Indian corporate hospitals, specialist doctors and surgeons have achieved a reputation for treating challenging diseases and surgical cases in a manner comparable with some of the world’s best hospitals. So much so, medical tourism has become an accepted phrase to define the phenomenon of overseas citizens, especially from emerging countries, visiting India to seek advanced treatments. Even the much derided government hospitals and also the better-respected railway hospitals have produced some of India’s finest physicians and surgeons. That said, Indian hospitals have some way to go before they match the best in the world in terms of hospital infrastructure, medical skills, nursing care and patient satisfaction. This paper develops a conceptual framework for a Medical Metropolis infrastructure in India that could lead a revolution in terms of India-centric global healthcare.
What constrains Indian hospitals?
The Indian hospital system has its basic roots and foundations in the government hospital network that focused on cities and towns, and in the public health and rural heath dispensary network that catered to the other parts of the country. Treatment was largely free but infrastructure (wards, theatres and equipment) tended to be poor and medical care insufficient. The public health system was constrained by low budgetary allocations and burdened by growing population. A few national health institutes were set up but to no avail, given the magnitude of healthcare needs. Despite successive five year plans, not much has changed in the public hospital system.
Though some great hospitals have been set up by industrialists and philanthropists, post-Indian independence in the private sector, it was only in the 1980s that the first Indian corporate initiative took shape in India. Since then, several corporate hospital establishments have emerged across the nation, some with geographic focus and some with pan-Indian footprint. Though most corporate initiatives confined themselves to metropolitan cities, a few have extended themselves to second tier cities. One group has ventured into rural medicine and tele-medicine as well. Charitable and voluntary health institutions have also been set up by socially conscious individuals and citizen groups.
Impressive as these achievements are, the Indian corporate hospital system, in the overall, is a relatively inaccessible monopoly with inadequate infrastructure and overworked doctors, insufficient nursing and uninsured patient population. The better known hospitals face severe patient and caretaker overload while ordinary hospitals lack the fundamentals of standard medical care. Even the larger hospitals fail to leverage information technology to achieve operational excellence and customer satisfaction.
Hospitals, the world over, face a classic efficacy-affordability dilemma. On one hand, cutting edge treatments cause cost increases while the growing burden of healthcare requires low cost treatment solutions. Typically, corporate structures drive up investor expectations of high returns while scale and scope demand infrastructural investments that have long gestation periods. If a truly global hospital system is to be established in India innovative financial solutions have to be formulated; however, prior to that what a truly global hospital system entails needs to be defined.
A global hospital system – the Medical Metropolis concept
A truly global hospital system needs to combine scale, scope and competence. In this model, it must have all the specialties relevant for alleviation of human suffering and promotion of wellness, not necessarily the few that drive high bed-occupancy or profitable corporate earnings.
From pediatrics to geriatrics, from initial birth to terminal illness and from planned treatment to emergency intervention, a world-class hospital system should be able to meet all the needs. In addition, the hospital should have an educational and social infrastructure that could position the hospital as a sustainable hub of medical tourism, and development. A hospital established on the above lines would, in fact, be a Medical Metropolis where the society develops around the hospital nucleus. However, to qualify as a growth trigger, the hospital should be truly world-class and differentiated.
Each such Medical Metropolis would need to build its outstanding and core competencies in some specialties while at the same time ensuring the presence of all the therapeutic categories, as a one-stop shop. This would be essential for timely and integrated patient care on a global scale. Ideally, therefore, a global hospital should have a three-tier system of super specialty, core specialty and generic specialty medical care.
In each specialty, there needs to be a relevant mix of cutting-edge physician and surgical services, state-of-the-art diagnostics, personalized nursing care, accessible pharmacy services and computerized patient management systems. Each specialty also must focus on a mix of outpatient and inpatient services to balance effective treatment with affordable cost. To support high standards of patient care and doctor availability, the hospital should take on board doctors and surgeons who are willing to dedicate themselves to only that institution.
A global hospital must compete favorably with the world’s best in terms of infrastructure and equipment. A futuristic corporate vision and a modular design strategy are essential to support competitive infrastructure. While the vision must be driven by corporate considerations of scale, scope and competence, the strategy must be driven by patient considerations of cure, care and comfort. Engineering provides the key to a synergistic fusion of these six essential attributes.
Indian hospitals suffer from a low priority accorded to facility engineering. Typically, all facilities and specialties are housed in one large block designed for a today that minimizes the investment rather than for a tomorrow that will see a patient surge. As a result, typical Indian hospitals suffer from crowded corridors and waiting rooms, cramped consultancy suites, shared diagnostic services, inadequate environmental controls and poor patient isolation systems. Walls, floors and ceilings are often of residential or commercial quality. The environmental standards and entry/exit protocols for operation theatres are not designed for 24 by 7 aseptic controls. Intensive care units are not designed around individual diseases and instead are used to house patients of diverse diseases, leading to possibilities of cross-infection.
