Things & Thinks Half & Half Ed. 6

This is the mid-year edition of the monthly dialog series and it has been fantastic to interact with so many experts over the first six months of the year. From the feedback I have received from readers it has definitely provided different lenses to think about healthcare, its challenges and possible solutions.

I am excited to give an entirely different perspective to healthcare by having Sarang Deo for this edition. Sarang Deo is Professor of Operations Management at the Indian School of Business, focusing on health care operations with special emphasis on investigating the impact of operations decisions on population level health outcomes. A renowned academic researcher, he frequently collaborates with international agencies such as the Clinton Health Access Initiative and the Bill and Melinda Gates Foundation and his research has been funded by the US National Science Foundation and Grand Challenges Canada.

T&T: Hi Sarang, welcome to Things & Thinks! I am so happy to have you as a guest. Let’s begin with your backstory?

SD: I grew up in Nagpur and as is true for many other kids growing in those days, Engineering and Medicine were the two only options that were standard! If you were good in maths then you would go for engineering and furthermore if you were good with your grades then you would go for one of the IITs (Indian Institute of Technology). So I went to IIT Bombay for chemical engineering; Curiously, I never thought about engineering as a passion. While I was always passionate about research, it did not seem exciting to do research in chemical engineering. I had this discussion with my classmates recently ‘hey, nobody motivated us by saying here are the big problems of humanity that chemical engineering can help solve’. It seemed all about designing boilers and heat exchangers! Anyways, so then I wrote CAT and then did MBA but I think that’s where I got hooked on to operations on the first course I took. It seemed like you were using engineering kind of thinking and chemical engineering to be honest because it’s all about processes but you are applying it to a slightly broader landscape. So you don’t only now have to think about the fluid going through pipes, but you can think about patients, you can think about dollars and so on and that was appealing. I didn’t want to get into academics right away and decided to get some work experience. I consulted for a couple of years for a pharma client and that’s where I got exposed to healthcare.

T&T: I did not know you consulted in pharma! How was the experience and how did it help you think about your research career?

SD: Well, it was mostly operations, cost reduction and supply chain rationalization in pharma but it did give me a window into the global pharma industry, especially the R&D space. Funnily when I went for my PhD, I had this notion that I will specialize in biotech or pharma. So although I was in operations my simplistic notion was that you pick an industry and then become an expert in an industry. Little did I know that you know academic PhD doesn’t work that way. You can’t specialize in a sector. You specialize in a discipline.

But that was the time when this whole genome sequencing and personalized medicine was picking up. So I started reading industry reports and stumbled upon flu vaccines; it was interesting that a lot of characteristics of the flu vaccine supply chain are similar to fashion apparel supply chain, the sense that there is a short selling season, the long production lead time-just like colors and styles change the strain changes every year so you can’t use anything from previous year- and maybe there are lessons that can be transported. Those were the kind of early research discussions I was having.

Then over time I realized I want to move from products to services. Speaking about the US healthcare economy, only about 20% of the cost base is pharma/product and the rest is services. so that transition happened and a lot of intermediate research has all been about service design.

T&T: How has been the journey since then, including your work at ISB?

SD:. After PhD, I spent four years at Kellogg as a faculty, and that was very useful to build professional networks with other academics in your field as well as in the global health space. I ended up doing some projects very early on that were of the ‘applied’ type-while the goal was still to publish in journals, the source of it was coming from practice. So in my second year as a faculty, I took a group of MBA students to Uganda on a field visit that was around a point of care device for early infant diagnosis of HIV that the Biotech Department at Northwestern University was developing and we did field research for them.

So I did some unusual things in the beginning and realized that publishing such work might be a bit difficult, but I can choose or source problems that are coming from practice as against the literature review approach to doing research.

That was fun and I think after I came to ISB, that only grew exponentially. Because I had a pipeline of research that I felt comfortable with and I could venture out and talk to people in the industry, including some large projects with entities such as the Gates Foundation. My research was anyway more on the resource-constrained settings and India has so many interesting and unique problems from that perspective. So all of this has led to all the work I have been able to lead at ISB.

