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[INNOVATION AT NARAYANA HRUDAYALAYA] August 12, 2013

INDIAN INSTITUTE OF MANAGEMENT KOZHIKODE

STRATEGIC MANAGEMENT OF INNOVATION

INNOVATION AT NARAYANA HRUDAYALAYA

SECTION B, GROUP 7

SHIFALI SASHIDHARAN 16/286

SONI KUMARI 16/288

SUBHRAJIT SARKAR 16/290

PARICHITA KAPOOR 16/275

NATASHA ADHANA 16/270

KAVYASHREE M 16/86

MONOJ KUMAR RABHA 16/91

SAUMYA KHETARPAL 16/163


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HEALTHCARE CONDITIONS IN INDIA

Though the healthcare sector is one of Indias largest in terms of revenue and employment, it

showcases the most inequitable scenario possible. On one side, patients from other countries fly

to India to get affordable medical treatment of good quality, boosting medical tourism. On the

other, many of these facilities are not available to the people residing in the country. Physical

infrastructure is highly inadequate in most parts of the nation. There is only one doctor available

for 1700 people in India.

As per a PWC report, there were of 15,393 hospitals in India in 2002 out of which roughly two-

thirds were public, and most of these public healthcare facilities provide only basic care. One

cause of this is years of under-funding. With a few exceptions, such as the All India Institute of

Medical Studies (AIIMS), most of the public health facilities are inefficient, under-staffed, with

poorly maintained medical equipment and overall inadequately managed. The number of public

health facilities also is far less than the requirement. For example, India needs almost 74,150

community health centres per million people but has less than half that number.

The condition in the rural areas is even worse than the urban areas despite initiatives like

National Rural Health Mission (NRHM). The following statistics are evidence of this:

50% of all villagers have no access to healthcare providers.

37% are chronically starved

10% of all babies die before their first birthday

50% of all babies are likely to be permanently stunted due to lack of proper nutrition

There is also a disparity in the urban and rural areas with respect to the human resources

available:

Urban India has four times more doctors and three times more nurses than rural India.

Only 193 of Indias 640 districts have medical colleges. The impactof this is that doctors

move away, either to urban centres with medical colleges or abroad because of which the

local community may suffer

Almost 80% of the medical colleges are located in South and West India creating a dearth of

professionals in Northern, Eastern and Central India


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Besides the above factors, the government spending on healthcare has remained low. In 2010,

approximately 5% of the nations GDP was spent on healthcare, less than any other BRIC

nation Out of this government spending was around 0.9% - a meagre amount. This has led to

very high out-of-pocket expenditure for the masses. Around 74% of total spending on healthcare

is done by the people themselves (out-of-pocket) and a majority of this is on drugs alone. Only

14% of the population is covered by some form of health insurance. Millions are forced into

poverty due to such high medical expenditure. The following table gives a comparison between

the percentage of GDP spent on healthcare; private expenditure in percentage and per capita

government expenditure on healthcare. Indias spending is not even close to the BRICS nations,

let alone the top bracket comprising of US and UK. Due to low spending by the government, a

majority of resources lie with the private sector only.

Source: Planning Commission Health Division report for the 12th Five Year Plan

Country Total % ofGDP for

healthcare

PrivateExpenditure

%

Per capitahealthcare

spend (US $)

Per capitagovernment spendson healthcare (US$)

India 4.1 70.8 132 39

USA 17.9 46.9 8362 4437

UK 9.6 16.1 3480 2919

South Africa 8.9 55.9 935 412

China 5.1 46.4 379 203

Brazil 9 53 1028 483

Pakistan 2.2 61.5 59 23

Nigeria 5.1 62.1 121 46

Russia 5.1 37.9 998 620

India has seen a shift in its disease burden from communicable to non-communicable diseases.

Cardiovascular diseases account for almost half of the deaths caused by non-communicable

diseases, being the largest cause of mortality. In 2008, around one-fourth of all deaths in India

were caused by cardiovascular diseases. They are expected to grow at around 9.2% annually

between the years 2005 and 2015.


