The hospital at Makunda
‘Fund small hospitals for their potential impact’
Civil Society News, New Delhi
FAR from the limelight, several small hospitals meet the basic healthcare needs of people in remote areas. Often, the services they provide are really not so basic. Much-needed surgeries get performed. Diseases are diagnosed early and dealt with. Institutional deliveries happen. Awareness-building improves community-wide health parameters.
How can such efforts be supported so that they don’t peter out because of the great challenges they face?
Dr Vijay Anand Ismavel has partnered with volunteers of the Wharton Business School to devise a rating tool which seeks to give public-spirited initiatives in healthcare visibility so that they have a chance to qualify for funding and also attract volunteers.
Called the Transformational Impact Rating System, it allows small hospitals to be identified, objectively assessed and funded when they are most in need of support.
Dr Ismavel knows what it takes to be one of those doctors out there. He and Dr Anne Miriam, his wife, ran the Makunda Leprosy and General Hospital for 30 years at the trijunction of Tripura, Mizoram and Assam.
Under them the hospital went from being defunct to sustainable. But their journey was full of ups and downs before they succeeded. Even as they served growing numbers of patients, their hospital lacked basic infrastructure because funds weren’t available. For 14 years they went without power supply!
Dr Ismavel hopes the Transformational Impact Rating System, once adopted, will help small hospitals, like the one at Makunda, find support, especially at crucial junctures.
Edited excerpts from an interview with Dr Ismavel who is currently at the Christian Medical College in Vellore.
Q: Many rating tools exist and serve as guidance for donors. What was the need to have one more rating tool?
We saw the need partly because of our experience at Makunda and partly based on what I saw on a visit to Africa.
Small hospitals need visibility and the support they get should be available based on the transformational impact they can have. The world of philanthropy and volunteers is mostly subjective and based on word of mouth.
Small hospitals require support at crucial junctures in their journey. There has to be a better understanding of the role they are playing.
Q: Could you explain that a little further?
At Makunda, we needed just Rs 10 lakh to improve the hospital infrastructure but couldn’t get it.
We really struggled through the early years. For the first 14 years from 1993 we lived without electricity. Just something like Rs 10 lakh would have made life so much simpler. We got electricity only in 2007.
I was doing operations without a cautery machine, which is used to stop bleeding. So, I had to keep pressure on the wound and use stitches.
Similarly, my wife had her MD in anaesthesia, but we were working without oxygen. We didn’t have an oxygen plant. The oxygen had to come from 12 hours away.
All these struggles, both in our personal life and professional life, made it a tough first 14 or 15 years. And not only for us, but for other people who worked with us.
We didn’t really need a lot of money. We just needed a little bit of money for things which would have made a major difference in the way we lived and worked. But the problem is nobody knew about us. We were invisible.
Like ours at Makunda, many small hospitals are located at places where they have the potential to make a transformational impact. But donors don’t know about them.
At Makunda we didn’t take our earned leave for 20 years. No one was willing to replace us — such were the conditions.
Q: What kind of money were you looking for in those early years?
The entire hospital’s budget in 1993 was about Rs 10 lakh. The salary budget was a paltry Rs 30,000 per month for the whole staff. We were getting just small bits of money.
There was an aid agency which said they would support all our expenses but on the condition that we would do only leprosy work. But we felt that leprosy was not a major problem in Assam. The real problem was mothers dying in childbirth and things like that.
Then in 2004 we started an English-medium school for the local people, in 2005 we started a branch hospital in Tripura and in 2006 we started a nursing school.
All these additions took up all the money. We didn’t have money for electrifying homes of the staff and things like that.
If we had received Rs10 lakh or some amount like that at that time we would have been able to have a generator in the hospital. And electrical lines to all the staff quarters. It would have made a huge difference.
|Dr Vijay Anand Ismavel: ‘I was doing operations
without a cautery machine’
The other problem was doctors and nurses did not want to come and join our hospital. When we would approach somebody, the first question would be where exactly is this hospital? And we didn’t have a good answer to that. And the second question would be how much money will you give? And again, we didn’t have a good answer to that either. And on top of that, if you said there’s no electricity then….
When I visited Africa in 2016 there was an Indian doctor trained at CMC Vellore similarly struggling and making improvisations. His life would have been made so much easier if he had had a little bit of money.
What I saw in Africa was the triggering factor in thinking of developing this transformational impact rating system.
Q: And what kind of surgeries were you yourself doing at Makunda?
We were doing very complicated surgeries because I was a paediatric surgeon. Way back then, I was the only paediatric surgeon for Manipur, Mizoram, Tripura, Meghalaya and the southern half of Assam. It was a very large area and we were getting patients from all over.
