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The Makunda Model: An Observational Study of High Quality, Accessible Healthcare in Low-Resource Settings

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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.
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ORIGINAL ARTICLE
The Makunda Model: An observational study of high quality,
accessible healthcare in low-resource settings
Caleb Flinta, Vijay Anand Ismavelb, and Ann Miriamc
a JD, MBA, Wharton School of Business, The University of Pennsylvania, Philadelphia, PA, USA
b MBBS, MS(General Surgery), MCh(Pediatric Surgery), Senior Administrative Officer, Makunda Christian Leprosy
and General Hospital, Bazaricherra, Assam, India
c MBBS, MD, Consultant Anesthesiologist, Makunda Christian Leprosy and General Hospital, Bazaricherra, Assam,
India
Abstract
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.
38 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
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.
Key words: poor-centric strategies, equal services, charity, Christian mission hospitals,
Makunda model
Introduction
The Makunda Christian Leprosy & General
Hospital,1 founded in 1950 by Baptist Mid-Mission
USA, is located in a remote region in Northeast India
at the border of three neighboring states: Assam,
Tripura, and Mizoram (see Figure 1). Originally a
leprosy colony on 1,000 acres of land, the hospital
became a general hospital from the late 1950s until
the early 1980s, when the expatriate staff running it
were asked to leave India. Consequently, the
hospital fell into a state of disuse until 1992 when it
became a member of the Emmanuel Health
Association (EHA), an association of 20 independent
hospitals in India.2
Figure 1
In October 1992, two of the authors, Drs Vijay
Anand Ismavel and Ann Miriam from the South
Indian state of Tamil Nadu, visited the hospital and
were impressed by the area’s needs. They were
motivated by a search for a location that provided the
highest potential for transformational impact, as
determined by the population that they could serve
divided by the number of other similar care
providers. Makunda was situated in a place that was
moderately populated with no other comparable
hospital within 100 km. It also had a large campus
that could be used to provide other services in the
future. Since EHA felt that it could not safely
assume responsibility for a hospital in such a remote
location, the founding doctors gave a career-long
commitment to serve there for 30 years. The early
days were difficult, but they persevered in spite of
the challenges.3
To cover the full time period they planned to
stay at Makunda Hospital, Drs Vijay and Ann
developed a 30-year strategic plan with three key
phases. Phase I was aimed at stability: resolving
tensions with local community members and
generating enough revenue to cover costs. Phase II
focused on local expansion, including building a
secondary school, nursing school, and branch
hospital to serve the community. Finally, Phase III
centered on distant impact, including developing and
sharing best practices with organizations in other
low-resource settings. This period also included a
new community college, a nature club, and a larger
emphasis on agriculture.
Today, 25 years into its strategic plan,
Makunda Hospital has completed two phases and is
well into its third. In the 2018-2019 fiscal year, the
hospital provided care for 109,509 outpatients, had
14,731 inpatient admissions, performed 6,588
surgeries (2,550 major), and conducted 5,871
deliveries. It also opened another branch in Tripura,
39 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
a neighboring state, that served 7,838 of these
patients in 2018-19. Makunda Hospital provides its
services at very low prices and provides 15% of its
income as charity to poor patients.
Furthermore, Makunda Hospital has created
various educational and agricultural businesses. It
runs a K-12 school system with over 1,000 students,
a nursing college with 61 students, and a nurse
assistant training program with 43 students. Most of
the nursing college and nurse assistant program
students stay in dormitories provided by Makunda
Hospital. On the agricultural side, Makunda owns a
farm that generates food for its school hostels for
most of the year, and it owns several fisheries and a
piggery. Finally, Makunda Hospital recently
designated a wildlife area within its boundaries and
created the “Makunda Nature Club” to document and
publish biodiversity records.4 All of these activities
are performed to further Makunda Hospital’s
mission to provide Christian service to the people of
Northeast India regardless of their background (see
Appendix I for the hospital’s mission statement).
The goal of our observational study was to
assess the impact of the Makunda Model on access
to quality healthcare within Northeast India and to
identify the underlying drivers for the hospital’s
financial sustainability and success. A team of
students from the Wharton School of Business
conducted the external research assisted by a faculty
member and generated an initial report about the
model.5 The team focused its research on how
Makunda Hospital utilizes poor-centric strategies
and thoughtful cost management to provide high-
quality care to the poor.
