

Fortunately, Novartis has designed their scheme to minimize unnecessary and burdensome lending at the rural clinic level. They identify needs a the rural level and connect the MFIs with the equipment providers. Funds do not pass through the hands of doctors or rural clinicians and they are not responsible for the (often timely) process of applying for loans. This set up allows health professions to provide more care and removes the risk of clinics acquiring unnecessary equipment and overly burdensome debt.

- Casey

Holy Jet Lag!

I left Boston in the evening of December 26 and after a stop-over in London, arrived in Delhi in the early hours of December 28.  I managed to sleep a good deal on the plane and the fact that it took two calendar days to arrive probably helped to mitigate the effects of jet lag on the way to India -- not to mention the most activity required of me in the first few days was finding a suitable spot on the beach to take a nap..

Fast-forward to my return home.  Wow!  I've definitely felt that time difference over the past 2 days. 

The time change is incredible.  When I woke up for breakfast on Sunday morning (before my flight), the Patriots were JUST kicking off the first quarter of their game against the Broncos.  I managed to follow the game on my phone until part way through the 3rd, when my cab got me to take my to my 12:30 pm flight.  That night at 10 pm, I was back in Boston... although for me it was more like 8:30 Monday morning. 

I got a good sleep Sunday night and Monday felt fine, but around 8 or so, I decided to take a quick "power" nap.  The power nap ended at 1:20 am with me fully clothed with all the lights on in my apartment.  Just like that almost 4 and a half hours had passed.  Today was similar, fine all day, "quick nap" around 6 and then woke up at 9:40pm.  Missed dinner and drinks with friends again and now it's midnight and I am WIDE awake. 

I feel like a narcoleptic... hopefully everything'll be back on a normal schedule soon.

Trash in India

Hello from Kolkata! This city is unlike any of the three we have visited and I will certainly write a good description and post photos when I get a better internet connection (I am currently writing from an internet cafe, it feels like 1997 again). For now I'd just like to write a short post about something interesting I learned yesterday.

One of the many things we commented on during the field seminar was the abundance of trash piled up high along roads and in alleys. I was told yesterday that this is not for lack of respect for the environment and public space, but rather the result of an unbroken habit that had formed long before the introduction of plastic and other non-biodegradable materials.

A friend and I stopped at a street stand for tea yesterday, where we were served chai in tiny clay pots. After finishing the chai, we did as everyone else had and threw the clay cups onto the ground, smashing them into pieces. The idea is that the broken clay pieces will just be washed away, no need for a trash can. The same is true for small woven leaf plates upon which street vendors serve their dishes. The leaf plates are intended for single-use and can be easily disposed of (tossed on the ground, like the clay pots).

I was told that at one point, India was quite ahead of the rest of the world in terms of being earth-friendly and green, since most materials were natural and could easily break down. The infrastructure and waste management programs to properly deal with the trash were never developed in the way that they had in other countries. When plastic was introduced, therefore, consumers treated it in the same way as they always had, out of habit and out of lack of other options for disposal.

Hopefully the country will manage to either catch up with the trash problem or revert to its traditional ways of using biodegradable products in restaurants and on the street.

