Illustration: Sameer Pawar
Scene: Narayana Health 2021 Annual Strategy Session: Getting Back to Business.
“What if this pandemic never goes away?” I ask a computer screen dotted with pixels somewhat resembling managers and doctors from across our network of hospitals. No response. Nine months into this pandemic and our videoconferencing skills were abortive at best.
“What if the world never goes back to normal, and this is what our future looks like?” I could sense the mood in the room shift a little, but still no response. I check the audio settings and curse the UX choices of the developers behind our videoconferencing app.
“How will our business thrive in a world permanently scarred by Covid-19?” I ask as loud as is possible in a professional setting.
A long silence and then someone helpfully chimes in, “Sir, we’re not able to follow you clearly.” Such a great example of failure to communicate strategic intent. Or maybe just audio issues.
The session did not go the way I had hoped it would. Everyone I spoke with maintained that the pandemic was almost over, and that business will get back to normal. I found this hard to believe. This rogue strand of RNA had already humbled the smartest people to ever face a television camera and brought the world economy to its knees. If there is a simple narrative, it would be that the coronavirus controls the world, and we need to do its bidding. The more nuanced narrative is that we will never wake up to a pre-Covid world, and we need to adapt our business to succeed in a new world order dominated by uncertainty. I was hoping we would come up with a better solution than copy-pasting the 2019 business plan for 2021 and hoping for the best.
Nobody knows for certain what this new world looks like, nor do they know how to succeed in that new world. But people like me are paid by their investors to predict the future and we need to have bold and confident strategies like ‘The Future is Digital’ or ‘We will SaaS our Blockchain on an Electric Cloud’. There is footage of me telling news channels quite confidently that masks are not necessary, the coronavirus will be contained to East Asia, and lockdowns will flatten the curve, so my credibility as a Covid expert is quite low. But I have a library full of books which use the words ‘disruptive innovation’ a lot, so I know exactly what companies that are nothing like mine did 30 years ago to survive in a country with a high ease-of-doing-business score. With the spirits of Harvard strategy professors whispering in my ear, my predictions for India’s future are: 1) Businesses will get disrupted; 2) People will still need health care; and 3) Magazine editors will still want Future of X articles from business leaders. India has highly skilled doctors, but the pace of their emigration is likely to skyrocket after the pandemic as the West faces a shortage of staff
Image: Amarjeet Kumar Singh / Sopa Images / Light Rocket via Getty Images
There are enough beneficiaries of today’s technology industry singing paeans to the benefits of technological innovation, but none from the past. I have sourced some of my favourite historical quotes on the topic:
“Why is that hairless ape carrying a stick twice his size?” Last thoughts of the first woolly mammoth to meet the pointy end of a spear.
“These printed Bibles sure seem to be getting popular. Should we ban them?” Pope Leo X, right before the Protestant Reformation.
“What do you mean the ghost people are carrying metal tubes that spit lightning and thunder?” Montezuma, last Emperor of the Aztecs.
As history shows us, time and time again, the benefits of disruption usually accrue to the ones doing the disrupting. We do not know what kind of disruption the health care industry will see, but we know that when books are written about us decades from now, we will belong to the ‘Can you believe they used to do this?’ chapter.
The next decade will see an explosion of software that will help doctors make better clinical decisions
Health care is still very hospital-centric and hospitals are the most expensive places to deliver health care because they have to account for every minor contingency. A hospital in India and a hospital in Germany are made of 90 percent similar components, even though their patients come from two completely different worlds. The cost of delivering health care has increased dramatically, led by higher input costs for drugs and consumables, followed by higher salaries to doctors and nurses working in a riskier clinical environment.
As Indian hospitals become even more specialised, they are leaving poor patients with regular ailments further and further behind. To make things worse, the spend on public health care is not growing as fast as the disease burden. This will keep increasing the quality gap between health care delivered in public hospitals versus private hospitals, which in turn will push the out-of-pocket health care spend, already among the highest in the world, even higher.
Narayana Health’s mission is to make high quality health care accessible to everyone. We made a name for ourselves by becoming a focus factory for low-cost surgical procedures and driving down costs through process innovation. We have now reached the limit of how low we can safely drive down costs and every incremental improvement we have rolled out has faced diminishing returns. The flaw lies in the current model of delivering ‘health care’, which Dr Robbie Pearl from Kaiser Permanente instead calls “delivering sick care”. Hospitals focus on delivering surgeries, medicines and procedures to patients in the most efficient way possible. But what if that is the wrong model? What if instead of lowering the cost of a medical procedure, we focus on preventing that procedure from having to take place?