Methods
Our observational study is primarily
descriptive and relies on a mixed methods research
design. We relied on three approaches to gather and
triangulate the necessary data: (1) in-depth
interviews, (2) facility observations, and (3)
document analysis. The interviews provided
qualitative insight about the impact of Makunda
Hospital and the drivers of its impact, verified
through facility observations and by reviewing and
analyzing hospital statistical and financial
documents. Makunda Hospital's Management
Committee and Research Committee provided
permission for the study and provided access to the
hospital's financial and statistical information.
Statistical data for other EHA hospitals were taken
from publicly available reports. IRB approval was
not deemed necessary for the study.
1. In-depth Interviews
A total of 31 in-depth interviews were
conducted by the Wharton research team of (a)
Makunda Hospital employees, (b) hospital patients
and community members, and (c) competitor
hospital administrators and staff, as summarized in
Table 1.
Table I. Number of Interviews by Interviewee Type
Type of Interview
# of In-Depth
Interviews
Makunda Hospital employees
16
Hospital patients and community
members
7
Competitor hospital administrators
and staff
8
Total Interviews
31
First, confidential interviews were conducted
by a Wharton research team member with 16
Makunda Hospital employees in a broad range of
roles, including managerial, clinical, teaching, and
technical positions (see Appendix II for details). At
the beginning of each interview, interviewees were
informed of the purpose of the study and that any
information they disclosed may be shared in an
anonymized format with hospital management or in
a published report, but that no statements would be
personally attributed to any specific individuals
without their permission. Interviews focused on the
strengths, weaknesses, changes, differentiators, and
impact of Makunda Hospital (see Appendix III for
the full list of survey questions used). After the
unique drivers behind the Makunda Model were
40 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
identified (i.e., poor-centric strategies and thoughtful
cost management), additional questions were used to
probe deeper. Interview notes were coded by these
drivers and reviewed by the other members of the
Wharton research team.
In addition, a Wharton research team member
visited five local communities representing a broad
cross-section of the hospital’s patients to understand
how patients and their families view Makunda
Hospital. A total of 7 in-depth interviews were
conducted, most with the assistance of a translator.
The five communities included the following
groups: (1) tea garden laborers, among the poorest
people in Indian society and who usually live in
crowded primitive huts and earn around INR 100
($1.42 USD) per day; (2) members of the Brahmin
community, who tend to occupy leadership positions
and live in larger homes with electricity; (3)
members of the Vaishya community, which include
skilled laborers who live in humble homes on their
own land; (4) members of the tribal community, who
cultivate rice for work and live in more isolated
communities; and (5) Muslim families, who make up
about a third of Makunda Hospital’s patients.
Finally, hospital administrators and staff from
three competitive hospitals in Northeast India,
including two government hospitals and another
mission hospital (also a member of EHA), were
interviewed. Questions focused on the services and
value proposition of those hospitals versus Makunda
Hospital. The following individuals were
interviewed in-depth, with additional physicians and
staff providing comments throughout the tour of the
facilities:
1. The Chief Medical Officer and Medical
Supervisor of Dharmanagar Civil Hospital.
This is the nearest district hospital in Tripura,
about 30 km from Makunda.
2. The Medical Superintendent and an
administrative officer of Karimganj Civil
Hospital. This is the nearest district hospital in
Assam, about 54 km from Makunda.
3. Senior Administrative Officer (CEO), Nursing
School Superintendent, Nursing Staff
Supervisor, and General Surgeon of Burrows
Memorial Christian Hospital. This is the
nearest mission hospital, about 123km from
Makunda.
2. Facility Observations
To understand Makunda Hospital’s model, an
extensive tour of the facilities was conducted, and
the outpatient experience was followed from check-
in to the waiting area to the physician consultation to
the pharmacy. Significant time was spent observing
patients and operational practices in each of these
areas. Then the lab testing rooms, operating rooms,
and inpatient facilities which include 162 beds
across the female ward, male ward, maternal ward,
pediatric ward, postnatal ward, high dependency
unit, and NICU were toured. Finally, other
facilities surrounding Makunda Hospital, including
the Makunda primary and secondary schools,
nursing and nursing assistant schools, grain farms
and fisheries, physician and staff dormitories, and
wildlife preservation area were visited. For purposes
of comparison, the facilities of both government
hospitals and the other mission hospital were also
toured.