Farewell to India

After nearly 24 hours of travel (layover included) we finally exited the airport and ventured out into the bright cold sunlight of Boston. The heavy moisture of the Indian air laced with the smell of smoke and sulfur was replaced by the cold crisp breeze lightly scented with coffee from one of many airport Dunkin' Donuts (a scent voiced as a much missed luxury of the two Co Founders of Mitra Biotech with whom I had the pleasure of dining last Thursday).  As we flew through traffic, the proportion of vehicle speed to level of anxiety was in complete opposition to that experienced on the roads of Delhi, Mumbai and Bangalore. The absence of the many volumes and peculiar ditties of horns was particularly noticeable, even the occasional shout and fist shake by my sister (our driver) which in the past had seemed loud and volatile now was merely a slight noise in comparison to the din of the past two weeks. The awareness of these basic environmental changes illustrate the impact that India has had on my perception of the world around me, I have no doubt that as time goes by more and more of what I observed and experienced in India will effect the way I see and participate in both my studies and my community. The largest contrast for me was the apparent transparency and consumer based structure of the healthcare industry.  A lot of what my classes focused on in evaluating the health care system in America was the moral hazard inherent in use of insurance in health care.While most Americans have little to no idea of how much their health care costs nor do they care to learn, in India prices are put on walls of hospitals and clinics because the patients pay out of pocket and need to know how much procedures will cost before deciding to go through with them. While the American patient is more likely to have unnecessary procedures and tests run because it does not have a direct impact on them, the Indian patient must weigh the value and quality of the procedure against the cost.  As we learned in our many visits India is likely to move towards an insurance based healthcare system as the middle class emerges.  It will be interesting to see whether patients will choose to have procedures keeping in mind the value and necessity or if they will become less involved in the decision process as the costs are contained within the insurance system. 

Out of India

The culture shock of coming back into the states is somewhat unexpected. I knew things were different in India, and while I was there everything was an experience, but as I come back to Boston and walk into my apartment I am bombarded with reminders of how different things are in the U.S. I was really bummed when my cab from the airport cost $30 instead of $3 like a tuk-tuk through town. But I was pleased it was a hybrid car and the driver abided by traffic laws. And this morning when I went out for breakfast and groceries I didn't have to think about whether or not it was ok to eat the food or buy fresh vegetables. I'm not worried about the power going out like it did even in our 5-star hotel on a regular basis. We are so fortunate to have the infrastructure in place to make us feel secure about our everyday environment.

Things I'll miss about India are the energy, culture, and welcoming people. And the things I'm most excited about returning to are ice, fresh vegetables, and the comparative quiet of Boston. I've never appreciated home more than I do now, but I've also never had such an enlightening experience abroad. Visiting India was the time of my life...and it's good to be home.

Matters of life, death, and makeup

As I boarded my 3:25 am flight home from Bangalore, I picked up an English language Indian newspaper. On the front page, above the fold, was a story about a woman who had died Thursday night after being turned away from a hospital in Kolkata. The 40-year old woman had given birth to twins on the street earlier in the night, and after her husband was finally able to get a cab to drive them to the nearest government hospital, she was refused admittance. The government hospital recommended she try another hospital, which likewise refused her and sent her back to the first. The article said that the incident was “under investigation.”

Looking up from the paper, the lovely Lufthansa flight attendants in their pageant-style make up reminded me of something that Ajay Bakshi, CEO at Max Healthcare, had said to us last week. “We don’t just hire the prettiest girl to sit at the front desk like you might see at some place like Fortis or Apollo (two of the largest private hospital chains in India); we hire someone who can actually help you and get your questions answered.”

As if I hadn’t already been hit over the head enough times with this idea of the “two Indias” during the seminar, here it was again! But the contrast between the private hospital’s capacity to focus on something as superficial as the good looks of their desk attendants and the incompetence of the public hospital being so profound that it would deny care to a woman who is bleeding to death after childbirth, for me translates all the imagery and statistics we have been absorbing over the last couple of weeks into their true meaning. The inequity that pervades every aspect of society in the two Indias is a matter of life or death for the majority of the population; it makes the complaints of our 99% look like pretty small beans.

The fact that the incident was front page news at least is encouraging. I have found stories about it online in other major English-language, Indian papers as well. The Times of India reports that the first hospital has claimed that “the allegation is the handiwork of some news channels” and there is no record that the husband ever showed up at their door. The babies, underweight and suffering from exposure, have since been admitted to the same government hospital that first turned their mother away. I wonder if in their lifetime a story like this will become as inconceivable to them as it is to me.

The Incredible Indias

Although on the map you can only see one India, in fact two Indias exist, especially when we examine the health sector. There is an India that is emerging, prospering, competing and innovating. There is another India that is growing, struggling, supporting and creating.

