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Institutionalising excellence…

All countries struggle to deliver affordable, high-quality healthcare to their citizens. A resource-constrained nation like India requires drastic re-engineering of the healthcare delivery model. This calls for multiple complementary interventions, starting from community-level disease prevention to complex multidisciplinary management of diseases like cancer and heart ailments.

Three realities amplify the healthcare challenges of India – large population, low per capita GDP and constrained investments. An acute shortage of doctors outside major metropolitan areas further compounds the problem. The challenge is becoming more critical with the rapid increase in chronic non-communicable diseases. Successive governments have attempted to bridge the gap between demand and supply. Still, there are Band-Aid fixes that tinker at the edges, e.g., opening more super-specialty hospitals, neither affordable nor appropriate to fill the demand-supply gap in healthcare.

An explosion in unmet need in a tertiary care

Discussion about healthcare in developing countries usually centres on sanitation, nutrition, vaccines, maternal health, childcare, and infectious diseases. A robust backbone of primary healthcare clinics to attend to these issues is the most cost-effective means to improve the health status of the population. However, we should not be blind to an emerging challenge: the burgeoning growth of morbidity due to non-communicable diseases like diabetes, heart disease, and obesity.

The famous cardiac surgeon, Dr Devi Shetty of Narayana Healthcare, estimates India requiring 2.5 million heart surgeries each year. But only about 100,000 are actually performed – mostly on wealthy patients who could afford the cost of treatment at expensive private hospitals. The rest wait endlessly for their turn at overstretched government hospitals and most die before they can get the care they need. Schemes like Ayushman Bharat are not sufficient to address the vast gap between available resources and demand.

This calls for multiple complementary interventions, starting from community-level disease-prevention to complex multidisciplinary management of diseases like cancer and heart disease. This article addresses the issue of the gap between supply and demand for hospital-based healthcare.
General Hospital model of tertiary healthcare

The classic tertiary (hospital-based) healthcare facility is a ‘General Hospital.’ It handles everything from the most complex multimodal treatments to more straightforward procedures performed in specialties like dentistry, ophthalmology, ENT… The GH model is the preferred model adopted by government hospitals as well as corporate hospitals.

General hospitals treat all-comers. The majority of cases seen in a GH require only the services of a single specialty using procedures amenable to standardisation. A multipurpose public hospital in trying to optimise resources across multiple specialities ends up being optimum for none. It is for this reason that we have standalone eye hospitals, (Aravind Eye Care is a prime example), performing cataract surgeries and obstetrics hospitals performing caesareans.

Several hospitals like Sankara Nethralaya in Chennai, LV Prasad Eye Institute in Hyderabad, Narayana Healthcare in Bengaluru for cardiac care were set up to deliver quality healthcare to the poor.

GH model increases costs, impairs quality

The GH model – by bringing under one roof treatment of both complex and straightforward cases conflates fundamentally different business models whose metrics of output, value, and payment are incompatible with one another. The GH model needlessly increases cost and impairs quality.

General hospitals are also highly capital-intensive. Given the need to cater to multiple specialties, these hospitals become bloated bureaucratic behemoths. They are doctor-centric and not patient-centric in their business processes. Furthermore, the high fixed cost inflates the cost of treatment. Co-locating different specialties that have different needs makes it impossible to allocate accurately costs of staffing and space. The complex organisation of the general hospital, with the inability to link input costs to the output value, leads to irrational billing and ballooning hospital bills.

Focused healthcare factories (FHFs)

The optimisation problem general hospitals face is similar to the optimisation problem faced by the sizeable unspecialised manufacturing organisations set up in the US in the 1960s and 1970s. Focused factories that specialise in a limited set of products were mooted as a response. Harvard Professor Regina Herzlinger in the 1990s put forward the idea of focused factories as a solution for the problems plaguing healthcare in the United States.

Focused healthcare factories focus on a limited set of specialties and clinical processes. There are examples of a centered healthcare hospital that came up as a response to the poor outcomes achieved at non-specialised general hospitals. In eight years, such a one-stop-shop halved hospital admissions and cut emergency admissions by 80 per cent. There were substantial savings in costs and lower consultation rates. Sankara Nethralaya offers a shining instance.

Focused healthcare hospitals work well since they permit standardisation of care using an algorithmic approach to clinical processes. Embedding repeatable and controllable processes along the whole sequence of patient care from admission to discharge, allows such facilities to deliver predictable, (high quality), outcomes at a predictable cost. Standardisation enables tasks to be shifted down the clinical hierarchy to junior doctors and even nurses, thus lowering costs without compromising quality. FHFs also derive the benefits of economies of scale and steeper learning curves for staff due to the high volumes. Furthermore, such FHFs become fertile areas for continuous improvement and innovation.

The concept of the FHF has to be scaled up nationally. The for-profit corporate sector may not be best suited to provide both affordable and high-quality care. The government may have to seed the creation of FHFs by building innovative partnerships with healthcare NGOs and physician cooperatives. Since this will take time, the government could also carve out embedded autonomous FHFs within large government hospitals. Such units must be independently resourced in terms of staffing and equipment and given sufficient autonomy to stand alone by themselves. Such standalone FHFs can become nodes in a nationally interconnected grid of FHFs. Such a grid will enable smaller, more remotely located FHFs to access the knowledge footprint of the virtual network. Standardised care protocols can be distributed from a central node and purchasing cost efficiencies can be maximised by aggregating the requirements and negotiating with vendors.


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