3. Document Analysis
Makunda Hospital provided financial and
statistical documents for review. This included over
10 years of historical revenue and cost data and
detailed patient volume statistics. Makunda
Hospital’s annual report and Emmanuel Hospital
Association’s annual reports (obtained from their
website) were reviewed and various financial
analyses were conducted to understand Makunda’s
model and how it compares to other hospitals both in
the United States and India. Finally, the patient
complaint log and statistical data on hospital
complications and mortalities were reviewed.
Based on these in-depth interviews, facility
observations, and detailed document analysis, the
Makunda Model and its impact on the local
community were evaluated.
41 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
Results
The impact assessment of Makunda Hospital’s
volume, efficiency, quality, and overall community
impact are presented below:
1. Volume
In the 2018-2019 fiscal year, Makunda
Hospital completed 109,549 outpatient visits (a 7.7%
compounded annual growth rate (CAGR) from
2014-19); 14,731 inpatient admissions (6.0%
CAGR); 6,588 surgeries (10.2% CAGR); and 5,871
deliveries (5.1% CAGR). Figure 2 shows Makunda
Hospital’s growth in deliveries and surgeries for the
period from 2007 to 2019.
Figure 2. Makunda Hospital’s Growth in Deliveries and Surgeries, 2007-2019
To put these numbers in context, we looked at
the Emmanuel Hospital Association6 (the largest
Christian non-profit healthcare provider in India
with 20 hospitals and 40+ community-based
projects), where the average hospital had 45,825
outpatient visits; 5,034 inpatient admissions; 1,542
major surgeries; and 1,245 deliveries. Of the 19
EHA hospitals reported, Makunda Hospital was the
largest by number of outpatients, deliveries, and
surgeries, and second largest by number of inpatients
and beds. Furthermore, many of the other EHA
hospitals are facing declining patient volume, as
opposed to Makunda, which has seen consistent
CAGR growth over the past several years.7
Although there are many external factors which
affect statistics among different EHA hospitals (such
as competition from nearby hospitals or lower
population densities), it is notable that Makunda has
grown to become one of the highest-volume EHA
hospitals despite starting off as a completely closed-
down hospital 25 years ago.
For an additional point of comparison, the
average hospital in the U.S. has 7,745 discharges per
year, with urban hospitals hitting 11,295 discharges
per year on average, and rural hospitals reaching
2,467 discharges per year on average.8 Furthermore,
U.S. hospitals tend to see about twice as many
outpatients as inpatients per year, far below
Makunda Hospital’s numbers.9 Overall, Makunda
Hospital has achieved very high patient volume,
especially considering its location in a remote area
0
1000
2000
3000
4000
5000
6000
Deliveries
Surgeries
42 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
of India, as seen in Figure 3, by expanding access to
quality healthcare services.
Figure 3. Comparison of Average Hospital Inpatient Volumes
2. Efficiency
In achieving these volumes, Makunda Hospital
operates on a total budget of $2.7M USD (for 2018-
19), which includes the total costs for the hospital,
educational, and agricultural portions of its
operations. The income from the hospital alone is
$2.2M and accounts for 83.9% of income. The non-
hospital activities run at a loss and are subsidized by
hospital income. Furthermore, Makunda Hospital
has run efficiently enough to reinvest nearly 6.5% of
its annual revenue in new buildings and equipment
(in 2018-19) and to write off 15% of its bills to
charity. For the fiscal year 2018-19, the average
outpatient cost was only $11.56 USD (INR 875), and
the average inpatient cost was only $68.03 USD
(INR 5150), figures that were substantiated by
examining detailed accounting and financial
documents. These numbers represent very efficient
costs per patient treated, particularly given that less
than 2.5% of operating revenue comes from external
sources.10
3. Quality
Makunda Hospital is well-known for its high-
quality services, particularly in maternal care. To
make our assessment of quality, we examined the
hospital’s certification, key performance metrics,
and qualitative interview responses.
First, Makunda Hospital has achieved entry-
level certification for safety and quality from the
National Accreditation Board for Hospitals and
Healthcare Providers (NABH).11 Such a
certification requires passing an extensive audit
process, creating a detailed quality assurance
process that includes continuous tracking of certain
metrics, and meeting stringent standards for the
treatment and disposal of medical waste products.