The first is an India which is like the US, which has shiny new hospitals with world class care but high prices, an India where millionaires exist and build twenty four story houses. This India has a relatively small population but is generating massive amounts of growth and is the force behind propelling India into the global arena in pharma, health service delivery, IT and R&D. In this India you can not only find American brands and products but also many Indian-Americans who have either come or returned to India because of the offered prosperity and opportunity. When walking through Max Healthcare or Religare I could have been in the US with the advanced technology and customer service. The technology being developed at the John Welches GE centre is mind blowing - bringing twenty cent ECGs to the people of India.

There exits another India which is like Cameroon, a west African country in which I spent two years. In this India there is poverty, poor services, a lack of infrastructure, and corruption, but there is also a sense of community. The majority of India falls under this description, and with a growing "bottom of the pyramid" India is challenged to find innovative ways to bring wealth and health to this sector. Some of the similarities to Cameroon were: - the existence of a sense of community and shared responsibility. Family and community are highly valued and health issues seem to be death with as a family, and have family impacts in terms of costs, travel, loss of income, support and care givers. - unwavering determination to survive. Dharavi was an example it this, a thriving slum with a significant economy. When we visited we saw school children learning and parents working. The pottery business was well developed and the determination of the workers to survive was evident through their producing more than they can sell. People work extremely hard but so not seem embittered or discontent with them lives. - authoritarian organizations with strict hierarchy are common in India like I saw in Cameroon. On one hand they can be advantageous in spurring ideas like in the case of Narayana where Devi Shetty's inspiration and leaderships drives the innovation in that organization. On the other hand this can lead to organizations unable to survive once their founder has left, and organizations that stifle thinking outside the box or questioning the leader.

 Overall, India is very diverse and has a dichotomy of systems and cultures working together. It was very nice to see that a lot of the big pharma, hospitals and multinationals are trying to help improve access and reduce cost for the rural poor living below the poverty line. There is a lot if work to be done in terms of universal health and improving fthe quality of life but if any country can do it, incredible India is the one.

A tale of three cities

It's been a quick, and sometimes not so quick, 2 weeks in India.  We're finishing up our visits in our third city, Bangalore, which has turned out to be a great summary of the whole experience. Delhi showed the stark differenes between public and private health care throughtout the country, while Mumbai showed how industry leaders were attempting to make a difference in "the bottom of the pyramid." Bangalore has been the showcase for innovation in Indian health care, highlighting where their future might be heading.  From Vaatsalaya's infrastructure in smaller urban areas to Narayana reaching out to the rural villages to try and eliminate preventable blindness in premature infants.  Not to mention Narayana's medical campuses that minimize costs through high capacity utilization and innovative leasing contracts with their technology vendors.  We also had dinner with the co-founders of Mitra last night. Their research will hopefully lead to a new generation of highly sensitive diagnostic tests for cancer, matching the right drug to the right cancer.  This could potentially decrease the amount of trial and error involved in finding the best cancer therapy for each unique patient.  As we found out, there used to be great opportunity to simply make an existing product in a cheaper way, but with the new patent laws in place, more of India will be forced to innovate.  I wonder how long it will be before India will catch up in that regard?? 

And by the way, GE is doing some pretty amazing work too.

Incredible !ndia

It’s hard to believe that tomorrow is our last site visit for the 2012 India Field Seminar and it should prove to be a very insightful one. We will visit GE’s John Welch Center and it will be exciting to see disruptive innovation in action. It will be especially interesting after our visit today where we saw what Narayana Nethralaya’s ophthalmology group is doing with mobile phones to help diagnose ROP among premature infants in rural villages.

