Efficiency: For Profit, For the People

As a sharp contrast to visiting AIIMS (All India Institute of Medical Sciences) in New Delhi our group spent the following day at Max Healthcare. Max Healthcare is a for profit system of high end hospitals. Walking through the main door it is almost necessary to turn around, look back outside and remind oneself that yes it is still India. There are dropped ceilings to cover wiring, occupancy can be measured by people per room instead of by people per square centimeter and it is easy to identify staff from patient. Oh and this strange intangible quality, what is it… Ah that’s it. Organization.

Beyond all the glitz and glamor (wait, I believe I just described a hospital the way someone from the jersey shore would describe a club) is a well-run system. The physical location of the hospital, the technology employed, a coordinated staff, intelligent use of consumable resources, doctor performance and especially the processes implemented all contribute toward the efficiency of this hospital chain. CEO Dr. Ajay Bakshi stressed the importance of this efficient system from a profitability standpoint (which he absolutely should) but the success that Max has implemented has effects that reach further than the bottom line.

First a quick look at realities. Capital expenditure is huge, especially for a new hospital. For a hospital to be profitable, or even economically sustainable, bed occupancy rates must be very high. Dr. Bakshi likened the model to the airline industry where every empty seat is lost revenue. At 85% occupancy the hospital is unprofitable and at 92-95% occupancy the hospital can be incredibly profitable. (Forgive the fuzzy statistics) Because of this some of hospital management’s greatest goals are to increase efficiency of the assets available by improving the points I mentioned before. Succeed in this and the hospital will succeed as an economic entity.

Theory time: Let us assume that at any given time there is a finite amount of resources (doctors, nurses, syringes, medical equipment, drugs…) available for the a product that I will generically call health care. With these resources X amount of product is available for consumption by the general population. This X amount of product can be divided up by either capitalist or socialist ideals but it is still a finite amount. However, through increased efficiency the system may be able to produce 1.2X or some such multiple and under any distribution system there is a greater good for society. In an open market scenario prices become cheaper and people at the bottom of the pyramid are able to afford more care and under social entitlement system more care is available for distribution to everyone. Purely Fantastic

Next question: Is a private model the best environment for fostering and providing incentives for efficiency?

As a side note: I have been in downward facing dog the entire time I have been writing this post.

The Difference Between Right and Left

So far this trip to India has been filled with opportunities to compare and contrast. For me, one of the most poignant contrasts to American culture is that everyone in India seems to be a philosopher. Your yuk-tuk driver, the president of the largest medical facility, a store-front owner, or a tour guide will all tell you incredible stories (some easier to follow than others) but they are deeply rooted in Indian culture and belief systems.

My favorite so far is what we learned during our trip to the Elephanta Caves. Our guide was amazing, and he told us the incredible philosophy behind "namaste" - or at least his version. And what he told us is that everything must reside in balance with its counterpart. He believes that when it comes to our intellectual priorities things have become unbalanced and there's "nothing left in the right [brain], and nothing right in the left." This was poignant for our group because throughout our business visits we have heard repeatedly about how Indians are great at science and math - the logical skills of the left brain - but often lack management capabilities and the softer skills of the right brain.

Maybe this is one thing we are slowly getting better about. When I think of my BU SMG classmates I see a variety of skills that harness both the hard and soft skills necessary for effective management. But regardless, finding that balance is something important to think about. I'm so glad I got to hear it from a great Indian philosopher.

Monkey Management

I have had several very exciting trips through various market stalls looking for just the right souvenir. I was surprised to find that it is nearly impossible to find a small wood carving of just one monkey. I kept thinking "but monkeys are so neat, and I've seen so many in person. Why wouldn't there be monkey souvenirs?" As I asked this question, the answer I got was "you have a lot of pigeons in the U.S. Do you buy souvenirs of pigeons?" I realized that I had been thinking with my own cultural perspective - that monkeys are exotic and amusing, whereas people living directly with monkeys may not see why a visitor would be interested.

I found myself falling into the same trap when talking with various healthcare providers. Although I have worked closely with many physicians from India, I do not believe that I have worked directly with any nurses or other ancillary medical staff trained in India. I walked through AIIMS and thought about how different the care model was to my own experience. I was expecting to find that nurses at Indian facilities were performing an exotic job that bore little resemblance to my own work. What I found from talking to the nurse at the mobile bus clinic and several other staff at AIIMS was that the nurses are trained to standards that allow them to practice in many countries around the world. Their education is of high enough quality that they can practice in many different settings. As well, the community health nurse described her job role in virtually the same way I would expect a community health nurse in the U.S. to. The major difference is in the community demographics. Ultimately, there are differences between nurses in the U.S. and India, but the amount of common ground was surprising and inspiring.

I came to India expecting to see major differences in the roles of nurses between the two countries. What I found was a striking amount of common ground. Just like with the monkeys, I was looking at the experience as exotic, when really there is a lot of normality to the situation.

