Think Beyond, Stay Ahead

"The greatest charity in healthcare is making it affordable"

Narayana Health’s founder Devi Shetty on why Narayana Hrudayalaya adopted path-breaking practices from the very start

Let me start with this oft-repeated joke about the conversation between a heart surgeon and a car-mechanic. A heart surgeon takes his car to the local mechanic for routine servicing. On learning that he is a heart surgeon, the mechanic remarks, “Is it not strange that we do the same thing — I fix the heart of a car, you fix people’s hearts. But why is it that you drive a car like this and I don’t?

The surgeon calmly replies, “That is because I fix it while the engine is running.” The point that I am trying to make here is that, in our profession there is no room for error. And that realisation has driven all the best practices that we have put in place at Narayana Hrudayalaya. We have what some medical professionals might think is a perplexing rule. In our operating rooms, music plays around the clock. Now, the rational being in you might jump out and say, “Hey, wait a minute, what is the operating surgeon doing listening to music? Is he or she not supposed to whole-heartedly focus on the medical procedure?” 

Granted, but to me, right from my days at the Guys Hospital in London, I have looked upon a good surgeon as an artist and you can see that when they are at work,  cutting and stitching. For a creative person you should create an environment where creativity flourishes. When I used to work in England, the operating room had no windows and being in artificial light from morning till night made you irritable.

Here, in all our operating rooms you have big windows and are with nature all the time. Then, operating rooms traditionally have monitors with alarms and beeps so that you are physically alert. Our approach is an antithesis. When you are operating you should be very cool, composed and in a good mood. We don’t need the machine to tell us that something is right or wrong. Instead you play soothing music in the background. That makes the environment different. So our surgeons can then operate from morning till night without fatigue. Interestingly all the Western hospitals have now adopted this practice.

Ray of hope

Patients and their relatives, when they come to the hospital, are hassled and understandably so. A visit to no other institution evokes so much tension. I see about 60 to 80 patients a day and perform at least one or two surgeries. The opportunity to make a difference to people’s lives and reassure them keeps us energised. Among my many patients could be a kid who is blue and gasping for breath. Next day, the kid is back in the ICU after the operation and you call the mother. She touches the baby and says, “Earlier he was dark. Now he is pink.” The following question is “Will he always remain like this?” To which you say, “yes.” This instant gratification is the beauty of this profession. 

However, getting to a position where we are acknowledged among the best in the world has hardly been a walk through Cubbon Park. Upon my return to India in 1989, I started work at BM Birla hospital in Calcutta. An outcome of that was not only a fluency in Bengali but also the privilege of tending to Mother Teresa. It was a great learning experience. I don’t think she really knew the enormity of her stature. When she was admitted to the hospital we got calls from the White House every day. I don’t think anybody can be like her or anywhere even close to her. The time I spent treating Mother also instilled in me the need to implement large scale health projects that would lead to mass scale benefits.

When we started Narayana Hrudayalaya, what certainly helped was that most of the people with whom we started the journey had trained and worked in England, the US or Australia. We knew we were as good as the best out there and, given the infrastructure, maybe we could do better. But building a boutique hospital was out of the question given the kind of cost reduction model that we had in mind. We were very clear that the whole structure could only be changed by scaling up operations.

Keeping our goal of lowering costs in mind and my domain knowledge, we started as a heart-care specialist as it is the most expensive procedure. It was like trying to master an F-16 fighter plane right from the start. If we were able to master that level of sophistication, then flying other aircraft/getting into other specialities would be child’s play. A caveat here, in case it makes us look like demi-gods.

In fact, the reality is far from it. If there is any surgeon who says that “I am in complete control; I am responsible for your life and death,” he is kidding himself. We realise that whatever we do, it is never in our hands. Patients whom we think are going to die for sure; we operate on them and they go home in seven days. At the same time people you think shouldn’t have any risk can die. Essentially, we realise the triviality of life. We also realise that there is a lot more than we see. You don’t really believe in god as a kid. But then as you grow up, a lot of incidents happen that convince you of His existence. 