Overall, the last two weeks have brought a range of visits, from candid interactive sessions to redundant template PowerPoint presentations. My favorite sessions by far were those where the passion of the founders, presenters, and/or organization members radiated throughout the visit, such as yesterday’s visit to Vaatsalya and last Friday’s visit to the National Rural Health Mission sub-centre in Palwal. Vaatsalya’s visit was refreshing and all of the presenters gave us in-depth insight into the company’s goal, structure, challenges, and candidly answered questions regarding what the future could hold for the hospital chain. Alternatively, the visit to the NRHM’s Palwal sub-centre showed us the true state of health care for most of India’s population. We were able to meet with ASHAs, volunteer women within each village who reach out and keep tabs on the people in the village. These women are the key links between villages and the health system, providing not only health education but also basic prenatal care and delivery help for women. After meeting the ASHA’s and asking them questions, I was touched by the pride and knowledge that they demonstrated. It was an experience I will never forget.

Thoughts after two weeks in India

I am surprised to find that I have become accustomed to some of the sites of the country—a pile of burning trash on the sidewalk is commonplace, and near-accidents on the street are expected. Walking to and from dinner tonight, we all felt a sense of pride for successfully crossing the street without getting hit by a speeding tuk-tuk or a motorcycle. We nimbly navigated holes in the sidewalk and wires hanging over us. I never realized how orderly Boston really is until I spent two weeks in India. In many ways, India is exactly how I imagined it would be, and in other ways, it’s been a stunning learning experience.

I am sad to be leaving India, and I hope that I will have the chance to travel here in the future. One major takeaway, from this week especially, is the variety of socially responsible business opportunities in India. It was particularly interesting today to hear from Paul Thomas of Biocon, an American living and working in India. Clearly, an American business and healthcare background can be an asset working with Indian firms looking to expand into a global market. The needs of the Indian population seem daunting, but we’ve seen a variety of organizations, each tackling a particular segment of the issue of health care in India. While we’ve heard quite a bit about the larger issues—malnutrition, lack of sanitary conditions, among others, we heard today of the less common though equally devastating issue of ROP in premature babies. I felt that this discussion was particularly moving, and demonstrates that there are a number of unmet medical needs all over the world that will take ingenuity and dedication to address. The opportunities for making a difference in the health of the world are unlimited and I’m coming away from this trip reinvigorated to continue learning and working in the health care field. I think that the business landscape in India will change dramatically in my lifetime and I’m excited to follow those changes.

Two Different Worlds

As a dual-degree MBA/MPH student focusing on global health, I operate between two different worlds in the schools I attend, the locations where my classes are held, the people I interact with, the content of my studies, and the underlying principles behind each degree. My time at the business school is driven by profits, efficiency, and management whereas the underlying drivers at the school of public health are care, aid, and social benefit. I love bridging both these worlds and I think there are so many important things that each area of work can learn from each other. I can only imagine that greater progress could be made in global health if problems could be looked at from both a “business” and a “public health” perspective because there are pros and cons to each. However, it is sometimes very difficult to figure out how to get people coming from these different worlds to speak the same language.

This has been illustrated during our visits in India through interactions with many different organizations and even through experiencing what life is like for the more than billion people who live here. Everything is extreme, most significantly, the contrast between rich/poor, city/rural, and educated/uneducated. In our class visits, the differences between government run facilities and non-profit organizations and for-profit or corporate entities has also been striking (a difference not unique to India). On one particular day we visited a very well intentioned non-profit organization that cared deeply about their cause but was not able to provide us with details on their cost structure or finances. They had the desire to do good for those who need it but their disorganization may have prevented them from effectively accomplishing their goals. Following that visit, we went to a very successful multi-national corporation that has the resources to make a huge positive impact but it was clear that that was not their priority. On the other hand, some of our visits have given me hope that the worlds of global public health and business can speak the same language. We learned about a venture that Novartis has implemented which benefits the bottom of the pyramid but also makes a profit. Tomorrow, we will visit GE India and learn about low-cost medical devices that are a key part of providing health care at a low cost. It is exciting to me to learn about these success stories because I believe that they will pave the way for the future of global health not just in India, but it countries all over the world.

