The Indian Institute of Management, Ahmedabad, (IIM-A) one of the premier business schools of India, held its first ever comprehensive health care consultation covering a wide range of issues concerning health care in India between 20th and 24th March 2006.

The objective of the exercise was to increase the interaction between academics, practitioners, administrators and members of industries associated and involved with health care.

The current Indian health care scenario is at best complex. Recent trends have witnessed the persistence of age old infectious and communicable diseases with a concomitant increase in lifestyle diseases such as Diabetes Mellitus and Ischemic Heart Disease. The health care delivery mechanisms in India have not grown with time. Government hospitals have neither infrastructure nor funds to cope with the changing trends of disease while Corporate hospitals (which have had a phenomenal growth in the last decade) though having the best of technology and facilities essentially function with a business outlook. In addition to this, issues like the exodus of quality doctors from government hospitals to private healthcare sector, and of medical personnel to greener pastures outside India, low penetration of health insurance, reservations in healthcare education for specific castes, etc. have only made high quality health care increasingly inaccessible and grim for the common man.

It is commendable that the Indian Institute of Management, Ahmedabad has come up with the idea of holding management consultations every year and bringing out a publication based on the proceedings of this consultation. In order to provide the necessary focus and thrust to the consultation, a National Advisory Committee was formed. A variety of health care facilities management and service delivery mechanisms was taken up as one of the themes for this consultation.

The Sri Sathya Sai Institute of Higher Medical Sciences (SSSIHMS), being a recognized provider of high quality health care totally free of cost, which is difficult to imagine and sustain in the present day world, was invited to share its unique and successful experiment in health care delivery along with many other providers of health care from different backgrounds. The presentation for SSSIHMS was made by Dr. Anil Kumar Mulpur, MS, MCh, FRCS (Edinburgh), FRCS(Glasgow), FRCS C/Th(Edinburgh), FIACS, FETCS and Head of the Department of Cardiothoracic and Vascular Surgery at the Baba’s Super Specialty Hospital (SSSIHMS), Bangalore.

Reflecting on the Conference, Dr. Anil says,

		“It was a great honor to represent the hospital in a large national platform, to a learned audience drawn from various walks of life. Misconceptions about waiting lists, free treatment, and volume of work done were at once removed from the minds of the audience. They all agreed that the divine force of Bhagawan Sri Sathya Sai Baba was singularly responsible for this success. Concerns were expressed about the practical possibility of replicating such a model.” Dr. Anil stressed that it is not impossible for others to take up this success story as a role model to replicate similar services in other parts of the country. “The presentation was very well received,” says Dr. Anil and continues, “It has been a learning experience for us on the employee retention policies which were being adopted by corporate hospitals using modern human resource management techniques. There is no doubt that we will need a good number of highly motivated and skilled doctors and paramedical staff to increase the volume of the work. Such frequent interactions with people who specialize in management do help in revisiting our own thinking.”
Dr. Anil Kumar Mulpur

So much for brief summary of what went on in IIM-A. But to give a complete picture of how the presentation was received by healthcare professionals and policy makers from different disciplines and important wings of society, what questions were raised, etc. we had invited Dr. Anil to our Radio Sai studio for a chat immediately after the conference. Below are excerpts from the conversation.

Prof. Venkataraman (GV) In Conversation With Dr. Anil Kumar Mulpur (AKM).

GV: Sai Ram Listeners and Greetings from Prashanti Nilayam. We are very happy to have in our studios today Dr Anilkumar Mulpur, who is a cardiac surgeon in Swami’s Hospital, in Bangalore.

The reason why we have invited Dr Mulpur to our studio is that he has just come back from Ahmedabad where he has attended a rather unique meeting. This meeting was convened by the Indian Institute of Management in Ahmedabad. I think it would be better for Dr Mulpur himself to describe as to why Indian Institute of Management, Ahmedabad convened this meeting, what it was all about, who all were present there and what they discussed. So doctor, please tell us about the meeting and what was the duration. AKM: Sai Ram everyone. The meeting was a 5 day program. It commenced on Monday and went on until Friday. Unfortunately, I could not be present for all the 5 days, I was there only for 2 days. GV: Roughly how many people participated?
		Prof. Venkataraman in conversation with Dr. Anil Kumar (left) at the Radio Sai Studio

AKM: There were about 110 participants.