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There are three key challenges being faced in the field of cardiac care in India: low availability,

low accessibility and low affordability for the masses. Low availability exists in terms of lack of

efficient healthcare infrastructure. Low accessibility refers to inequitable access to facilities as

mentioned previously. Around 60% of the hospitals are located in the urban areas; these cater to

only 30% of the population. Only 13% of the rural population has access to primary healthcare

facilities and only 10% to a hospital. Primary and Secondary healthcare facilities in India focus

mainly on infectious diseases or child and maternal health, thus being under prepared to handle

cardiovascular diseases. Low affordability of quality care is a major concern as big hospitals have

a high cost of treatment due to usage of advanced technology. This problem is aggravated by the

low penetration of health insurance. Large out of pocket payments and low coverage means

financial distress for many. Healthcare expenditure on chronic diseases can account for up to

70% of the average monthly salary of people in the low income group, and around 45% in the

highest income group. Around 28% of all diseases in the rural areas go untreated due to financial

constraints. Controlling costs therefore is essential, considering the fact that more than two-

thirds of the population lives on less than $2 a day. A study by the Public Health Foundation of

India and the London School of Hygiene & Tropical Medicine found that in India

noncommunicable ailments such as heart disease are now more common among the poor than

the rich.


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NARAYANA HRUDAYALAYA

To answer the issue of lack of affordability of quality cardiac care, Dr. Devi Shetty opened his

flagship hospital in Bangalore in 2001: Narayana Hrudayalaya Health City. Reducing costs

through purchase of cheaper scrubs and spurning air-conditioning and the like, Dr. Shetty has

managed to reduce the price of artery-clearing coronary bypass surgery to almost half of what it

was 20 years ago. Currently the price stands at 95,000 rupees ($1,555). He aims to bring this

down further to $800 within a decade. The same procedure costs $106,385 at Ohios Cleveland

Clinic, according to data from the Centres for Medicare & Medicaid Services. He has thus

proved that it is possible to deliver high quality cardiac care at a cost which is affordable for the

masses. As per Dr. Shetty, The current price of everything that you see in health care is

predominantly opportunistic pricing and the outcome of inefficiency. The following graph

illustrates cost of the bypass in other countries:

Despite the fact that one-fourth of the people in India die of a heart attack, only 1-1.2 lakh heart

surgeries are performed in year, falling short of the estimated two million surgeries needed.

Dr.Shetty plans to add 30,000 beds over the next decade to the 6,000 his hospitals have now, and

he has identified 100 towns with populations of 500,000 to 1 million that have no heart hospital.


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BUSINESSMODELOFNARAYANAHRUDAYALAYA:

The following framework will help in explaining the business model of Narayana Hrudayalaya in

great detail:

Value Offering:

The target population is mainly the people at the bottom of the pyramid. Narayana Hrudayalaya

(henceforth to be referred as NH) aims to provide affordable and accessible healthcare to all

Indian citizens with stress given on preventive healthcare through awareness campaigns rather

than curing the illness. In order to reach out to the poor people NH has an integrated network

of hospitals, mobile vans and tele-medicine network through video conferencing.

Operational Strategy:

Since NH is not driven by commercial interests and the main objective was to bring about a

revolution in making healthcare accessible to poorer sections of the society, there was a constant

focus on cost control across the complete value chain. NH has a lean organisational structure.

Here the surgeons concentrate mainly on surgeries and consultations and not on administrative

tasks, where specialists are involved. Hence peoples responsibilities are such that is their core

competency. Girls from poor homes are trained as nurses. This serves two purposes: The salaries

are lower and also being from the same condition the nurses have an inner urge to service the

poor better. Also extended working hours for surgeons and extended availability of OTs ensure

that surgeries take place in high volumes. Thus the business model of NH is low margin high

volume model.

Delivery Channel:

The delivery channel is a mix of in-house treatment and tele-medicine. People are both treated in

NH hospitals as well as expertise/advice is given over phone or video conferencing.

Customer Interface Strategy:

NH has engaged locals in their operations, honing their skills and training them for last mile

connectivity to consumers. NH also has launched micro-insurance schemes like Yeshaswini and

Arogya Raksha, which help make healthcare affordable for the masses.


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Yeshaswini Insurance Scheme:

The Yeshaswini health insurance scheme, launched in June 2003, was developed by the Narayana

Hrudayala Foundation in association with the Department of Cooperation, Government of

Karnataka, to cater for 17 lakh farmers. The scheme is self-funded and does not have insurance

cover from any insurance company.