Second, Makunda Hospital tracks favorably on
key metrics for hospital quality, including overall
inpatient mortality and maternal mortality rates. In
2018, the overall mortality rate in the hospital was
2.0%, down from 2.4% in 2016. The proportion of
maternal deaths among mothers who delivered in
Makunda similarly declined from 0.5% in 2016 to
0.1% in 2018. Considering that many community
members come to Makunda Hospital only for their
most complicated births (as noted by those we
interviewed), this is particularly indicative of its
standards of quality. The hospital has been part of a
private-public partnership with National Health
Mission Assam for maternal and child health
services since 2008 and is recognized as a referral
center for high-risk obstetrics patients in the district.
Makunda’s impact on local measures of health is
also noticeable. For example, as shown below in
Table 2, the MMR and IMR rates for the region
dropped significantly in the district of Karimganj
during the years (2009 to 2013) in which Makunda
Hospital sharply increased its number of deliveries
(as captured above in Figure 2).12
Table 2. MMR & IMR Statistics for Karimganj District
Year
2009-10
2010-11
2012-13
MMR per
100,000 live
births
474
342
281
IMR per 1,000
live births
87
69
69
14,731
5,034
7,745
0
5,000
10,000
15,000
Volume
Makunda EHA Average Hospital US Hospitals
43 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
During interviews, we found near-universal
respect for Makunda Hospital among both
competitive hospital administrators and community
members. One government hospital administrator
indicated his hospital loses “many, many patients”
to Makunda Hospital despite the fact that Makunda
Hospital charges for its services (as opposed to
government hospitals, which are essentially free)
and despite the fact that it is located hours away.
Though he had not visited Makunda Hospital
himself, he said, “We hear from patients that the
services are much better there; people tell us that it
is well-managed, patient satisfaction is high, and it
has good cleanliness.” Another government
administrator said that Makunda Hospital was well
respected by their staff of doctors, and many of this
hospital’s patients know it for its strong maternal
services and travel hours to go there instead for
baby deliveries. One hospital staff member at the
Burrows Memorial Christian Hospital stated that
Makunda is “probably the best-run mission hospital
in India” and added that many healthcare
professionals like to start their careers there because
of the great training it provides.
When local community members were visited,
one previous patient asserted that Makunda
Hospital is the “best hospital in Assam” and “we
know that they will take care of us.” Similar
confirmations of the community’s trust in Makunda
Hospital were made in each of the five communities
who were visited. In the tea garden community,
one mother said that she brought her dying son to
Makunda Hospital at the urging of friends despite
believing it was too late. Her positive experience
with her son’s recovery led her to bring back her
three other children over the years and to strongly
recommend the hospital to any of her friends who
need services.
4. Community Impact
Makunda Hospital is unique from many private
hospitals in India in that it was founded specifically
with the intent to help the poor, and its management
team has proactively worked to ensure that all
hospital policies and decisions are carefully
designed to benefit them. In 2018-2019, 15% of its
patients received charity for the services it
provides; in many cases, these patients would
otherwise not have received treatment at all and
would have died or lived with great pain. Over
time, Makunda has built a reputation for low
baseline prices and charity for those who cannot
afford even these prices, and more generally for
taking care of anyone who comes to its doors.
While Makunda Hospital has had a
substantial impact on healthcare in the local
community, interviews revealed that its impact
extends far beyond that to the community at large,
including a K-12 program started in 2004 that
educates more than 1000 students each year. In
addition to its K-12 education program, Makunda
operates a nursing assistant program started in 2015
and a nursing school program started in 2006 to
train local community members in preparation for
working at Makunda Hospital and other locations.
Both of these training programs are subsidized by
the hospital so that poor communities can access
these services. In addition to education, Makunda
provides direct employment to hundreds of people,
with cascading benefits on the local economy.
Some people we interviewed described the
transformation they have seen in the local
marketplace over the past few decades as more
people with more income have stayed in the area
because of the employment and educational
opportunities. The government has also recognized
the value of Makunda as a service provider for the
local community, bestowing it with the Chief
Ministers Certificate of Commendation in 2015,
and has invested money in local infrastructure and
provided support for new hospital construction
projects.