The Purpose Of The IIM-A Health Conference

GV: Who called for the meeting and what is the purpose?

AKM: The meeting was called for the first time by Indian Institute of Management. This meeting, in their words is the unique first ever Management Consultation to get the Health Care Providers and Health Care Policy Makers together to sort out certain burning issues.

GV: Why is IIM Ahmedabad interested in this? What is there in it for them, if I may ask so, as it is a business school?

		AKM: My own feeling is that these schools has now started to look at the potential which the health care sector has to offer, as over a period of 5 to 10 years, this sector is really going to open up. Therefore I think they are looking at the business point as well. GV: What are the primary motives of this conference? AKM: India is a signatory for what you called as “Alma Ata Declaration.” The Indian Government is committed to give health status that is acceptable to the community. The deadline for the goals is the year 2015. The Indian Institute of Management thought they will try to help the Government by trying to get all the information from the health care providers. GV: Can you describe what the goals are?
IIM - A Campus

AKM: These goals are related to health care in a multifactor manner. They include maternal and child health, literacy, provision of safe drinking water, rural employment, rural electrification and sanitation, and such things which will have repercussions on the health status at the community level.

GV: The State is supposed to provide these things.

AKM: The Indian Government has an obligation. The expectation anywhere in the world is that the Government or rulers have to provide this. Now we talk of health as a fundamental right. So people now have started to demand that this is their right and they are after the Government to demand that this right is attended to.

Who Attended The Conference

GV: What kind of people participated in the conference?

AKM: This was a conglomeration of different people from all walks of life. We had Health Ministers, Health Secretaries, Politicians, Bureaucrats, and Government Civil Servants who are running large civil hospitals, Non Governmental Organizations, the Corporate Sector plus the industry. Industry also has a certain role to play.

GV: What about Doctors? AKM: Doctors were there but this is not a purely medical conference. They would have formed about 1/5 th to 1/4 th of the attendees. GV: What was the role you were expected to play and why were you invited? AKM: They had a certain general knowledge about the scenario of healthcare status delivery and healthcare delivery systems in India and they knew that the Sri Sathya Sai organizations are doing phenomenal and unique work in this field. GV: You mean medical camps?
		Dr. Anil presenting Sai Healthcare...

AKM: Yes, Medical Camps and the related activities in terms of “Gram Seva” (Village Service Outreach Programme) and so on. Our beloved Director Dr. Safaya was invited. For personal reasons he could not go and he deputed me to go. He gave me his ideas. We all know what Sathya Sai Seva Organizations do.

[To download the powerpoint presentation of Dr. Anil at IIM-A, Click here.]

GV: The Hospital is not really connected to the Sathya Sai Organization. It is an institution of its own right and a world famous one too. Was the role played by the Hospital in the Indian Medical Scenario any consideration when the invitation was extended?

AKM: Yes, because they have actually looked at the tertiary care which we are providing. In fact that was the main theme. Tertiary care provision, that is extremely costly, they wondered “How come your Organization is able to give it totally free of cost? What is the secret?” How Did The Conference Proceed GV: Now that you have given us the background to the meeting, the participants and the purpose, how about telling us what you saw and what you heard? AKM: What I have seen is a genuine interest for the first time from the healthcare policy makers to find out what exactly is going wrong with making policies.

Why despite policy making, a good 60 years after independence, we are no way near provision of safe drinking water to State Capitals, leave alone district headquarters and villages. How should we be going about the so called private and public enterprise partnerships, to involve more of non-Governmental organizations and how exactly Government should be taking up these projects to give them a new turn, so that at least now they can come on to the right path and try to deliver health care system to all the sectors of the society?

GV: You mentioned drinking water; this was discussed in the context of ensuring health and avoiding water borne disease?