The scheme offers free consultations, diagnostics at discounted rates and all types of operations

on the stomach, brain, gall bladder, spine, bones, kidneys and heart for a monthly payment of

INR 5 ( 0.09) (INR 60 per person per year). The Government pays INR 2.50 (0.045) (INR 30

a year) for every member, making it a yearly premium of INR 90 (1.64). This year it has been

increased to INR 120 ( 2.19) for every adult member and INR 60 ( 1.09) for children below 18

years to encourage family membership.

Results:

In the first year the scheme had 1.7 million people and in the second year around 2.5 million

people. At the end of 18 months more than 22,000 farmers had undergone operations.

Finance Strategy:

Narayana Hrudayalaya follows the cross-subsidised approach, where they target the high- andmid-income segments apart from the low-income segment, and charge them as per their paying

capacity. This has helped both offering a high performance/ price ratio to the poorest segment.


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FINANCIALSTRUCTURE:

The financial structure of NH can be explained under the following heads:

1. Revenue Mix:

50 per cent from heart surgeries

9 per cent from CCUs

8 per cent from OPD

Rest from donations

2. Cost per patient:

The average price realization, after taking into account the flexible prices that

NH charged for different patients, for heart surgery in a typical month was

US$2,300 ; the break-even cost was about US$1,800

3. Revenue Stream:

Corporate paying through medical insurance schemes

Affluent individuals paying bills as per market rates

4. Profit Figures:

The EBITDA for NH was around 20 per cent while Apollo Hospitals (leader

in its class) has a EBITDA of only 16.3% in 2011.This shows the tremendous

levels of process innovations done by people at NH.


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HUMANCAPITALMANAGEMENT

Every day in NH, large volume of open-heart surgeries and catheterization is done. To handle

such large volume, there is a pool of skilled and qualified medical staffs. Moreover, there is high

level of capacity utilization and staff productivity to handle procedure effectively and efficiently.

There are major challenges of staff retention and recruitment in NH. Staff retention came in

picture due to increasing opportunities for nurses to get high wages in other organisations and

recruitment was seen as issue because of involvement of high cost in recruitment process. To

respond these challenges, NH used intensive training programmes which help to promote

specialist and other medical staff from within its staff pool to keep cost down. These

programmes also helped to provide growth path for medical staffs. Nursing is very important

part of staffs duties and had high turnover rate.Training programmes were developed to retain

nurses, which included:

Intensive training with critical-care experience

Cardiac nursing for six months in the critical care unit

For recruitment purpose, NH has done noticeable work:

Started nursing college to ensure constant supply of qualified nurses at relatively low cost

Since, govt. subsidies and loans from banks made easy for people from remote area and

poorer communities to study and train to be nurses

NH has also realized that its nurses were in high demand in India & abroad. This situation

appeared as opportunity for nurses to leave NH for getting higher salaries in other part of India

& abroad. So, for staff retention, NH adopted a policy of paying high wages.

This policy had provision of:

Higher wages to a core group of nurses to retain them

Filling up the remaining need by a continuous flow of incoming nurses from its own

training institution.

With the help of training and recruitment programmes along with payment policy, NH managed

staff retention and had cost effective recruitment of skilled medical staffs.


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INNOVATION IN THE BUSINESSES PROCESS

More care to more patients

Narayanan Hrudayalaya undergoes a list of processes as described below:

Family physician or OPD performs first level screening

If required, patient is recommended a heart surgery

Patients enter NH and pay minimal Rs.300 as registration fee

Further tests and screening is performed on enrolled patients

Cost of package is assessed after a word with surgeon and availability of money for

discounts

Patients financial background is assessed by billing staff. Government concession or

relief if available are paid and patients are advised for the same

Patient turned to charity if needed, to find donors

Surgery performed

Innovation comes in the level of linking financial structure to day-to-day problems. Rarely one

finds companies which roll out insurance schemes, support poor, reduce the prices to benefit the

needy and link this financial modeling to increase their volumes of patients which in turn willlower their effective cost. NH achieved a breakthrough by achieving the right combination of

financial schemes, reducing their inventory to increase volume of patients which the hospital can

efficiently handle. To compare the hospitals with other hospitals:

