Tracking the Challenges of Global Health in India and Nepal

Students from GlobalHealth Lab, one of the healthcare course offerings at the MIT Sloan School of Mangement, travel each spring to tackle the challenges of the health sector in Sub-Saharan Africa and South Asia.  Students work intensively on campus and then spend 2 weeks on site at a health organization.  The following are my observations, as I travel to work with the student teams at the host organizations. 

Many of my observations are about the setting in which these health organizations struggle to survive and serve their ever growing patient populations.  These health organizations not only face the typical challenges of all organizations, but suffer from further struggles found in low-resource settings.


March 21, 2013

First day in Hyderabad, India

I traveled to meet with our MIT students and 2 faculty at the Indian Business School.  There we met with Professor Sarang Deo and Aditya Jain.  They have spent time analyzing data and making some observations at the L. V. Prasad Eye Institute.

The work they have done, yet to be published, is very helpful to the students and the observations, surveys, and interviews they will complete over the next two weeks.  Professor Deo has previously published papers including “Improving Access to Community-based Chronic Care through Improvd Capacity Allocation,” which suggests a 15% improvement in healthcare outcomes with improved capacity allocation.  He also published results of a time and motion study titled, “Modeling the Impact of Integrating HIV and Outpatient Health Services on Patient Waiting Times in an Urban Health Clinic in Zambia.”

The 3-wheeled rickshaw and scooter pictured here provide a good indication of the typical mode of transport in Hyderabad.  I have not been to India in many years and had forgotten that traffic rules tend to be a suggestion.  There are many blowing horns, cars, rickshaws, buses, trucks, scooters, and people weaving in and out of the roadways.  This all happens with no apparent road rage, and infrequent accidents!  The people I have met are warm and welcoming, a great reminder of my previous trips to India and the joy of life found here.  The other picture is another street seen.  For those of you who have spent time in the US, especially in Massachusetts, you know how concerned we are about auto safety – seatbelts, helmuts on motorcycle riders, car seats for children, etc.  The scooter/motorcycle pictured here carries 2 adults and 2 children at a fairly rapid speed.  A child in front of the father and a child between the parents, with the mother taking up the rear position seated sideways.

I am not sure what system works better.  All I know is that when I was growing up there were no seatbelts or helmuts.  Some how we survived!


March 22, 2013

Visit to LifeSpring Hospital, Hyderabad

Anat Kumar, the former CEO and founder of LifeSpring had a vision of offering maternal healthcare to poor women close to their homes.   He  has built 12 hospitals since 2008 in Hyderabad.  He recently left, and the hospital is now run by Vijay Srinivas and Sushmit Mitra.  Shushmit recently joined as COO.  LifeSpring is doing what it can to support the poor women in the area. 

Women are assigned to “rooms” with 2 beds, one for them and the new baby, the other for their “attendant,”  usually a female family member.  The “rooms” remind me of ED/ER areas in US hospitals - a narrow section of one large room separated by curtains.  The conditions are challenging.  Men are left to wait in the waiting room where signs describing their quality policy and fees are clearly displayed. 

The prices are minimal for this population of women, but still more than many can afford.  A basic OB/GYN consultation is 100 INR (about 2 $US).  The surrounding neighborhood is very poor, and obviously in need of such services.   Building this many hospitals in such a short time is quite a significant accomplishment!

The conditions found here are very challenging.  LifeSpring is trying to maintain itself as a profit-making organization, and struggles to do so.  It will be interesting to see how they fare now that Anat Kumar is no longer part of the hospital.  Vijay Srinivas has been there many years, as have some of the doctors.  Perhaps they will be able to continue the growth and development of more LifeSpring Hospitals.


March 23, 2013

Visit to L V Prasad Eye Institute, Hyderabad

I was very fortunate to spend the day with our LVPEI team and Sashi Mohan, Associate Director of Operations, and a delightful meeting with Dr. G. C. Sekhar, Vice Chair of LVPEI and Director of the Center of Excellence.  The work they are doing for eye care is known throughout the world. 

Sashi is a high-energy enthusiastic leader for L V Prasad.  He was educated in the US with a BS in Engineering from U. of Michigan and holds a law degree from Columbia.  He views his work at LVPEI as an apprenticeship on the way to achieving his much higher goals.  He and his wife, a pediatrician, plan to open a hospital for children in Hyderabad. 