An American in Indian Court

When told that our meeting with Pravin Anand was pushed back because he was stuck in court, the law student that I am wondered aloud, quite loud, "Can we go to court?" Moments later the request was granted, and we were on our way to Delhi High Court. I must first thank my classmates for their patience and willingness to accompany me on one of the highlights of my trip. As with most of our adventures in Delhi before arriving at our destination there was a lot of waiting and looking for potential bathrooms on the part of the students and a lot of seeking out proper contacts, making arrangements, and herding us like cattle from one check point to another for our amazingly patient and amiable guide. Several checkpoints and one slightly uncomfortable pat down later we were granted access to the courthouse.  The door to the chambers opened and the similarities between the American and Indian systems were immediately apparent. Unlike an orderly American court, groups of lawyers in proper dress of what looked to be black robes with white, Mark Twain like collars flanked both sides of the small room saving space solely for the massive duffel bags stuffed with physical copies of documents and books of rules and law. Having been briefed on the particularities of the IP case I was able to follow along with part of the arguments, unfortunately my American ear was unable to decipher most of the dialogue as it was masked by the Delhi accents of the solicitors (appointed by the court to argue the case for the advocates) as well as the commentary from the advocates correcting and supplementing the statements.  Keeping with the Delhi I have come to know, the procedure for each team to state their argument was in place, however it was just as likely for that argument to be interrupted than for the statement to be finished. In a surprising lack of deference solicitors would also speak over and argue against the judges despite ending all sentences with the customary "M'Lord" (the Indian version of "Your Honor"). My experience in Indian Court is analogous to my experience in India in general; I wish I learned more about the procedure and substance of Indian Law to fully understand and adequately question the situation before me, unfortunately the breadth of the Indian Constitution alone is beyond the scope of which I can accomplish while in its country of origin and so I will continue to simply enjoy the opportunity before me as it is extraordinary. 

Hello Delhi Belly

So this is my first blog post, and I am still unsure of what to say. I walked into this trip with a little trepidation, due to the feedback or lack of feedback from my friends that had already visited India. Whenever I would ask someone about their trip they would not have much to say, which I took as negative. Now I realize that their silence is because it is hard to find words to describe India and you have to experience the place to understand even the surface of this country. With a population of 1.3 billion (1/6^th of the world’s population), India provides it visitors with a sensory overload….. everything is magnified.

India is also a place of contradiction. The landscape has vibrant colors and beautiful monuments, but they are covered in trash. Also, they have hospital facilities that look similar to ones in the states, and they have hospitals that look completely run down. We got a tour of both these types of facilities. The first is Max Healthcare and the second is A.I.I.M.S.

A.I.I.M.S., the premier medical college and teaching hospital in India, is a government facility with 1766 beds. The place is absolutely enormous, and looks like a medical factory just processing one person after another. Although it seems run down, looks can be deceiving because AIIMS offers some of the best care in India. On the other spectrum is Max Healthcare, a private hospital. Walking into this place you would think you are at Beth Israel if it wasn’t for the Devanagari script written on the walls.

As the government spends more money on healthcare, the question is where should this money go?

Expectations and Perceptions

It is always interesting to travel to a place that you have preconceptions about and figure out what you truly think about it after you experience it. I often thought of this before coming to India. My initial reactions are that this country is difficult to describe. Perhaps this is also how Indians feel about describing Americans and the United States in general. In our visits to various healthcare and public health facilities, and in our visit to a village outside Delhi, it has been fascinating to hear how different Indian’s perceive Americans.

At several visits, we heard the perception that Americans have mismanaged our healthcare system. Indian doctors and administrators were (rightfully) shocked to hear how much we spend on healthcare in contrast to our health outcomes. At another visit, it was interesting to hear a perception that Indians are good at all things related to math and science but that Americans are talented at management and problem-solving. In contrast, when we visited a rural village and clinics, it was as if we were royalty and some students reflected on the fact that perhaps this was the most anticipated event in this village in a long time. It seemed as though all their facilities had been cleaned for our visit, we were followed throughout the village by children, and we were even interviewed and videotaped to be on the evening news.

I am not sure what to attribute these various attitudes to but I would guess that it is a combination of perception based on history, current events in the media, and popular culture/movies depending on the audience. In talking with Professor Mark Allan who was here during the financial collapse in US markets during the fall of 2008, I learned that Indians used to consider the United States as a country that could do no wrong. Based on our visit thus-far, it seems as though this perception has changed. Maybe this isn’t only due to the financial crisis in the US but also India’s rise as a world player in many different arenas. Perhaps this is a good thing for a country learning to gain confidence as it grows, especially in the fields of healthcare, technology, and business. I will be eager to see where Indian’s perceptions of Americans go in the future.

Rural India healthcare

Yesterday, our group visited sites belonging to the public health program of India. We visited three separate sites, each visit becoming closer to the local village. While the trip was quite instructive in Indian culture and values as a whole, it also demonstrated the shortcomings and victories of the public health sector in India. While several beds were empty and we were not always given a straight answer to questions about the availability of doctors or how widespread the usage of public health services are in India, the trip made clear India is focusing on important healthcare concerns, such as maternal care and contraception, and even doing more innovative things than the US, such as through India's use of Ashas. These women live in and belong to a village where they also work, know the health issues of their fellow village people, and treat and refer those people. This model seemed to me to be one of their greatest assets in engaging the Indian people in public health services. the visits were eye-opening in this manner but also exciting and interesting to interact one on one with the Indian people living in one village.