NHs heart hospital of 1000 beds achieves a rate of 35 heart surgeries/day on average

And in 2011, NHs surgeons performed 6272 heart operations last year- quite high

Quite high compared to 4128 surgeries, in a leading American hospital

NHs surgeons are freed from paper work including Shetty to increase their efficiency of

performing surgeries

NHs surgeons review P&L of previous day to account for full payers for the coming day

HIGH VOLUME OF OPEN HEART SURGERIES

NH has high capacity utilisation and high staff productivity. They achieve this by several

ways by increasing the working time of doctors or by decreasing the space between two

beds in a typical operation theatre. NH has reduced the time of setup for an operationand time of performing an operation and procedures to one of the lowest in the world.


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Not only Longer- shift hours, but NH also has its operation theatres running for long

period of time, not 6 hours typically which most of the cardiac OTs run. Innovation

process comes in the process by the fact that surgeries are performed at night also, which

was not seen even at Americas leading hospitals.

PROCUREMENT

NH sources its materials from several sources of suppliers and not a single supplier

because their purchasing frequency in high. They typically do not stock a lot of inventory

and hence they enter into short term contract, generally weakly with all of its suppliers.

This reduced the scope of opportunistic profits for the suppliers

To adapt to a low cost model, NH reduced the fixed cost and went on the path of

leasing equipment instead of purchasing the equipments.

PARTNERSHIPS

NH linked every process to reduce the cost and increase the volumes. Their partnerships

were also were a part of the same framework. NH had partnerships with state

government and insurance companies to bring financial schemes and assistance for poor.

This resulted into a feedback loop to again increase the volume of patients.

It also had an agreement with Texas instruments for reducing the cost of monitoring, by

building instruments, which again led to a feedback loop of high volume of patients.

NH even launched Arogya Raksha which was also an insurance scheme with Biocon

and ICICI Lombard Ltd. It resulted in a surge of the patients. There were instances

where patients were required to give an insurance premium of 15 cents per month.

HUMAN RESOURCES HANDLING

Continuous training programmes to promote specialists and other medical staff

Started a nursing college to ensure constant supply of qualified nurses at lower cost

6 month training in CCU and nurses were found in good demand in abroad and India.

Higher wages, financial help for a core group of nurses to retain them


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OTHER INNOVATIONS IN PROCESS OF NARAYANA HRUDAYALAYA ARE:

NH reduced the cost of a typical ECG machine from US 750$ to less than 300$.

NH with its own software company wrote the software for ECG machine to read

data into to the PC to reduce cost

No licensing fee charged when sold to other hospitals

NH in association with TI built a digital X-Ray plate that was priced at US 300$

instead of conventional US 82000$

Required less no. of radiologists

Mobile outreach vans were launched for cardiac diagnosis and care

The vans carried all cardiac equipment and generator for power failure with a

cardiologist and technicians

Low cost screenings were performed, and counseling for NH was also done

Telemedicine as used to increase the access of health care in rural areas through

Bangalore and Kolkata and has reached 14 indian cities now

Hrudya Post was organized in association with Karnataka Postal Circle which

allowed rural patients to scan and send their medical records which after being

analyzed were sent back with detailed report from NH

Dispersion of 100 dialysis facilities is making NH Indias biggest kidney care

provider


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COST REDUCTION THROUGH TECHNOLOGICAL INNOVATIONS

There are 3 major components to the costs of providing medical care:

1. Wages: Salaries of health care professionals

2. Fixed Cost: Cost of medical equipment

3. Real Estate: Cost of Land

SALARIES

Narayanas workforce consists of 42 internationally trained and experienced consultant surgeons.

Consultant productivity is maximised through using their time effectively and the support of

lower skilled staff. Junior surgeons would open and close surgical procedures while consultants

would only do the most complex part of the operation. Allowing them to spend one hour on a

six hour operation, and often do two procedures at once. In addition Narayana make much

greater use of pre-graduate doctors and low skilled staff, often in the form of non-clinical

employees trained in specific tasks. To attract and retain the best manpower, NH pays

compensation at par with the best. However due to longer work hours, they are able to perform

more surgeries per day, thus reducing the cost per procedure.