T&T: Is there something you learned in college that’s proved almost wrong?

SD:. So not sure if this is what you are looking for, but in college, if I had been a bit more focused on academics, it may have been a bit more fruitful. What with the JEE and IIT, you feel you have arrived which I think is a very misleading notion. It robs you of a lot of learning that you can have. If I now want to revisit, I would say ‘hey, if a certain class is boring or if a certain faculty is not engaging, that should not prevent me from learning.’ And that’s what I tell my students as well all the time.

Just determine what you will learn and how you will learn….don’t be myopic about the other things.

T&T: Are you practising something deliberately these days?

SD: It turns out that as you grow up in academia, there is an element of project management coming in. Especially given the administrative responsibilities that I have at the ISB, it’s always four or five projects running, then my own research, my teaching and so on. So for the last few months I am trying to deliberately carve out some time for myself, for the core things that got me into academics in the first place-thinking, structuring, analyzing. So that has been hard but I have been trying.

Another practice is reading. Once again, I end up spending so much time writing and doing my research work that there isn’t much time to read other stuff and reading freely is even harder. By that I mean you may read because you want to cite a paper and you want to see how yours is different but that’s very directed reading right? Learning about completely different things is sometimes difficult and to some extent I think podcasts have helped me. Because like everyone, I have been doing the lockdown chores during the pandemic and podcasts help as you can do those in parallel to some of these mundane tasks.

T&T: What’s something new you’ve learnt about yourself in the past 3–6 months?

SD: I think it’s a constant journey, but mostly it is like reinforcing that I don’t like certain things! But I think a lot of times not being able to say no is also not helpful in the long run, right? It’s just as simple as that. Sometimes everything looks interesting, you can’t be doing everything and there is a trade-off between breadth and depth. So as you start getting 200% capacity utilization or more. Uh, these things start to become important.

I think what the whole last year locked down and being closer to family has also done is to try and find the right balance between these things. It is hard and I may not be fully there yet but that’s what I have learnt about myself.

T&T: Talking about family makes a good transition to my next question; in the recent past, what did you learn from a healthcare system encounter as a patient/caregiver?

SD: Over not just six months, fortunately or unfortunately, but over the last decade I’ve been observing health care both as a caregiver and from a research point of view. So interesting things like when I was working on this Tuberculosis project and a large part of it was private sector engagement-how do we improve diagnostic and treatment practices of the private sector in India and at the same time, I was taking my mother-in-law to this private physician who is very good- very thorough, evidence based. But she still orders a discredited test to rule out tuberculosis even though more advanced molecular tests are now recommended and easily available.

So you realize that despite all these efforts and despite also physicians trying to keep track, it’s not easy for them. One thing that I always say is it’s not individuals who are at fault, there’s a shortcoming where it’s the way the system is organised. And then we end up having these conversations with doctors where they will confide in me, saying I don’t really like managing the front office. I know there is a queue there and there is a lot of waiting. But, I’m leaving it to my front front office people and then suddenly there is so much of a skill gap at the front office.

Same thing with a discharge process. So I always use this example when I’m teaching, even to the doctors, right? I say, hey, just last month I had to go through this discharge process and I’ll tell you what I went through. where you know the CEO of the hospital is most likely a student and they will come and say first What can I do? Is everything OK? And while all of that is happening at the actual type of discharge, all the known deficits of the process, they are still present in some form or other.

T&T: So from your viewpoint, have there been any changes on the patient experience and physician enablement perspectives?

SD: Not a sustained change from my personal experience, Santosh, to be honest. If I go back ten years, when my father-in-law was first admitted for a heart ailment to now, some things have changed. Discharge processes have improved, bedside manners have got better.

I think now there is a bit of realization saying what is the health system? What is the patient care pathway? Which stakeholder needs to be strengthened and added?

So I think that bit of language is changing. What I think is not yet changing is the clinicians still are not clear on what they should do with technology.

T&T: What do you think about our current healthcare ecosystem? And what are some of the top challenges?