A global hospital could adopt as a design option, a hub and spoke facility engineering strategy. As per this, each specialty (super, core or generic) would be housed in a dedicated specialty block, with its own primary wards, diagnostic laboratories and operation theatres. All the specialty blocks would be connected to a central sophisticated diagnostic facility which will house only the highly advanced facilities such as Gamma Camera, PET Scanner and Multi-speed MRI. All other equipment such as X- ray, Ultra-sound, Doppler, ECG and CT Scanners would be housed in individual blocks. Where treatment requires additional sophisticated equipment (for example, the Gamma Knife, Linear Accelerator, Multilead Collimeter in respect of oncology, and Light Speed CT and Radial Lounge in respect of cardiovascular surgery) such facilities must be integrated within the specializations. While this design philosophy may appear to be investment-intensive, it would be relevant and beneficial in terms of fulfilling the above six attributes. Establishment of world scale capacity would be a prerequisite for a globally competitive hospital.
The facility design should provide separate entry corridors for unhindered emergency cases, backed by a multi-specialty emergency ward, with appropriate connectivity to the central hospital services.
Hospital acquired infections, especially from multi-drug resistant bugs is a world-wide concern. An ability to assure sterility in super-critical areas such as operation theatres, endotoxin-free environment in intensive care units and appropriate clean environment in all zones would be a key differentiator for a world-class hospital. It is essential to achieve this by adopting sterility assurance and clean room practices from pharmaceutical companies manufacturing aseptic products.
The design for sterility assurance would involve deployment of sophisticated HVAC systems with HEPA filters and ensuring requisite air changes. Operation theatres, together with preparation rooms, recovery rooms, dispensing rooms, equipment rooms should be treated as integrated units with positive air differentials and door locks as required.
Corridor design assumes great importance. A surgical floor especially would require at least two dedicated corridors, one for patients and doctors as well as sterile materials and the other for infectious materials. Lifts and elevators should be designed to facilitate non-contaminating movement as above. Change rooms, washing facilities, lockers for street clothes and infection eradicating solutions should be provided logically at applicable points.
It is also important to establish modern laundries on the site with steam sterilizers for patient, doctor and nurse gowning materials and autoclave equipment for sterilization of surgical garments and instruments. Fumigation systems, agents and cycles should be established and validated. Utilities for uninterrupted power, steam, air, oxygen and other hospital essentials have to be designed for peak performance of the hospital facility.
Medicare through systems and processes
The success of modern medicine and surgery lies in the rapid development of specializations and high-end pharmaceutical products. This emphasis on specialization has, at the same time, become the bane of modern medicine with the human body being treated as several specialized parts rather than one integrated whole. The premium for specialization has also placed skill ahead of system and ego ahead of empathy. Despite the growing evidence that several disorders are interconnected (eg., metabolic syndrome), that there is so much more to be understood of human physiology (eg., cancer), that pharmacogenomics is still a nascent science (eg., genetic variability) and that pharmaceutical treatment is still imprecise (eg., unknown side effects, drug interactions and contraindications), modern medical practitioners are increasingly dismissive of the need to treat any disease in a holistic way.
A true hospital should bring in systems and processes, leveraging information technology to a large extent, to keep a complete track of the patient’s physiology in a wholesome manner. Systems such as co-lead in treatment, peer review of treatment at entry and exit as well as progress milestones and independent quality audit of patient treatment need to be implemented.
As with aseptic pharmaceutical facilities, sterility has to be built in by design engineering, assured by validation processes, and further reinforced by infection control processes. This requires establishment of a quality assurance division, right from the green-field stage so that the facilities are designed and executed in the right manner, all equipment are validated and all processes are implemented with total compliance. Drawing up of SOPs and training of all personnel would be critical requirements. Defining and implementing Good Clinical Practice (GCP) would go a long way in not only sterility assurance and infection control but also in overall medical treatment.
Given the equal priority to be accorded to outpatient and inpatient care, it is imperative that the facilities are designed to separate the entry and exit systems for outpatients and inpatients and their respective caretakers, providing for adequate waiting space for different categories of patients and caretakers. Outpatient blocks should ideally be designed for different specialties and backed by relevant dedicated laboratory services.
The Medical Metropolis should have a wellness campus which provides rehabilitation and rejuvenation services, deploying a wide range of Indian and oriental methods. Yoga and meditation can contribute to a total treatment paradigm while Ayurveda can provide natural cures. A Spa, gymnasium, joggers’ track, nutritional laboratory and fitness studio can help the treated patients and their caretakers explore new horizons in healthy living.
Also relevant would be a geriatric medicine centre which could also extend into an old age home dedicated for the care of senior citizens with NGO or socially conscious corporate groups or charitable entities. Arguably, a home health service is also a primary need to take care of an ageing society. It will not only reduce the pressure on hospital services but also enhance customer relationship management, building in the process excellent brand equity for the Medical Metropolis.