Getting started

While I was clear about coming back from England, I was not very sure of settling down in Bangalore. I kept shuttling from Calcutta where I had an established practice and it is quite amazing how Narayana Hrudayalaya took birth. It was my brother-in-law who convinced his father to leave a legacy, given the vast wealth that he had created through his construction business. So he decided to give me the capital to build a hospital so long it was in Bangalore.

By no stretch of  imagination did he think it would grow and become this big. The investment required to start this hospital at that time came to Rs.80-100 crore. It wasn’t easy to get that kind of money. Our success is a combination of sheer luck and god’s grace, not wisdom.

The private equity investment that followed was also crucial as we needed resources to scale up. Before the PE money came in we were just a two-hospital group — Bangalore and Calcutta. Now we have 14 hospitals in 11 cities and are about to add another six. External investors also brought in discipline, which initially was not very much to our liking.

The artists that we are, we wanted to work with total freedom, but at the same time we realised that money is a very scarce commodity. If you operate in an unstructured manner, it works fine so long as you are small. Not so when you are scaling up; if you do, you run the risk of falling flat on your face. And that surely is not a recipe for building a great institution. 

The greatest healthcare innovation in the future is not going to be a magic pill or a new scanner. It is going to be a change in the process of delivering healthcare. We are trying to convert the entire process delivery of healthcare into processes by making people accountable. Let me give you an example. I go to the changing room and find that my operating clothes are not there. Traditionally, the surgeon will scream at somebody and ask them to fetch it.

But we haven’t addressed the problem. The moment something is not right, the first guy you dial is the helpline. They will call the person responsible for bringing your operating gear. The sterilised suit will come within 10 minutes, but much before you will get a SMS that your complaint has been registered. Then there is an enquiry as to why it happened. Every week our COO goes through all the complaints and ensures that they don’t happen again. When you have smart people running the hospital, everything will be fine. But you cannot build a system based on smart people. You build a system around dumb people, then you will excel. This is what we are trying to do.

School of thought

We were focused on becoming a low-cost healthcare provider and will continue to remain so within and outside India without cutting any corners. The reason that we went in for Joint Commission International (JCI) accreditation is because we were profiled on the cover page of Wall Street Journal. Till date, we remain the only hospital in history to be profiled on the cover page of WSJ. But that high profile publicity was followed by a lot of criticism.

Remarks like, “How can they do heart surgery for $2,000? It must be the Indian way of doing it” were passed. So we just wanted to give them a message that the same organisation that accredits their hospitals accredits us too. Our process and infrastructure is exactly like theirs but we charge a fraction of what they do without compromising on quality.

We never really had any role model but our target was to be cheaper than the All India Institute of Medical Sciences. We wanted to compete with a government hospital in terms of pricing. That said, you can never change this country without the participation of the government. If any private entrepreneur thinks that he can change the country without the help of the government, he is mistaken. In my experience the government is a very good partner.

I am not saying that it will give things to you on a platter. Eight years ago we came up with a very crazy idea that with Rs.5 a month you can run a health insurance scheme. While it originated in Karnataka, the government accepted the idea and adopted it as a state program in various names and forms. In its effort to improve healthcare access, the government might also force private hospitals to accept patients with state-funded low cost insurance programs. There will be no scope to say, “I am a private hospital; I don’t get aid from you.” They will force you to fall in line. We have seen what they have done with education. They will do the same with healthcare too. The net result will be a substantial improvement of healthcare standards in the country.

Charity is not scalable. Free service has its limits. Even Bill Gates, who is involved with so many charitable causes, will find it difficult to distribute his vast wealth endlessly. Pretty soon it will be exhausted. On the other side, even poor people are only asking for affordable and not free care. “I can only give you Rs.10,000. Can you do my operation?” That is what they want. The greatest charity in healthcare is reducing the cost and making it affordable.