SD: For Indian healthcare system, being highly fragmented is my biggest concern as well as somehow a hope for our healthcare system in India.. We have a billion retail consumers who are paying out of pocket and purchasing a health care service at the point of delivery, which is very inefficient. So it is important and critical to get to some amount of consolidation, right? And this is something that people have been talking about and tinkering around it, but it’s not clear what forces will precipitate that consolidation. In other economies, it has always happened through consolidation in healthcare financing and then finances in-turn bringing the discipline to get consolidation in the delivery space. I mean, one would hope that something like PMJAY will take us in that direction. I do interact with them and there have been discussions about what to do at this level. Still, the struggles currently are with setting prices and setting rates, which seems quite transactional.

Every time that I have talked to the CEO and deputy additional CEOs and I have asked hey, what’s your game plan like? And the answers are currently we want to build markets in Tier 2- Tier 3 cities etc, but the jump in thinking from setting prices to creating markets and then reaching things like outcomes is a long journey. I’m hearing some good things on the oncology front and that’s because you know players like Tata Memorial Hospital have tried to advocate.

There may not be similar advocates in other areas, but the fear is that we don’t want to become US like right either. I don’t think US through consolidation has done anything good and ours is as fragmented or, you know, mixed public private system as theirs.

We don’t want to and should have to commit all their mistakes for 30–40 years and then get to the realization. Hopefully there is some leapfrogging that we could do.

T&T: And how about the private sector?

SD: That’s a big discussion to have. Unfortunately in India we have these so-called public-health people and private sector people and this dichotomy hasn’t helped us.

I think the trouble is that the three functions of the state (government) are all mixed up, which is provisioning, financing and regulating. And because there isn’t too much clarity in those, the private sector always has a bogeyman or some sort of excuse, and they can obfuscate their inefficiencies & their ineffectiveness.

So even when setting prices, the private sector will say-you’re setting the same prices for public hospitals and private hospitals, but public hospitals get supply side subsidies. And so then of course, it’s far easier for them to manage those prices than us. Uhm, and then the finance regulator will say OK, but can you show me what your costs are to the private hospital? And for a combination of lack of information and data and unwillingness to open Pandora’s box, they will cloud out costs and so then you know it goes nowhere. That I think is a hump that we’ll have to cross before we can do some good policy thinking.

T&T: What do you think about the pandemic response?

SD: There are so many angles, I got involved early on from the diagnostic/testing angle, then the vaccine manufacturing and supply and then now with the oxygen supply chain. The issue with COVID is it has shone light on all the existing gaps in the health system and accentuated some of the deficiencies ?

Take, for example, the budgeting for expenditure on vaccines-it’s not clear who is the right person to talk to. So you start the talk at the secretary level, you know they understand. Then you go at the joint Secretary level and they kind of understand, health Commissioner they understand. And then suddenly there’s a drop. There is no one who they can delegate to and take actions at the ground level.

And same with testing, so you know ICMR has said that pooled testing can be done only in A-B-C situations, for instance, positivity rate should be less than 5%. Now, there is almost no one at the state level who can interpret that policy and adapt it to their setting, if say, the positivity rate is 10%.

T&T: If you are asked to bet on something about healthcare in future, what will that be?

SD: I don’t know. It’s hard to say what the bet is! What I would like to see happen is some focus on value. So whenever I have discussions with people, it’s very clear that there is very little value creation in the health system and so some efforts to identify where the value is being destroyed and how can some of the value be accrued? Because only then you can talk about value based payment and performance based payments etc. I think right now it’s so far away.

There’s some interesting experiments again in pockets where you know there’s emphasis on health and wellness and CureFit is a good example. I use that in my class where you know you want to have a very different way of thinking. Yeah, uh, if you want to go down that path because. Uh, otherwise things are highly medicalized so one bet is that there’s a generational change where people think actively about health and Wellness.

T&T: and conversely, is there something that you would bet against?