Sashi proudly shared the hospital, describing in detail each operating area, medical procedure, lab, waiting room, patient ward, and private suite.  LVPEI not only serves those who can afford standard rates, but those who have nothing.  An area outside the hospital has been set aside for those who arrive too late in the day to be seen.  There they spend the night and eat their meals under a large tent-like structure to protect them from the elements. 

Dr. G. C. is highly focused and a great System Dynamics enthusiast.  He had read about SD in a paper, “The effects of structures ondecision-making policies in health Care” by Anja Tuulonen from the Department of Ophthalmology, University of Oulu, Oulu, Finland.  (in Acta Ophtalmologica Scandinavica 2005).  This has increased in interest in SD even further, and hopes that it will become instrumental in improving LVPEI’s new way of thinking about their services. 

Dr. G. C. would like to provide the best quality care for free for all of the patients who cannot pay.  This comment led to a great discussion about how to constrain demand – price vs. quality.  He seemed surprised by the notion that any constraint might be necessary.  He had hoped to offer an “infinite” amount of care as needed.  I also suggested he read Jay Forrester’s “Counterintuitive Behavior of Social Systems.”  LVPEI is a role model for many hospitals and appears prominently on other academic websites.


March 25, 2013

Visit to G S Memorial Plastic Surgery Hospital and Trauma Center, Varanasi

One cannot visit G. S. Memorial without recognizing the amazing accomplishments of its founder Dr. Subodh Singh. His kindness, generosity, and concern for his patients is unsurpassed.  He is widely known for his cleft lip and palate surgeries, to which he has recently added surgeries for burn patients.  Dr. Subodh (as he is known to his patients) has a dream to serve more patients who need care in the area surrounding Varanasi.  He has been grateful for the support from SmileTrain which covers the cost of most of the surgeries that he performs for cleft lip and palate. 

Dr. Subodh’s original medical training was specializing in burns.  His hope is to build a new hospital (limited expansion capability in the current location except to add a floor on top of the current 5 stories) on 3 acres of land he has acquired.  There he could continue the much needed cleft work as well as incorporate his burn specialty. 

Last week he had a chance to meet with Brian Mullaney, the former CEO of SmileTrain and now the CEO of WonderWork.  Brian is interested in focusing on burn patients, and had traveled to India to meet with hospitals that could use support from WonderWork.  Politics may create some challenges for Dr. Subodh getting the needed support, but perhaps there is a solution.

Dr. Subodh took me for a sunrise boat trip on the Ganges, where we had an opportunity to explore many areas of interest from medicine to religion to photography.  Upon our arrival, we met one of his former patients.  The scars from burns across her chest were visible.  She smiled and gently took my hand to greet me, speaking in extremely good English.  Dr. Subodh later explained that she had been a beggar on the steps of Ganges.  A “foreign” woman had brought her to see Dr. Subodh for help.  She had been burned by her husband and abandoned by her family.  Her chin was burned and became attached to her chest, so she was unable to look up.  Her arms were similarly connected to her sides.  Her first surgery allowed her to look up.  She returned to the streets to learn to exist.  Later she returned to Dr. Subodh to have her arms repaired.  He told her he would help, if she stopped begging.  She promised that she would.  Now she works on the Ganges steps, not begging, but selling souveniers to tourists, where she has learned English.  She also helps care for the woman who helped her get treatment.

Later that day, while meeting with Dr. Subodh in his office, there were constant interruptions.  His time is in great demand from all of the staff.  He takes these interruptions very calmly and carries on.  One interruption came from a family with an infant who had just had cleft surgery.  The father, mother, uncle, and grandfather all came in to talk with Dr. Subodh about next steps for their daughter.  Most of the conversation was in Hindi, but the bit of English that was spoken was about their gratitude for the surgery, and plans for further work as needed.  After they left, Dr. Subodh told me that they had come all the way from Dubai for the surgery.  Although, orginally from India, they live in Dubai.  The grandparents, who live in India, but hundreds of miles from Varanasi, had heard about Dr. Subodh and contacted them after the birth of their granddaughter.  Dr. Subodh was in contact with the family in Dubai and arranged for them to have the girl's surgery at his hospital once she was old enough.

The hospital houses patients in large rooms with beds in close proximity.  Our wonderful MIT Sloan students were given a private hospital room as their base camp.  Children from the ward across the hall were frequent visitors.  John Gillis holds Manu, a favorite at the hospital who had burn surgery.  Maya , another favorite was delighted to meet a new visitor.  She too has had burn surgery.