Discussion
Analyzing data from interviews, documents,
and facility observations to understand how
Makunda Hospital achieves such levels of impact,
we found that Makunda Hospital’s business model
44 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
revolves around two key business practices: (1)
poor-centric strategies, and (2) thoughtful cost
management. These business practices enable
Makunda Hospital to operate a business model of
generating higher total earnings by providing very
high volumes of very low-margin services. This
approach permits Makunda to achieve economies
of scale and lower prices, drawing in more price-
sensitive patients, which in turn creates more scale
and enables them to further lower prices creating
a virtuous cycle. Makunda Hospital has also been
able to attract talented young professionals seeking
good training opportunities at a high-volume
facility. These business practices poor-centric
strategies and focused cost management are the
keys to this virtuous high-volume, low-margin,
strategic advantage.
1. Poor-Centric Strategies
Makunda Hospital employs a range of
innovative poor-centric strategies that have enabled
it to drive high patient volume in a low-resource
setting which drive demand. These include (a) an
ability-to-pay based pricing approach, (b) equal
services for all, (c) hyper-tailored charity, and (d)
addressing cultural barriers to usage through
community engagement.
(a) Ability-to-Pay Based Pricing Approach.
Traditionally, hospitals decide on a set of
services to offer and adopt “costing” methods to fix
prices. Instead, Makunda asked the question,
“What can the poor afford to pay?” and then figured
out how to provide services that fit within that price
point. This was based on community engagement
in the early years; for example, the cost of an
outpatient consultation was fixed as the cost of
having a village haircut. This decision to start
with consumer’s ability to pay drove all the other
decisions regarding costs. Many hospital patients
are already hard pressed to pay for a car ride to the
hospital, which often costs more than the actual
hospital services. The decision to make the
hospital’s price points more accessible was the
difference between touching only a wealthier subset
of the population and reaching nearly the full local
population with important implications for a
high-volume, low-margin strategy. Costly services
such as treatment in an intensive care unit (ICU),
which can quickly impoverish a poor family, are
substantially lowered at Makunda Hospital through
internal cross-subsidies from other departments,
where costs are easily affordable and large volumes
generate greater departmental profits. To illustrate,
ICU care at Makunda (including ventilation and all
procedures but excluding drugs) is charged at INR
650 ($8.60 USD) per day. This is cross-subsidized
by income from other departments such as
ultrasound, which performed 16,854 higher-margin
ultrasound scans in 2018-19.
(b) Equal Services for All.
Another key decision made early on was to
provide equal services to all patients regardless of
wealth. Many mission-driven hospitals utilize what
amounts to a freemium-like model, in which
wealthy individuals pay much more for much better
services in order to subsidize services to the poor.13
In these models, the wealthy are placed in a
separate, shorter queue; receive private rooms; and
have a private consultation with a physician of their
choice. In contrast, the poor are placed in the longer
queue and in general inpatient wards.
The problem with the freemium-like model is
that the wealthy expect better services because they
know they are paying more and, thus, demand more
attention from physicians and staff. In addition, to
keep their business, hospital administrators must
cater to the needs of wealthier patients by providing
what they want, when they want it. Over time, the
organization and processes of the hospital become
increasingly oriented towards providing services
for the wealthy at the expense of the poor often
unintentionally. As this occurs, the poor feel more
and more out of place in the hospital and come to
see themselves as second-class citizens, so they
come less and less often and refer their family and
friends less and less often. At the end of the day,
45 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
this reduces volumes, which reduces scale and
increases costs, which requires higher pricing to
compensate creating a vicious cycle.
In contrast, Makunda Hospital has held to its
philosophy of providing equal services to all
patients, regardless of wealth. The hospital is
unique in that it has no private wards, only general
wards with reasonable privacy. According to
Makunda administrators and employees, this
practice is probably the most obvious evidence of
equal treatment for the poor when they come to the
hospital. This has served to bolster Makunda
Hospital’s brand as a place for the poor to go, which
drives volumes and revenue up while
simultaneously upholding the ideals that led the
founding doctors to reopen the hospital in the first
place.
(c) Hyper-Tailored Charity.
In fulfilling its mandate to help the poor,
Makunda Hospital like many other mission
hospitals frequently provides services to poor
patients for free. Doing so exposes mission
hospitals to both type I and type II errors; that is,
they may fail to provide aid to those who truly need
it, or they may provide aid to those who do not
actually need it and lose the corresponding revenue
they could have earned to support their hospital.