AKM: That’s correct.

GV: When they were talking about water, was there any opportunity for them to know about Swami’s massive drinking water projects?

AKM: I have told them about the project even before they could ask me. <<laughter>>

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I have given them the phenomenal statistics that you have generated. So far Sathya Sai Central Trust has spent about 180 million US Dollars. Those figures were mind boggling. They couldn’t believe that in a record time we are able to cater to 10 million people, without ever approaching any Governmental Organization.

SLIDE 65

SSSIHMS – Questions Raised And Doubts Dispelled GV: What were the questions about Swami’s healthcare system? AKM: The only question they had was “What is the source of your funding?” And I told them that the preamble of the Hospital is that we are going to provide healthcare free without reference to caste, color, creed, Nationality, religion, economic status and most importantly, there are no leaflets, no donation boxes. There is no solicitation for fund donation at any stage whether it is in Ashram or any of the institute. And obviously, people voluntarily donate, every penny is accounted for and that goes into human service. GV: What kind of questions was asked about Swami’s hospital health care system? For them it must have come as a great revelation and also possibly a shock!
		During the question-answer session...

AKM: Yes. The key question is how on earth is it possible to give free medical care totally, absolutely free, to anybody who walks in the hospital? This is an experiment and our hospitals have been doing this for a good decade and a half. The message has not percolated. One thing I have seen is people still have lots of misconceptions. Even when they were announcing that I will be speaking, they thought this is sort of a private hospital, managed by a trust and we are collecting funds. There are similar hospitals of that background. In the opening remarks when I said that it is 100% free they all sat upright on the chairs and listened.

GV: Did they ask you about the kind of treatment?

AKM: Yes. What I have told them is the whole spectrum of the disease which we are addressing to. I actually combined the statistics of Prashanthi Nilayam and Whitefield. We have done over 24,000 cardiac operations, over 5,500 neuro surgical operations; I have given them a good breakup, as of today. More importantly what I did with the help of our technical officers, I arrived at the monetary value of the work which has been done in these tertiary care hospitals so far. Just monetary value, as in the market value of each procedure, and it came to a huge figure something like 660 crores, 150 Million US Dollars. There are organizations which have no-profit no loss basis, where they will still take some money from the patients. In our case whether it is a valve or coronary artery by pass surgery, we do it total free of cost.

GV: Did people appreciate the fact that most of the beneficiaries were absolutely poor people?

AKM: Yes. I also tried to emphasize that we have absolutely no selection. A patient may be millionaire, and he will get the same treatment. A homeless patient may be coming and he will still get the same treatment. There is no discrimination at all; this is something unique. We don’t have any special rooms in the hospital, everybody is treated equally.

GV: Did you show any pictures? I am sure you would have done it.

AKM: I have not only shown the pictures of the hospitals, interiors of the hospitals, operation theatres, intensive care unit complexes. I also took the opportunity to project what we have been doing in social care and Educare in terms of our university’s recognition by the National Accreditation Assessment Council, our having achieved a double plus grade, what the Institutions look like and a few very impressive photos of the Water Projects.

The Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore

GV: You seem to have been an ambassador for all the institutions of Swami. I think I should kidnap you and keep you here so that you become a spokesman for all those Institutions for and on behalf of Radio Sai. <<laughter>> What kind of other issues were discussed? You mentioned general problems like sanitation, healthcare, etc.

Other Important Issues Discussed

AKM: The important issues were “What is the cross-sectional status of health care delivery, especially in the corporate sector?”

GV: What do you mean by that?

AKM: As you speak in 2006, “How are certain hospitals which have no-profit, no-loss functioning? And what is their modus operandi?” “How are the problems faced by civil hospitals and so called Government hospitals unique and how are they being tackled, with lots of political pressures, etc. and interferences which are characteristic of our health care delivery system even at tertiary level in Government set up?”

And then they discussed about Tele-medicine and what technology can do so that remote people can be accessible as far as health care is concerned. They showed certain shots where we had the Chief of ISRO coming up and speaking to us, Mr Sathya Murthy. Other things discussed were about the experiments which have been done by Non-Governmental Organizations.