SD: Not sure if this is a bet against, but I’m concerned that we may lose the promise that technology holds, right? So there is the window we have now of everyone talking about AI etc and what’s not clear to me if those are being used at scale to improve health outcomes or access to health or what have you? At the fear of being termed a socialist, I see healthcare technology innovations currently is very private sector thinking right now; It’s all affecting 0.1% of the population. And of course there’s a lot of excitement and it will lead to investment and then turning around and people will make a lot of their investment. But will it affect if even 10% or 15% of the population is being served is unclear. So I don’t know where those business model innovations are…

T&T: I completely agree, and I see this difference between the global health innovations and the ones happening in India. Within the US/EU ecosystems, there are many technology start-ups working on public-health problems.

SD: Right, and there’s a pocket here and there in India, too. But the money is altogether absent, barring some investment coming from the foundations and nonprofits, if at all. Most of the investment is all about high-end tertiary care or in things like making it easy to take appointments or to view your records or test results, that sort of thing.

T&T: Do you have a favorite grudge in healthcare?

SD: For me, it is not enough people/organisations thinking in terms of system design. Starting from education, I think there has to be a change and some changes are happening in the way doctors are trained, right? We train people in medicine very early and after that they’re locked into it, right? So once you are into medicine then you have no time to read anything else, especially talking about reading freely. So reading and awareness about patients, environments beyond clinical medicine and so on is low. Thinking about your role in the overall healthcare system so that breadth of perspective has to come early.

T&T: I completely agree, and to that extent, systems thinking is not a catchy enough topic that seeks attention, right?

SD: Yes, it is partly correct and some of that again has a legacy of old-school systems training of boxes and arrows diagrams, followed by dense text etc. But it can be made interesting for today’s generation- by systems, I just mean acknowledging that healthcare stakeholders and players are different parts that interact with each other. And the decision that you take in one part may affect other parts and that I think the mistake we make is to say that that thinking will come naturally at once. And it’s not true, right?

T&T: What is your advice to someone starting in healthcare, whether a fresher or someone who has worked in other sectors and is now making transition to healthcare?

SD: For me the issue is to start with a problem; A lot of people come to me and think they have ‘to do a start-up’. You have to start from an observation, and this can come from experience, from different perspectives and observing, and also maybe to some extent reading. So I would suggest taking time to do that.

I often tell many of my students if you are invested in the sector, then first learn the sector. Don’t dabble, but really invest yourself, embed yourself in any part of the healthcare.

The broader issue is all of us are busy, all of us thinking to build something fairly quickly and start showing results. If you are starting new, you have a window of asking dumb questions and there is nothing wrong in trying to figure out those issues. And after you have understood the sector a bit and have an understanding of why some things call for those dumb questions, then you are in position to start thinking of your idea, your solution etc.

T&T: And so coming to the close, how do you see the academic interactions with other stakeholders changing?

SD: I think there is definitely a growing understanding that there can be collaboration with academics and policymakers, academics and the private sector and so far. Recently I heard from the National Health Authority that they are drafting a policy for data sharing with foreign universities. This was unheard of that we have a data sharing policy and it’s great, right? I mean it’s not by default that academics do research and publish peer reviewed work. Uh, whereas in more developed economies it’s the standard approach, so practitioners are getting sensitized to this and they are able to frame the right question.

And that approach to working with academics is changing in the right direction. So policy makers, other stakeholders think they have a question, they acknowledge that academics will take some time to answer that question. So let’s differentiate them from consulting companies. And let’s not go to them when I have to implement something in three months. Versus saying I have now data over four years and could you distill out and extract what has happened and what the key insights are? I think that is changing a bit.

T&T: And do you see this change happening everywhere or this is a more ‘ISB Special scenario’?

SD: Ha! I don’t know. The unfortunate part is that I’m not very plugged into the Indian academic circles, because the professional networks of operations management, supply chain management are more or less all European and North American.

The health research fraternity is very unique, so there are top-notch clinical researchers, there are some very good epidemiologists. But then when it comes to health services research or health systems research, there is a large gap. But things are changing. A new entity called Indian Health Systems Consortium has recently been established with the goal of bringing together individuals who think about health systems including quantitative modelers like me as well as qualitative researchers. It’s still nascent, but it’s gathering momentum.

T&T: Sarang, it has been wonderful catching up with you! I have learnt so much from this discussion, thank you so much for your time and sharing your thoughts!