COST OF MEDICAL EQUIPMENT

The fixed cost or the equipment costs are reined by maximising the asset utilisation. Within the

same Health City (a series of larger-than-usual centres specializing in cardiology, eye, trauma,

orthopaedics, neurosciences, dental and cancer care; comprising of 16 hospitals and 5700 beds.),

the various specialties share expensive imaging equipment and other facilities such as laser, cyber

knife and blood bank, and run them round the clock instead of 7-8 hours daily, thus increasing

asset utilization. They also are able to convince the vendors to simply park their machines in the

hospital instead of outright purchase and buy consumables from them, thus saving on Capex.

COST OF LAND

NH partners with the Governments and real estate owners to get land at subsidized rates and

procure medical technology at lease.


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Apart from the measures taken to reduce these costs individually NH has adopted a unique

principle of economies of scale for lowering the total healthcare costs by increasing the scale of

its operation and its turnover by increasing accessibility. NH has created Health Cities with

huge capacities in terms of infrastructure (hospital beds, OTs, catheterisation labs, dialysis

centres and human resources).

Standardisation: Because of the greater volumes Organization has been able to hone its

physicians towards greater proficiency levels, and also negotiate better prices for inputs directly

from vendors. This enables to streamline Organizations workflows, processes and build systems

towards better efficiency and costeffectiveness.

Cost of visiting consultant: A rural healthcare service, Hrudaya Post, was launched with

Karnataka postal circle to enable rural heart patients to scan and send their medical records to

NH for consultation, from nearest post office. The hospital would revert back with a detailed

report and advice to the patient, within 24 hours, free of cost. This arrangement helps in saving

time and money required for visiting consultants.

Telemedicine and ICT: Through the use of telemedicine and other Information and

Communication Technology applications, NH is able to share medical expertise with remoteparts of India as well other countries. The NH has migrated to digital radiology achieving better

throughput and image quality.

Coronary Care Units:The use of telecare to bring expert medical care to the local level remains

limited in the NHS. Smaller Coronary Care Units (CCUs) are linked to the major cardiac centres

and GPs are trained to provide checks and administer basic treatment. Hospital based specialists

provide consultations through the internet and videoconferencing. To date 53,000 patients have

been treated this way. Only 1 per cent of cases treated in CCUs require surgery.


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In order to increase their reach, they took control of the distribution channel. They introduced

Mobile Outreach Vans which took medical units and doctors to extremely rural areas and set up

camps, where the poor could get treatment close to their locality without having to incur

additional travel or stay expenses. For this, they had to bring about innovation in their surgical

procedure also so that the duration of the surgery is reduced and patients can return home the

same day. They also introduced Telemedicine.

The Yeshaswini Insurance Scheme started by NH in collaboration with the government was

another major step of integrating Complementors into the system in order to make healthcare

accessible to the poor.

Thus, NH adapted to the needs of the market through operational effectiveness by improved

performance drivers and integrating Complementors into the core of their system. By targeting

the right customers through their involvement in the distribution channels, and bringing about

innovations in all operations to improve efficiency and reduce costs, NH has been consistently

attracting more customers and operating on profits. Their strategy is thus best aligned with the

System Lock-In concept.


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INNOVATION CAPABILITY OF NH

NH has been driving innovation in the following spheres of its activity:

Learning: By concentrating on their specializations, time taken by doctors to operate

considerable reduced with increase in experience, thus allowing them to cater to larger number

of patients in the same time period. This helped increase returns and reach.

R&D:Improving the operation procedure also helped doctors focus just on their core function,

while the rest of the work was done by specially trained staff. NH also invested in technological

innovation to develop new technology which would help reduce the fixed costs associated with

surgery and thus improve margins.

Resource Allocation:NH ensured adequate inventory management, which again helped reduce

costs and improve profits. They also trained their nurses, and focus on specialization for doctors

made them better in their service.

Marketing:NH conducted a number of open camps to make patients aware and increase their

customer base. These camps were a major source of footfall for NH. Also, use of Mobile

Outreach Vans and Telemedicine procedures helped in making known their service, and made it

more accessible to the rural population.

Organization:NH ensured that it adopts a business model that runs on profit, and not just one

that runs on funds and donations from a trust. This was important to keep the organization

growing and to expand their services. A constant source of revenue and objective to attain

economies of scale to reduce costs was a strategic decision to make their service accessible to all.

