The Makunda Model: An Observational Study of High Quality, Accessible Healthcare in Low-Resource Settings
Background: Mission hospitals in low-resource regions of the world face significant challenges in providing high-quality, accessible care to patients. External funding is limited and can fluctuate significantly from year to year. Additionally, attracting and retaining well-qualified healthcare professionals for more than short stints can seem almost impossible. Located in a remote region in Northeast India, the Makunda Christian Leprosy & General Hospital has developed a model over the past 25 years that has enabled it to sustainably expand access to high-quality care for the region’s poor, which we evaluate in this paper.
Methods: We combine an external assessment by a research team at the Wharton School of Business with internal insights from two leaders at Makunda Hospital to evaluate the Makunda Model. The external assessment included 31 in-depth, on-site interviews of patients, employees, and competitor hospital administrators; physical observation of Makunda’s facilities and operational practices; and an analysis of years of financial documents and hospital statistics.
Results: We studied the impact of the Makunda Model on volumes, efficiency, quality, and community impact. In 2018-19, Makunda Hospital provided 109,549 outpatient visits, 14,731 hospital admissions, 6,588 surgeries (2550 major), and 5,871 baby deliveries in a 162-bed facility with a bed occupancy rate of 88%. The hospital operates with an annual budget of $2.7M ($1 = INR 75.70) and receives only 2.5% of its operating revenue from external sources. The hospital has developed a strong reputation in the community and beyond for providing excellent maternal care and catering to the poor.
Discussion: The hospital’s business model revolves around two key business strategies: (a) poor-centric strategies and (b) thoughtful cost management. Innovative poor-centric strategies include “ability-to-pay” based pricing, equal services for all (in contrast to a freemium model), hyper-tailored charity (using the “shared meals” and “vital assets” tests), and community engagement. Thoughtful cost management is accomplished by “revised gold standard” treatment protocols and recruitment and retention of an efficient workforce.
Conclusion: We conclude that Makunda Hospital’s unique combination of poor-centric strategies and thoughtful cost management have enabled it to achieve the volumes necessary to sustainably improve access to care for the poor in Northeast India.
Makunda Nature Club. Opening our eyes to the biodiversity around us [Internet]. Green Hub Festival 2018. YouTube. 2018 May 20. Available from: https://www.youtube.com/watch?v=oRBRAsdYuTY
Flint C, Fernandez K, Parikh A, Ridge S, Sammut S. The Makunda Model: a study of high-quality, accessible healthcare in low-resource settings [Internet]. Wharton Health Care Management Alumni Association. 2019 Spring. Available from: https://www.whartonhealthcare.org/the_makunda_model
Emmanuel Hospital Association 2017-18 Annual Report [Internet]. Available from: https://eha-health.org/downloads/annual-reports
Based on analysis of EHA Annual Reports [Note]. https://eha-health.org/downloads/annual-reports.
Stranges E, Holmquist L, Andrews RM. Inpatient stays in rural hospitals, 2007. Statistical Brief #85 Healthcare Cost and Utilization Project [Internet]. Agency for Healthcare Research and Quality. 2010 January. Available from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb85.pdf
US Census Bureau. Analysis of American Hospital Association Annual Survey data, 2014, for community hospitals. US Census Bureau: National and State Population Estimates [Internet]. 2014 July 1. Available from: http://www.census.gov/popest/data/national/asrh/2014/index.html.
Ellison A. Average hospital expenses per inpatient day across 50 states. Becker’s Hospital CFO Report [Internet]. 2019 January 4. Available from: https://www.beckershospitalreview.com/finance/average-hospital-expenses-per-inpatient-day-across-50-states.html.
National Accreditation Board for Hospitals & Healthcare Providers [Internet]. Available from: https://www.nabh.co/.
Based on Annual Health survey fact sheets and Kolkata Missions — November 2016.pptx. Other hospitals in the area may have contributed to this improvement, including Karimganj Civil Hospital, which had 2,333 deliveries in 2016; and Silchar Medical College, which had 10,236 deliveries in 2016 (see www.smcassam.gov.in for more recent statistics). But Makunda certainly played a role given its relatively high and rapidly increasing patient volumes [Note].
Narayan R. Robbing Peter to pay Paul. Christ Med J India. 1993 Jan-Mar;8(1): 8-9.
Ismavel VA. Pneumonostomy in the surgical management of bilateral hydatid cysts of the lung. Ped Surgery Intl.2001 Feb;17(1):29-31. https://doi.org/10.1007/s003830000439
Anand V, Thomas G, Zachariah N, Sen S, Chacko J. Use of plastic material from a urine drainage bag in the staged closure of gastroschisis. J Indian Assoc Paed Surg. 1999 Jan.4(1):31-3.
Miriam A, Korula G. A simple glucose insulin regimen for perioperative blood glucose control: the Vellore Regimen. Anesth Analg. 2004 Sept;99(2):598-602. https://doi.org/10.1213/01.ANE.0000122824.21065.CA
Magotra R. Public hospital and private practice. Ind J Med Ethics. 1998;6(4).
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