Narayana Health has always looked up to health systems like Kaiser Permanente that manage the entire spectrum of care for their patient members. We believe that a fully integrated health care system that incorporates preventative medicine, primary, secondary and tertiary care in a coordinated manner is more relevant to developing countries like India with a younger and poorer population. This is the only way to ensure that hospitals are completely aligned with a patient’s long-term incentive to live a healthy life. Narayana Health has begun the process of becoming a fully integrated health care provider and we will know over the next 10 years whether this was the right call.
Digital technology has wreaked havoc across massive industries like transportation, hospitality, food, media, retail and finance, and transformed those industries into something my grandfather would scarcely recognise. There is nothing to suggest that the health care industry will be immune to disruptive innovation coming from non-traditional health care companies catering to the aspirations of a digital-native customer base. There are several billion-dollar health care startups that are bypassing hospitals and offering primary care directly to patients. The largest technology companies in the world have expressed an interest in building a health care vertical and are partnering with health care providers to build solutions that bend the cost/quality curve.
Tech companies need large amounts of patient data and clinical insight to build technology solutions that can automate medical decision-making. The next decade will see an explosion of software that will help doctors make better clinical decisions or empower patients to take care of their own health. It will be interesting to see if tech companies continue working with hospitals once they realise they can sell their products directly to patients or doctors and cut out the intermediary. They do make lovely presentations about being together forever, but we have built a large software development arm of our own. Just in case.
The medical field has benefited immensely from scientific progress and cutting-edge technology that has made it possible to cure diseases that were previously thought incurable. Technologies like CRISPR have the potential to eliminate certain types of cancers and genetic disease. Newer classes of drugs and medical implants can extend the average person’s lifespan. None of these were developed in India, and we are completely reliant on universities or companies from the developed world for cutting-edge innovation. Despite our size, we do not have enough specialists available for treating complex diseases and recording their results in a searchable electronic format. The few specialists who are available are too busy treating patients to spend any time doing unremunerated clinical research.
India will need to rapidly scale up the medical education and health care infrastructure to 10 times the present size, to have the critical mass of health care professionals required for innovation to flourish. Clinical research is one field that India can dominate because we have the most critical raw ingredient—millions and millions of sick people. Over the coming years, most major Indian hospitals will run large clinical research divisions in partnership with multinational drug companies or foreign universities.
The future holds great promise, but there are several worrying signals for Indian health care in the near term. Our public finances are stretched thin, and the government will be severely constrained in its ability to ramp up health care spending to fund a national procedure reimbursement scheme and a national Covid vaccination programme at the same time. Procedure reimbursements from government programmes have not changed in over seven years, and most hospitals have huge accounts receivable from government payors. Private equity investment into new hospitals has stopped as the ten-year return on capital is less than the cost of capital for greenfield projects. Most of the investment coming into the Indian hospital sector is being used to fund M&A deals, not add more beds.
The part that worries me most is the growing shortage of skilled manpower. The pace of emigration of Indian doctors and nurses will skyrocket after the pandemic as health care systems in the West face staffing shortages from early retirements of their stressed-out health care workers. Medicine is not a preferred option for students from developed countries, and their governments will relax the visa requirements to encourage a large number of skilled doctors and nurses from Asia to fill the gap. India has some of the most highly skilled doctors in the world working in an environment that does not always value their output. Relatively few doctors who graduate become specialists and earn enough to live in a nice neighbourhood, drive a nice car and put their kids in a good school. Those who don’t get into artificially scarce postgraduate training programmes will get disheartened and start looking abroad.
History is littered with examples of pandemics reshaping society. The Justinian plagues split the Roman empire and ended the Mediterranean dominance of Europe. The Black Death tilted the feudal compact in favour of the peasants. The Spanish flu spurred the creation of national health care systems and influences hospital design up to the present day. The Covid pandemic has laid bare the fragility of our health care systems and been an equal-opportunity destroyer of rich and poor lives across the country. Through the darkest days of this pandemic, I console myself with the hope that millions of people who have lost someone to Covid are going to find their voice. They will rise up to the people in power and say, “Never again”. They will demand a better system that provides health care for everyone, because until all of us are safe, none of us are safe. ● The writer is executive director and group COO, Narayana Health
(This story appears in the 21 May, 2021 issue of Forbes India. To visit our Archives, click here.)