Strategic Planning: NH reduced their administrational roles to the minimum required

numbers. Dr. Shetty himself spent some of his time to overlook the operation of the hospital,

while the rest of the administrative task was handled by professionals.

Thus, NH is able to continuously transform its knowledge and ideas into new processes and systems in order to

improve its operations and technologies to achieve greater profits and innovative capabilities.


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SCALABILITY OF NHOPERATIONS AND EXPANSION STRATEGIES AND PLANS

NH expansion plans

Narayana Hrudayala started its operation in a 25acre facility in Bangalore with about 300 beds

and 5 Operation theatres. Today it has 6000 beds with 17 hospitals, present in 13 locations

across the country performing roughly 120 surgeries per day and attending 80,000 OPD patients

per month. By 2020, they plan to reach 30,000 beds developing similar health cities, like the one

in Bangalore, across the country. They are also looking at expanding the facility to abroad by

creating three or four health cities around the US border.

NH expansion strategy

Keeping in view the great demand for healthcare in India and also to achieve economies of scale

and scope, NH has adopted a unique principle of constructing Health Cities across the country

for lowering healthcare costs and increasing accessibility. Health Cities have huge capacities in

terms of infrastructure - hospital beds, operation theatres, labs, dialysis centres, human resources

etc. They are a series of larger-than-usual centres specializing in different areas apart from

cardiology like the eye care, orthopaedics, neurology, dental and cancer care.

Handling greater volumes has helped NH to hone the proficiency of the specialists to greater

levels. They partner with the Governments and real estate owners and are able to get lands at a

subsidized rate. Most of the medical technology is leased, with many vendors parking their

equipment in the hospital free of cost and are paid on usage basis. NH has this bargaining

power, mainly due to the higher volumes of surgeries performed. This reduces the capital

expenditure. They use generic drugs extensively and go for bulk purchases from medical stores

negotiating discounts.

One of the main challenges in the healthcare industry is the lack of skilled manpower. A person

who hands over the instruments during an appendix operation is usually a BSc in nursing. But

such skilled labour is not required to do such tasks. NH extensively employs semi-skilled labour

and trains them, thus bringing down operating expenditure. The consultants have a better

productivity as a junior surgeon would open and close surgical procedures while consultants

would do only the most complex part of the operation.


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MAJOR CHALLENGES AT NARAYANA HRUDAYALAYA

The following are the major challenges that are currently faced by NH:

Increasing capacity without lowering quality

Overly Bureaucratic Government machinery

Regulations in starting new medical colleges to train doctors and nurses

Making available Telemedicine & high tech healthcare for all

Extending health insurance services to poor and rural Indian population through micro-

health insurance scheme (Yeshaswini)

Expansion of core cardiac surgery facilities across India and other geographies

The major obstacle for NH in expanding its healthcare facilities is the overly bureaucratic

government machinery. The Government has done little for encouraging and promoting the

initiatives of NH. Healthcare items have to go through high import duties and no subsidies are

provided. Also, getting land and other resources for expansion of medical centres is another

hurdle in the path of NH.

As most of the rural population has very low income, the issue of financing for health insuranceis a major constraint in providing health insurance. Also there is no healthcare infrastructure like

hospitals, dispensaries; etc in most of the areas and the state is unable to develop these facilities

due to high expenses involved. Further, it is very essential for NH to have a constant supply of

trained medical professionals and staff to maintain its high quality and low cost.

Possible Solutions:

Increase government participation in various schemes

Partnership with government hospitals for providing basic facilities and primary

treatment in case of heart ailments

Use the infrastructure of government hospitals for tele-medicine

For providing healthcare insurance to the poor, involve both the poor and state

governments as stakeholders

Collaborate with cooperatives and NGOs to expand the facilities to rural masses

Increase the use of ICT (Currently, it is using cloud for its hospital management system)


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REFERENCES

1. Growth Champions: The Battle for Sustained Innovation Leadership- By The

Growth Agenda

2. Healthcare for All: Narayana Hrudayalaya, Bangalore- Prabakar Kothandaraman

& Sunita Mookerjee

3. Narayana Hrudayalaya - Caring with Compassion, Gp Capt (Dr) Sanjeev Sood,

Hospital and Health Systems Administrator, Air Force Hospital, Chandigarh

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