We operated on a lot of babies who did not have a connection between the mouth and the stomach. If they swallowed milk, it would all go into the lungs. When such babies are about five or six hours old you need to open the chest and disconnect the oesophagus and then reconnect it in the normal position. It’s a bit of a complicated operation. And after that, these babies cannot breathe for the next four or five days. But we didn’t have a ventilator. So, my wife would be ventilating these babies by hand for four or five days till they became alright. All of these babies recovered and we have met some of them who are 20 years old now.
Q: And your work was going unnoticed and there weren’t funds?
All we needed at that time was a little bit of a push. But this is the story of small hospitals: they don’t find support when they are most vulnerable. When they grow very strong and they’re able to become self-sufficient, that is when they become visible to donors. And people start funding them because they’re creating a lot of impact.
But they are at their most vulnerable at the time when they are not visible, when much may not be happening, but the potential for transformational impact is great.
We wanted to create a sort of tool that would make such hospitals visible not by measuring impact because impact has not yet occurred, but visible because of various factors and their potential impact.
Q: What exactly is lacking in current rating systems?
Briefly, many of these will only rate you if you are above a certain turnover. Some of the larger rating agencies will only include hospitals whose turnover is more than $1 million a year. Others will only rate you if you fit into certain categories. Most of them are rating large hospitals which are already doing good work.
There is no rating system which will rate unknown hospitals, which are just starting up. They don’t attract the attention of philanthropists.
Q: Is it a problem that rating agencies decide who they will rate?
Yeah. So many of them don’t rate people who apply to them. They rate people who are invited. Not everybody can get rated by them.
And the other thing is some of these ratings are extremely complicated and you might have to hire people who will be paid to come and verify. It is not affordable for a small set-up.
Q: Are notions of sustainability a problem?
Yes. Just take the location of a hospital. Kerala already has excellent heath facilities. Putting money there will not make much of a change. But if you take some place in Bihar, where the maternal mortality is about 300, just starting a facility which can do Caesarean sections might bring maternal mortality down to 200 very easily and without much effort. There are risks and benefits the donor should consider.
Q: How would the kind of system you are proposing change the thinking of donors?
It basically looks at three sets of factors. The first set involves the impact in the community. Hospitals located in poor areas where there are no other hospitals nearby and government infrastructure is poor will have a bigger impact.
The second set of factors are best practices. Does the hospital have a good auditing system? Is there a management and governance mechanism which holds people accountable? The third group of factors is how the management takes care of people who work there, like human resource practices.
When we did this study, we got about 120 factors from all the interviews and discussions. Those were narrowed down, I think, to about 74 factors which come under the categories I have mentioned.
Q: So, do you feel this kind of information would be enough to convince donors?
They would still want to do due diligence. This is a screening tool. It was devised for the whole world. Suppose someone wants to put money into a hospital working with leprosy patients in East Africa. They put in leprosy and East Africa as filters and get the names of 20 hospitals.
Q: How can you be sure that the information a hospital has provided for the rating is accurate?
What we thought of is that the first level of rating will be done through self-assessment. The hospital has a questionnaire into which they put in information and that generates the score. That is a casual level of rating.
And then when somebody actually visits the hospital, they confirm that what was reported was correct. Now it becomes a verified level of rating. For example, a donor is invited to rate the hospital and agrees with whatever the hospital has claimed. Or volunteers and staff endorse it. As time passes, more and more people will give their opinions. And then it will become a more accurate assessment.
Q: You have said that sometimes having volunteers supporting a hospital is more important than donations.
Volunteers and staff. Volunteers means they are unpaid, but there is also staff. The same rating can be used to attract staff who get a salary.
Q: Do volunteers work well? What draws them to small hospitals?
Makunda had a partnership with the Royal Tropical Institute in Amsterdam. We would get two to four residents who came to Makunda for six months to complete their MD in Global Health and Tropical Medicine.
Many of them were interviewed to understand what would motivate them to consider a hospital. And what would put them off.
They weren’t interested in the money. They were looking for adventure and an exciting sort of place. Disparities bothered them — like some members of the staff being treated differently to others. A great motivation was to work in a poor country and to learn things they had never seen, perhaps only read about in books.
Q: This is what volunteers from the First World might want to find. But what you need are volunteers from within the country.
This tool is actually proof of principle. It is a sort of demonstrator. But it has to be modified according to its application. For example, we are developing a tool to bring post-graduate doctors into the mission hospital network in India. All the factors will be modified to suit India. Based on health indicators, you can choose which state and district you want to work in.
Q: Modified to suit what the volunteer or the funder is looking for?
You know, for example, the Government of India gives some financial support to certain not-for-profit institutions. In Tamil Nadu, the state government gives funding to not-for-profit schools to subsidize education for poor students. In Assam, we at Makunda receive some support from the government for the hospital. To make an objective choice of which hospitals to select, the government could use a tool like this. Otherwise, very often it could be subjective.