Hospital as an eco-system
The above specifications would certainly help build and manage a world-class hospital. However, a more holistic living experience remains an aspiration and a gap. A hospital campus is almost inevitably seen as a place where concern, anxiety and seriousness reign supreme, to be ultimately relieved as a patient gets cured. The patient is central to the current hospital designs. Little emphasis is placed on caretakers and overall pre-admission and post-admission lives of either the patients or their caretakers. However, a hospital can be a microcosm of the society with all its thrills and frills. That alone can capture India’s potential as the global hub of medical tourism.
Entrepreneurs and corporate groups should look at setting up a global hospital in the larger canvas of creating a global metropolis, where the hospital is merely an integral and helpful part of a mini-society. The global hospital eco-system would have education, culture, entertainment, township for hospital employees, hotels and hospitality services, to mention a few social facets that would supplement the hospital infrastructure.
A global hospital eco-system should be a fountain of talent. Three types of educational institutions would provide an educational trigger for growth of the hospital system itself. A medical college dedicated to graduate, post-graduate and research courses, a paramedical college which is focused on developing paramedics such as physiotherapists, speech therapists, rehabilitation specialists, biochemists, laboratory and biomedical technicians and a nursing college which will provide the much-needed stock of qualified nurses would lay a robust talent base not only for the hospital but for the larger society itself.
Working in a global hospital which offers the world’s most competitive services will be a high pressure job, often involving extended sessions in theatres, wards and consultancy suites. The workforce would be productive and logistically efficient if the eco-system includes a township for different categories of employees including medical professionals. Quarters for nurses and technicians as well as employees of essential utilities would ensure that the hospital can be run with the highest degree of assurance as well as employee convenience.
Medical tourism would rest on a creative and comfortable exposure to the myriad hues of Indian culture. Ideally, the eco-system should have a cultural village where Indian arts, both ancient and contemporary, are showcased. The village could also house Indian handicrafts and organize periodic cultural fairs. Strategic tie-ups can be had with other cultural and tourist spots in the vicinity for providing a holistic cultural experience to the caretakers.
The medical eco-system will also house a multiplex which will offer state-of-the-art cinematic and artistic experiences alongside an exciting shopping experience. With multiple screens and stages catering to movies and fine arts in Indian and foreign languages the multiplex can attract not only the medical tourists but also the city residents themselves. The shopping complex should sport more Indian labels than foreign labels so that the medical tourists can carry back the high quality Indian goods at competitive prices. Textiles, handicrafts, jewellery and other consumer goods could have a pride of place.
In several hospitals the world over, the caretakers and families of the patients get short shrift. Overcrowding in hospital corridors and/or expensive stays at far-off places severely depress the emotional and economic wellbeing of the families of the patients. Establishment of caretaker dormitories and budget as well as star hotels for the visiting families would help the families of patients visit India with greater assurance and comfort. A spectrum of restaurants offering the wide range of Indian cuisine would complete the picture.
Needless to add, the eco-system will be efficient only when it has banking services (including ATMs), travel services and telecommunication services in ample measure. Complete wi-fi coverage all across the Medical Metropolis would be essential in these times. Rental services for cellular phones, laptops, net books and other gadgets will help the caretakers remain connected and even carry out official and personal chores seamlessly.
Financing the Metropolis
A globally-competitive yet uniquely Indian Medical Metropolis is probably akin to creating a whole new city based on medical science and expertise. At the very least, a Medical Metropolis of the order envisaged would require land bank of 2500 to 5000 acres with approved land-use zoning and future expansion opportunities. It would well qualify as an infrastructural project.
The Indian governments (Central and State) should support the Medical Metropolis projects by providing land at subsidized rates in return for a mix of free treatment, free beds for below-the-poverty-line (BPL) population and royalties from revenues. This would need to be supplemented by soft loans from banking institutions for project funding.
The financial profile of India Corporate hospitals significantly varies, given the vast difference in bed strength, from say 80 to 8000 beds, and in the network of hospitals, from 1 to 40. Two of the largest groups have deployed USD 150 million and USD 360 million as capital to develop network of 10 and 40 hospitals respectively, with bed strengths of 2000 and 7500 respectively. Clearly, even with corporate structures, Indian hospitals are substantially cheaper to establish and operate.
Given the scale and scope of facilities proposed for a Medical Metropolis it is to be expected that the investment cost will be around 2X of the current investment norms. It may also be economically unviable for a single entity to bear all the infrastructural investments relating to the non-hospital assets. The governments and the lending institutions should allow the lead sponsor to rope in partners for each of the additional social infrastructural items such as education, culture, entertainment, hotels and hospitality services. A special purpose vehicle backed by a consortium of corporations with expertise in each of the areas and private equity firms will be ideally equipped to launch and develop the Medical Metropolis concept.
The concept of Medical Metropolis could achieve for India, in the healthcare sector, what the concept of industrial estates and special economic zones have done for China (and even India) in terms of globally competitive development, benefitting not only the national economy but national and international healthcare as well.
Posted by Dr CB Rao on July 20, 2009.