Dr. Subodh kindly invited the press to interview us.  The Times of India printed an article describing (somewhat accurately) the information we had provided.  The article is found here: 

Just before the press conference, I noted in the meeting room, a huge poster with an image of a young girl in need of cleft surgery.  The poster was titled Smile Pinki (  I asked what that meant, and learned the wonderful story about the Oscar winning documentary that follows the young girl, Pinki, through the process of having her cleft surgery at G S Memorial by Dr. Subodh. 

It amazed me to hear and have first hand experience of the amazing work being performed by Dr. Subodh and his staff.  The world is a better place for people like these who spend their lives devoted to helping those who would otherwise not receive the care they so urgently need.

Ironically, the day before I arrived there was a terrible accident in Varanasi causing serious burns.  This prompted the Times of India to report:

Banaras Hindu University V-C seeks special burns ward at SSL hospital

Moved by the plight of burn patients from Bihar, the vice-chancellor of Banaras Hindu University (BHU) Lalji Singh has called for a special burn centre and skin culture facility at Sir Sunderlal Hospital of the Institute of Medical Sciences.

The awareness level has been raised, and hopefully Dr. Subodh will be able to carry out his goals.


March 27, 2013

Visit to Himalayan Healthcare, Ilam Municipality, Nepal

Traveling to the Parajuli Hospital in Ilam was quite an adventure.  I flew into Nepal,  had a few hours of sleep at a Kathmandu hotel, then off the next morning for another flight to inch my way closer to the Hospital.  The flight that runs parallel to the Himalayas is quite extraordinary.  See the view of Mt. Everest just beyond the plane propeller. 

After the flight, the ride of a lifetime began.  I was picked up by a driver and guide to take me up the mountain.  I had arrived on Holi, the Hindu holiday of colors and fun making.  I spent much of the 3-hour drive to the hospital, dodging colors by closing the car window.  Fortunately, I was spared, although it looked like fun was had by all.  The road to Ilam is filled with switchback sections that run up the mountain, reaching about 6,000 feet above sea level.  For those who suffer from car sickness, it must be agony.  I had planned to read and work for the 3 hours, but found that impossible because of the car movement, despite not suffering from motion sickness typically.

Upon arrival in Ilam, the hospital rises above the dirt road with its  bright white paint gleamng in the sun.  Is it in stark contrast to other buildings along the way and the hundreds of tea bushes in the surrounding area.  It was great to the see students waiting to greet me.  I was introduced to Milan Gurung, who joined the Hospital as a consultant in the past month.  Milan teaches hospital administration at a local university and has consulted with many hospitals in Nepal and Malaysia.  He is a great resource for other contacts in the area.

The day I arrived, the hospital only had one patient.  The facilities are relatively modern, and apparently meet WHO standards.  The nearby government hospital is drawing patients away from the Ilam Hospital, creating a serious challenge.  The beds, equipment, and 2 doctors are waiting to serve a community that needs the services, but have become reluctant patients.  A significant challenge if the Hospital is to continue.

After the tour of the Hospital we were invited to plant tea bushes.  Each of us planted one that would grow in sight of the Hospital for the next 60 years – the expected life of a tea bush.  This was a great way to leave behind a lasting symbol of our concern for the Hospital and the surrounding community.

We later enjoyed a wonderful meal by candlelight (not for ambience, but because of lack of electricity) at the canteen, which is managed by a wonderful woman, who is a great chef!

Early the next morning, we were on the road for the 3-hour drive back to the airport.  All of us tightly packed in a car heading at a rapid pace to the awaiting plane.  We flew back to Kathmandu to meet up with Anil and Soni Parajuli, pictured below, who are in charge of Himalayan Healthcare and its 32 projects, one of which is the Hospital.

The students presented their project and recommendations for the Hospital – sell it or specialize to attract more patients.  Anil has spent many years trying to think of the best thing to do for the Hospital.  He has worked very hard to bring healthcare to the rural Ilam region.  I found him struggling to decide how to continue.  He has so many projects that he is running, and they require a lot of his attention.  The day I arrived, he was preparing for his semi-annual medical trek.  There were 17 doctors ready to travel with Anil and his family to serve the medical needs of the poorest Nepali people.  A staff of about 120 was needed to make this trek successful and carry all of the tents, food, and medical equipment.

Anil thinks that a reasonable amount of funding would be sufficient to keep the Hospital open and operating for the area.  It will be interesting to see how he decided to proceed for the next year.