The Grocery Store

In every country I visit there is one stop that I am sure to make. A local grocery store. Food (much like children) is a connecting point for people from different cultures and a grocery store is a center place for food. In fact, I would argue that it is a better way to see what food is commonplace than a restaurant is. Therefore, while in Mumbai I visited what I deemed to be a mid sized grocery.

Since you are waiting in such suspense I will share the highlights. The is the allocation of store space is quite telling. Of the food selection roughly 1/3 of the shelf space was dedicated to each of the following: Dry bulk grains (lentils, rice, flours), fresh vegetables and packaged snack foods. From this I deduced the a few points. Meat is really not a daily priority even amongst non-vegetarians. Large scale refrigeration is not widespread as there was very small section for milk products and essentially no freezer section. Food preparation is still done primarily in the home. With very few pre-baked bread products I assumed that daily carbohydrates are prepared at home.

Implications? Not many but is a cultural experience that implies food preparation is timely process that more than likely keeps a large female population out of the labor force. Also, given the sharp rise in diabetes in India I was surprised to see relatively few sweets.

Cow Patties & Big Pharma

We’ve been reminded frequently during this seminar that the vast majority of India’s 1.2 billion people live in rural areas where access to healthcare is spotty at best. The reasons for the lack of quality healthcare outside urban areas are many, including lack of infrastructure, a largely impoverished population without means to pay for care; the very low level of public health care spending in India; and the lack of qualified healthcare providers particularly outside of the larger cities. Each of these factors influences the other; for example, we learned at the Public Health Foundation of India that there is a 70% absentee rate of doctors in public rural health facilities. A physician is hired for a job, but he fails to show up at the public facility 70% of the time because he can make more money seeing patients privately than the public system pays him. These factors create something like a perfect storm of inadequate healthcare, and what’s left behind is a country with one of the world’s 10 largest economies, producing health outcomes in its poorest states that are on par with Sub-Saharan Africa and struggling nations like Bangladesh.

As an MBA student, what I’m about to write may be considered sacrilege, but I work for a charitable, nonprofit healthcare organization, and I cannot help that I am fully indoctrinated in that model! I am fascinated that organizations like Novartis and Sanofi Aventis look at India’s public health failure in the rural areas and see a business opportunity. It brings to mind the artfully-stacked piles of cow dung patties we saw in the semi-urban villages outside of Delhi. These pharma companies are following the steps of that first guy who so long ago must have picked up a pile of poop, and said to himself, “this smells awful, but I bet we can use it for fuel.”

While personally my left-leaning perspective leads me to doubt that private enterprise can ever be trusted on its own to do right by individuals and communities as a whole, I have to acknowledge that business moves fast while government… well, lately it seems like the world-over, government just doesn’t move. Novartis in particular is working in rural communities towards improving health through its Arogya Parivar Rural Program. Of course their true intent is to sell these people drugs, and our guest speaker Anirban Roy who heads the program was forthcoming about that, but if Novartis sells medication that the community needs, at prices they can afford, while also improving the public’s awareness of other important health concerns, is there a problem? Well, at least for now, Big Pharma’s activities may be one of the most effective, if not the only, public health projects that the rural communities have going. I just hope someone is keeping an eye on them!

Public – Private partnership is a catch phrase we’ve been hearing a lot over the last week and a half, largely in relation to how private hospitals will provide care to those who cannot afford to pay. If we can compare health care in India to crossing the street in India, I feel like what we are seeing is the Private sector taking the Public sector by the hand and leading them into traffic. The only way to get anywhere here is to step in front of on-coming vehicles, and it seems like the Public sector isn’t ready to lead the way across the street quite yet.

Elephanta Caves

Lessons from the Elephanta Caves: Namaste!, Perspectives, and Creating with Awareness.