The next topic discussed was to look at the disease burden and projections. For example “What is the Psychiatry disease burden like? What is the Neurology burden? What is the cardiology disease burden like in the next few years?” so that they can frame policies and change existing policies such that these individual problems can be looked at.

The Unique Counseling Department At SSSIHMS

GV: I want to ask you a question, which I think you would appreciate, since you deal with patients, many often poor and illiterate. When an educated person comes to you as a patient, you can ask questions and he will understand what you are trying to ask and will give you fairly precise answers. When a person comes, who does not know how to describe his address, you may not be able to find out by asking questions what exactly the patient is suffering from. His descriptors are vague; he is not used to this kind of dialogue. You have of course your instruments, which will tell their own story, but in the ultimate analysis, you would I am sure, like to talk to the patients – were these kind of problems, addressed at all? I think it is one thing to treat educated patients and quite another thing to treat someone who absolutely has no idea of what modern medicine is.

AKM: This was not particularly addressed in the meeting. In our hospital scenario, luckily we have a group of Doctors who speak a good variety of languages. And the other thing is we have the counseling department who try and get in touch with somebody who can exactly translate. By the time they have come to tertiary hospital, they have all the objective data with them and it is easy for us to go through the data and have an idea of what exactly is the problem. More importantly, when it comes to counseling them about what exactly they should do after we do the operation; we are doing a pretty good job. I am sure you are aware of the Pilot project we have taken up in Karnataka state where we have involved District level Doctors who are going to follow these patients with Sathya Sai Seva organizations. And every single patient is actually followed up! This probably doesn’t happen in any part of the world, including developed countries like America, as this will cost a lot of money.
		Counselling a patient....a unique facet of SSSIHMS, WF

GV: And this is absolutely fascinating, I didn’t know about it. Why don’t you enlighten and educate me and our listeners a little bit more about our follow up program, where you are going to use the services of Doctor devotees, to follow-up post operative or post treatment scenario of Patients who are treated in Swami’s hospital? Tell us something more.

AKM: Whenever we see a patient, we have always been trained to see him as a whole in the background of his family, in the background of his occupation and never to do piece-meal work. So a tertiary care specialist will come to do only a piecemeal work, but he should not lose the sight of the overall background of the patient

GV: In what way is that important?

AKM: In what we call as a tertiary level of health delivery, we have something known as “Disability limitation and rehabilitation.”

GV: Can you explain what Primary, Secondary and Tertiary care is? AKM: Primary care is where the patient for the first time comes into contact with any health care provider. In India it could be a primary health care center or a rural center or a sub center or it could be in our context, the Sri Sathya Sai Organization doing a “Grama Seva” Activity. (Village Outreach Programme) That is the first time a patient is in contact with somebody who has a medical background. Certain of the diseases, a good 80% of them can be treated at that level, such as infectious diseases.

You pick up certain problems which cannot be solved at village level, in the Government setup District Hospitals that provide secondary care. In the Sri Sathya Sai Seva Organizations, the equivalent will be Sri Sathya Sai General Hospital and also similar hospitals and nursing home which have been identified by our groups of workers in various parts of India.

GV: In a General Hospital, what kind of attention and treatment do patients get? AKM: In General Hospitals, you have specialties like General Medicine, General Surgery, Pediatrics, Ophthalmology, ENT, Obstetrics and Gynecology, Gastroenterology, Orthopedics, these are some of the specialties where patients can be diagnosed what his ailments is and treatment can be given to satisfaction of the patient.

GV: What is Tertiary Care?

AKM: Tertiary Care is where you have advanced specialties like Cardiology, Cardio thoracic surgery, Neurology, Nephrology, Neuro surgery, Plastic surgery and certain advanced aspects such as Gastro Entrology and Pediatric surgery. They are all tertiary care, where second level of referral will come to them. They are very specialized in certain aspects and they cater to that and the patient is transferred back to the Primary care physicians so that they are followed up.

