All countries struggle to deliver affordable, high-quality healthcare to their citizens. If a resource-constrained nation like India is to achieve the twin goals of affordable and quality healthcare for all, it will require drastic re-engineering of the healthcare delivery model. India faces two main realities: a large population and low per capita GDP, leaving little room for the substantial investments necessary to build healthcare infrastructure. An acute shortage of doctors outside major metropolitan areas further compounds the problem. The rapid growth in prevalence of chronic non-communicable diseases threatens to transform a critical issue to one of apocalyptic dimensions. Successive governments have attempted to bridge the gap between supply and demand by applying band-aid fixes, for example by opening more super-specialty hospitals. This is neither affordable when done at the required scale nor an appropriate response to the supply-demand gap in healthcare.

While primary healthcare has to be the backbone on which any healthcare system is built, we should not be blind to the needs of vast numbers of Indians awaiting hospital-based tertiary care for illnesses like heart disease and cancer. Cardiac surgeon Devi Shetty (Narayana Health) has stated that a country of India’s size requires 2.5 million heart surgeries to be performed each year. About 1,00,000 are performed on wealthy patients who can afford expensive private hospitals. The rest wait endlessly for their turn at overstretched government hospitals and most die before they get the care they need. A recent article in the medical journal The Lancet estimates that close to 2.4 million Indians die each year due to lack of access to healthcare or poor quality healthcare.

General hospital model

The classic tertiary (hospital-based) healthcare facility is a general hospital (GH) — a multi-specialty facility that treats everyone and handles everything, from the most complex multi-modal treatments to more straightforward procedures in specialties like dentistry, ophthalmology, and ENT. A majority of patients fall into the latter category, requiring the services of a single specialty using procedures that can be standardised. A multi-purpose GH, by trying to optimise resources and processes across multiple specialties, ends up being sub-optimal for all.

The GH model brings under one roof the treatment of both complex and straightforward cases, conflating business models with incompatible metrics of output, value, and payment. This results in a needless increase in cost and impairment of quality.

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

Focussed healthcare

The optimisation problem GHs face is similar to the one faced by the large unspecialised manufacturing organisations set up in the US in the 1960s and 1970s. Focussed factories that specialise in a limited set of products were mooted as a response. In the 1990s, Harvard professor Regina Herzlinger put forward the idea of focussed factories as a solution for the problems plaguing healthcare in the US.

Focussed healthcare factories (FHFs) specialise in a limited set of specialties and clinical processes. The Georgia Sickle Cell Center in Atlanta is an example of an FHF that arose as a response to the poor outcomes achieved in sickle cell patients at non-specialised centres. In eight years, this one-stop shop halved hospital admissions and cut emergency admissions by 80 per cent. The Shouldice Hernia Hospital in Ontario specialises in hernia surgery. The cost of a hernia repair at Shouldice is 30 per cent lower than the reimbursement rate in the US. This lower cost is achieved with better outcomes — a complication rate of 0.5 per cent versus 5-10 per cent outside. Similarly, the Coxa Hospital for Joint Replacement in Finland has a complication rate of 0.1 per cent wersus a rate of 10-12 per cent at a GH performing the same procedure.

FHFs work 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. The standardisation enables tasks to be shifted down the clinical hierarchy to junior doctors and even nurses, thus lowering costs without compromising quality. FHFs also enable steeper learning curves for staff due to the high volumes. The experience of the staff and the structured learning environment creates conditions that are congenial for innovation and continuous improvement.

Integrating FHFs

For FHFs to impact healthcare in a significant way, the concept of the FHF has to be scaled up nationally. The for-profit sector may not be best suited to orchestrate this. The government must play its role and seed the creation of FHFs in partnership with healthcare NGOs and physician cooperatives. Since this will take time, the government could, as an intermediate step, carve out embedded FHFs within large government hospitals. Such units must be independently resourced and have sufficient autonomy in operation. Individual FHFs can become nodes in a nationally interconnected grid. Such a grid will enable smaller and remotely-located FHFs to access the knowledge footprint of the virtual network. For example, standardised care protocols can be distributed from a central node and purchasing cost efficiencies can be maximised by consolidating the requirements of the network when negotiating with vendors.

The FHF model has already taken root in two specialties: eye care and obstetrics. The National Cancer Grid is an example of how such a model can be deployed to serve the vast numbers of cancer patients across the country. The task now is to repurpose this experience in other specialties.

India faces unique challenges in delivering high quality, affordable healthcare to the masses. The FHF model leverages India’s enormous patient numbers to create a system that delivers scalable, high-quality care at lower cost. If India can marry its skills in executing large-scale mission-oriented projects with its information technology capabilities, there is no reason why it cannot be a global epicentre for high-quality healthcare. Such capabilities will also be attractive to patients from other countries that do not have the critical mass required to build similar large-scale, high-volume care networks.

Swaminathan Subramaniam is an independent healthcare industry consultant. This article is adapted from his book ‘Healing Hands’, and is by special arrangement with the Centre for the Advanced Study of India, University of Pennsylvania.