So far, on the Indian Field Seminar, we have visited several healthcare sites ranging from premium hospitals like Max Healthcare to community health centers in rural villages and urban slums. We visited large pharma companies like Glaxosmithkline, research institutions, and even the Public Health Foundation of India, to mention a few. All generously welcomed our class and showed us extremely impressive hospitality.

All had different perspectives to offer. But, what did they all have in common? And, what did any of this have to do with our trip to the Elephanta Caves?

Well, I firmly believe that in order to truly understand a foreign market like the Indian healthcare system, one must also have an understanding of the surrounding culture and philosophy in numerous contexts. This would be difficult to achieve by simply visiting sites without an understanding of the reasoning or explanation of the surrounding culture. Cultural exposure is so important to truly understand different populations.

As tourists at the Elephanta Caves, it would have been very easy for us to pass through the caves, taking pictures, simply appreciating the awe inspiring and symbolic edifices that had been carved out of the side of the mountain, all without knowing the cultural significance behind them. Luckily, we had a great tour guide who insisted that we listen rather than take pictures. This would not be a normal tour.

As we moved from edifice to edifice around the cave, the lifeless edifices came to life. They were no longer statues carved into the mountain. They had meaning and a significance that a camera or video could never capture.

But the "aha" moment didn't occur until the guide pointed out the importance of perspective, especially as one walked from edifice to edifice. It was only from specific places in the cave that one could peer through openings in the caves to view another statue. Capturing this perspective would require special attention to detail, otherwise it would be grossly overlooked. These unique perspectives also carried a deep cultural and sometimes philosophical meaning. It was clear that those who carved the edifices "created with awareness".

Toward the tour's end, our tour guide, who had attracted other tourists, spoke about the meaning of "Namaste!" A traditional Indian greeting, which when translated to Hindi means "not me, you", as our tour guide explained.

According to Wikipedia, Namaste also means "I salute or recognize your presence or existence in society and the universe."

As we conversed with CEO's and other community health leaders, a passion and desire for healthcare innovation was conveyed and it became evident that they brought this "Namaste" philosophy to the Indian healthcare system as they worked feverishly to reach populations near and far, even those in rural areas, where only 60% currently have access to medicine. Their goal? To provide low cost, accessible healthcare.

It seems that of those who held this philosophy, the most successful leaders created innovation with high awareness.

For example, on our visit to the Council of Scientific and Industrial Research, one of the scientists showed us a genomic map of India that highlighted areas of differing genomic polymorphisms within the population. These differences, according to the scientist was significant enough to cause differences in a drug's efficacy and ultimately the body's response to medicinal drugs-completely fascinating.

However, as the scientist passed around his "genomic card," which looked like a debit card, complete with validation dates, I wondered about the practical application of such a rich source of information, only to learn minutes later that while he had this genomic card, there was no current market to utilize this information, and he had no current plans to collaborate with other institutions How would others become aware of this information? How would it be used successfully? What was the plan? What was the larger perspective?

In contrast, look at Arogya Parivar, Novartis' rural health program (the first of its kinda by a large pharma company) ,which employs a "social business model," that other companies are attempting to duplicate as we speak. It was created with an awareness of sustainability. Self-sustainable, this program broke- even within 30 months of its inception. As a result, the program is successfully able to offer care in the long term, providing a platform to address rampant diseases in rural areas.

This shows the importance of creating with awareness, especially during innovation!

Namaste!!

Whatever Floats Your Goat

Did you know that in Mumbai, at temperatures over 80 degrees, goats are so cold they need to wear sweaters? On my first day in Delhi I was amazed at how many dogs were wearing coats. Although you might think that these are simply stray dogs wandering through the market looking for food, it was very apparent that these are pets who are loved. As we walked through some of the Dharavi housing yesterday we saw a number of goats wearing covers ranging from a burlap sack to a brand-new orange sweatshirt. When asked, the people explained that it is very cold out, and they didn't want the goat to get cold. And frankly, after living through a Mumbai summer, the goat may very well be acclimated to the heat. Here is yet another example of how my preconceived notions are being challenged as I experience India in so many ways.