In our situation (in India), what is happening is we have the Primary and Secondary and after that, they go to the tertiary, and when they go back, there is no proper follow-up. In our hospitals, they come to tertiary, from the length and breadth of the country.

Nowhere in the world, are we able to produce solid data, to say, for example what happened to valve replacement patients after 5 or 10 years, describing how good are they, how does their symptom status improve? Are they able to go back to professional life? Can they lead normal family life? Are they productive from a social and economic perspective? In Karnataka what we thought is instead of taking the whole India in one go, we would involve District Level Devotee Doctors and Non-Devotee Doctors who have a bent to do certain social activities. We called for a conference. We gave them what exactly cardiac and neuron surgical care means. We started identifying persons in individual districts and even taluks where the patients can go to them for help. And we just follow them up.

GV: How many doctors are empanelled in the follow-up service?

AKM: More than 100 doctors covering all the 27 districts of Karnataka, roughly 4 doctors per district.

GV: Now the doctors are there, how do the patients know where they have to go to see the Doctors?

AKM: When we discharge, we tell them who the nearest contact person is. We also tell them where a good quality laboratory is. Again there is no uniform standard in labs. And certain of the life saving medicines, such as Warfarin, we need to alter, which is an anti coagulant, in the light of their investigations. If he goes to a lab where the investigations are done and I cannot depend on the quality of the investigations, we are doing more harm than good. So we try to identify good quality labs, good quality doctors and direct the patients to them, so that we can take sensible decisions.

GV: When was this programme started?

AKM: This is a good one and a half years ago.

GV: What are the results so far? What are the trends that you can see? First of all, is this working out well? Do patients go?

AKM: Patients do go there. And we also identified some teething problems. Some of the doctors are at a loss to explain as they themselves have no full information. They do not understand what abbreviations mean? What exactly the final diagnosis printed on the discharge summary mean? We have tried to clarify this to them. We will probably call them for second round conference shortly and clarify their doubts/questions.

GV: And later, what is the method through which the Doctors communicate to you?

AKM: Manual, for the time being also by electronic media. Electronic Media is not present everywhere, but we try to encourage them to use electronic media (internet), as it is quite fast and they can answer them.

We also hopefully will install a hot line and any patient can ring that number 24x7 and have some clarifications. That would mean you will have a million calls a day. <<Laughter>>

Initially you will have some physicians who will screen them 24x7 and if that physician cannot answer, they will have access to the Hotline, so that the patient will have access to a Primary caring Doctor 24x7 in a tertiary set up.

Preventive Care And Health Education

GV: Let me fan out and ask some general questions. You have seen hundreds and hundreds of patients, poor people coming with all kinds of ailments. Do you believe that many of these problems can be avoided by some care earlier in the life of the patient? AKM: Absolutely correct, it is very unfortunate thing that even today, in 2006, up to 30% of hospital cardiac admissions are because of rheumatic heart disease. GV: Tell us a little bit about that.

AKM: Rheumatic Heart Disease starts off with streptococcal infection of the throat. And if this particular infection of the throat is diagnosed properly and treated with adequate antibiotics like penicillin in the community and general community health status and environment is improved, in terms of housing and prevention of overcrowding we will never have this magnitude of problem.

GV: When you are taking about Healthcare for all, we are not able to provide even access to something like buying a tablet, what do you do?

AKM: On paper, all these areas which you have mentioned Government will say, “They also fall under such and such sub-center, which belongs to a Primary Health center.” It is open secret that we don’t have adequate doctors in rural background or paramedical personnel and therefore someone who probably has half knowledge gives out dangerous medicines.

The villagers are totally away from civilization. On one hand you have got such advancement in Information Technology. On the other hand we have 70% of rural India where only 25% of doctors are practicing. This issue needs to be addressed by Government.

GV: Apart from this you talked about education. You can use the medium of Television, which is commercialized, even in the Government sector. So who is going to talk about Primary Health Care and matters relating to being clean, taking precautions, taking Vitamin A to avoid problems to the eye at an early age – how are we to do this?