I was amazed by the extensive work that Vaatsalya is doing to ensure excellence in patient care and operations. I was not prepared today to hear a presentation on getting hospital certification after my experience with the rural health facilities we saw in Palwal. Although they were clearly providing services for the public good, the difference in approach was completely dissimilar. I hope that organizations such as Vaatsalya can continue to find ways to improve patient care and their bottom line in the rural, lower income market.

The Unspoken Truth

It has been reported that there are large amounts of corruption in the Indian healthcare system. We have not spoken much about the corruption as we don't want to offend someone or question part of the culture of business in India. Today, however, I met two people who spoke honestly about corruption in the system.

First we had a site visit with the corporate office of Vaatsalya. They are a private company building a network of hospitals for semi-urban areas at affordable prices. The company, which was started in 2005, is not profitable. They also are adamant about not receiving bribes. The executives today told us that they would be profitable if they accepted the bribes which are standard in many similar healthcare organizations.

This evening I had dinner with an executive in Bangalore. In the informal and congenial setting, we were able to ask about the prevalence of corruption. He explained that in his twenties, he was adamant about not giving or receiving bribes. While he is still adamant about curbing the corruption, he also admits that in order to get business done in India, there are some bribes that must be made.

The younger generation apparently is less likely to be part of the corruption. As this population ages, perhaps the corruption will subside. Until then, it is part of getting things done in India.

Mumbai

After being sick in Delhi for 3 days, I finally feel better in Mumbai. The sunshine might have something to do with it - it's beautiful here. We arrived on Saturday, which was our shopping day. I got to barter with the street vendors for some gifts. It was fun, but I feel a little guilty since they could probably use the few hundred rupies more than I could. This morning we visited the Elephanta Caves off the coast of Mumbai. We took a rickety, wooden boat to the island, but the ride was actually relaxing. I didn't expect the island to be as touristy as it was though. It was very crowded and on either side of the long path we had to walk up to the caves were vendors trying to sell crafts or t-shirts. The caves themselves were incredible. Our guide showed us the main cave, the Shiva cave, with carvings all depicting the legend of the god Shiva. The rest of the day we spent wandering around Mumbai, trying and failing to find a temple. Before I left for India, people kept telling me that the amount of poverty is shocking. It definitely is. Children constantly followed us with their hands reaching out for money. People live on busy streets here - their kitchens and bathrooms are sidewalks. The area we're staying in is one of the nicest in Mumbai, and in this same area we saw people giving their baby a bath and cooking on makeshift stoves right next to traffic. It can be really difficult to watch at times. At the same time, they make their living on these streets selling crafts, clothes, and food. I heard that the government could force the homeless off the streets, but fortunately remains relaxed about it. I have to wonder where all of these people would go, and how worse off they would be if the city cracked down on them.

Is For-Profit that bad??

Man…. India can really take a person down. Unfortunately, I was not able to join the group today because I got a stomach bug. We were pre-warned about getting sick, but I didn’t realize it would affect so many people. With that being said, seeing India is worth the illness, and you just have to be careful when you visit.

So, yesterday we spoke with three big pharma companies, Novartis, Sanofi, and Cipla. The first two discussed their rural program initiatives, while the third spoke about their international development.

Novartis’ Arogya Parivar rural program involves a 360 approach to getting medicine into rural India. It is a for-profit model that entails investing in all aspects of the rural health care from education to infrastructure. Furthermore, they package the medicine in small dosages to make it more affordable to their target customers.

Novartis said they went for the for-profit model instead of a CSR direction because it made the program more sustainable. If the program was a CSR then it could be subject to disbandment during economic downturns. Therefore, the for-profit model insures sustainability and sustainability insures reaching more rural areas.

In summation, Novartis has been able to achieve what so many NGO’s have failed at, so should we rethink our approach…..