The Sri Sathya Sai Institute of Higher Medical Sciences, Puttaparthi

AKM: We know that Government is unable to do this; there is no doubt about it - because of sheer population, numbers, etc. So what I feel is the so called non-Governmental and voluntary organizations have to do a large part. The projects of the Sri Sathya Sai Seva Organizations are a role model.

We have started this; we have shown how it can be done. My take home message in the Indian Institute of Management was “Comprehensive health care can be provided at primary, secondary and tertiary level, absolutely free of cost with a good quality.”

SLIDE 48

And I said, “We are not here to wipe the disease burden from the face of the humanity. People should look at us and take our role model and grow in greater numbers and replicate this.”

Go to villages and speak to them about health education, sanitation and safe drinking water. Actively take part, involve the community, adopt villages, even industry should to this.

Only then we will be able to make any progress and tackle this. This is a phenomenal problem. 70% of doctors who are concentrated in cities are not willing to go to rural areas where you have actual occurrence of these many problems. GV: Can I ask you a provocative question and make a suggestion? There is a reason why I am going to do that. Some years ago I was having a chat with Dr Ramanathan Iyer of the hospital. He is also very passionately committed to helping poor people. So I told him, Dr Iyer, we have this big Sri Sathya Sai Seva Organization. Why don’t we some how or the other, make some charts using which when the volunteers go to the villages for any work, they explain in simple language, “This is how you should take care of your teeth. This will give you benefits.” This is what you can eat; so that you can avoid these problems. This is what you do with the water? And stuff like that.

The goal is there is a preventive approach. And some of these cardiac problems also can be covered. Now that you have started this follow-up do you think it is worthwhile to initiate by bringing together these two great institutions created by Swami, the Hospital and the Organization to spread health care education?

AKM: You are absolutely right, and I fully agree with you, that is how we should go about. Hyderabad Youth also have done quite a bit on this. They have actually issued certain guidelines for somebody who wants to go and do gram seva, what are things that should be done. You are absolutely correct, we should create a common collection of reproducible charts.

The Last Word – Let’s See Sai In All

GV: This is the challenge that Swami is giving us. With all these multi media it can be made very attractive and it is not at all difficult. So Doctor, I would like to thank you for sparing us some time and telling us about the meeting.

Have the last word – what do you think must be done on the National Scale as a next step? There was one meeting in Ahmedabad, some kind of followup is needed. On a national scale, what should be done next?

AKM: If you see what Swamis 80th birthday speech, in the first very few sentences, He said “Who is bothered about wiping the tears of the common poor man?” That is absolutely true, he has said this several times in the presence of distinguished senior politicians. I strongly believe in Yatha Raja Thatha Praja {“As is the King So are the People”.} Unless we have value based politicians, sitting in high positions, value based Policy Makers who are sitting in high positions, who are able to earmark a large chunk of funds. The current state is that only 8 paise out of 100 is reaching the common man. This is not enough.

You need to have clean politicians, value based politics, corrupt free bureaucrats then comes high quality medical education and only then we will be able to have a proper health care delivery system. This I think, holds good for any country.

GV: Doctor, you are asking for the moon! <<Laughter>> How about some practical suggestions? AKM: For practical things, unless we have the grassroots change, we are not going to get anywhere. If you don’t want me to ask for the moon, I think social organizations like ours should straight away get on with it and do a great more deal than what we do today. Swami has been giving us directives. He is right there to supervise; “You don’t have to come to Prashanthi Nilayam. Wherever you are and are doing selfless service, I am there with you. I am there in every person, in every person you are talking to.” I think that should get into our people. GV: What is the message you would like to give our listeners as a parting gesture? AKM: I can’t better say than what Swami said “Love All, Serve all”. GV: Thank you very much Doctor, it was so nice having you here and I hope I will be talking to you about the hospital and your patients again.

AKM: It is an honor and a great privilege talking to you and allow me to share my thoughts. I am part of Sathya Sai Organization, wherever I am. You have my full commitment.

GV: Thank you. God Bless You. Jai Sai Ram.

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