What makes Makunda Hospital unique is the
hyper-tailored methods it uses to both identify those
who truly need charity and to provide it to them in
the most effective manner. Historically, Makunda
Hospital has identified the poor primarily through a
set of behavioral observations, and more recently, it
has experimented with more formalized diagnostic
tools. Two notable examples of behavioral
observations the shared meals testand vital
assets test merit specific mention. These
observational criteria to diagnose financial
vulnerability and the risk of destitution are
currently being studied and validated by the
hospital.
First, in the shared meals test, physicians and
nurses (who spend the most time with patients) are
instructed to pay attention to the meal habits of
family members and friends who accompany a
patient at the hospital. If family members and
friends frequently skip meals or share a single meal
among multiple people, they are identified for
charity. This is based on the fact that poor people
are willing to go through suffering to get treatment,
a behavior that is difficult for wealthy patients to
fake.
Second, in the vital assets test, Makunda
employees pay attention to how patients act with
regards to their medical bills. The poorest of
patients will frequently ask how much an additional
service will cost and may try to limit their stay in
the hospital when they feel they have exhausted
their budget even when a doctor recommends that
they stay longer. Interestingly, the founding
doctors found that the poorest patients are actually
much less likely to ask for charity than the
moderately well-off patients, who are more likely
to try to negotiate on hospital bills to get them
reduced even though they can afford to pay. In
contrast, the poor typically go to great lengths to
pay a bill, including selling so-called “vital assets”
that they need for basic living (such as their home)
or to maintain their livelihood (such as a work
animal or farming equipment). One technique
Makunda employees use is to ask how a patient will
pay for a planned or billed medical expense. If the
patient says they have the money, will be able to
borrow the money, or will sell some non-essential
items, they are allowed to do so. However, if they
mention sale of a “vital asset” that is specially
mentioned on a list created by Makunda, they
receive charity. Furthermore, if Makunda Hospital
finds out after the fact that a patient has sold a “vital
asset” (often a distress sale at low value), it goes out
into the community and repurchases the asset on
behalf of the patient.
If a patient says that they will need to sell a vital
asset in order to pay for services, they are asked
how much they could pay if they do not sell the vital
asset. They are then asked to pay that amount, and
the rest is written off as charity. Many poor people
46 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
have a strong sense of dignity and often ask for the
pending amount to be kept as “due” rather than ask
for charity. One practice Makunda engages in is to
write off all “due” amounts at the end of the
financial year.
Another way Makunda Hospital provides
charity in a targeted way is to write off large
medical expenses related to unexpected
complications. Since complications happen so
infrequently, writing them off is a relatively small
cost for the hospital to incur when spread across
many procedures, while not doing so would impose
a huge financial burden on a single individual. In
effect, Makunda Hospital is providing a form of
informal insurance to make healthcare more
accessible to the poor.
From a business perspective, Makunda
Hospital’s unique focus on identifying and
providing tailored charity enables it to retain
revenues from those who can afford to pay
essentially operating as a form of efficient price
discrimination and drives patient volume by
reinforcing Makunda Hospital’s brand as a hospital
for the poor, by retaining patients, and by
encouraging referrals.
(d) Removing Cultural Barriers Through
Community Engagement.
During the early years of Makunda Hospital, it
sought to expand its labor and delivery services but
initially faced slow growth. At the time in
Northeast India, most villages had an informally
designated woman to help with childbirth within
that village. This midwife also helped with
household work like cooking and taking care of the
children when the mother had her delivery, thus,
ensuring the least disruption to the family. This
practice was so convenient that villagers were
willing to forget about the occasional maternal
death, saying that it was inevitable. Based on local
infant and maternal mortality rates, the founding
doctors knew that many mothers and babies were
dying during childbirth, but when they asked the de
facto village midwife in each of the villages if they
had seen any deaths, each of them indicated that
they had not. However, by digging deeper, the
doctors realized that the village midwives were
witnessing significant infant and maternal mortality
but were afraid to admit it and were secretly
terrified of complicated deliveries such as
malpresentation, hemorrhage, and eclampsia but
did not know what to do about them because their
communities looked to them as the experts.
In response, Makunda Hospital began to
encourage village midwives to send only their most
complicated cases to the hospital. When a village
midwife brought such a complicated patient to the
hospital, doctors at the hospital explained to the
family that the mother’s life had been saved
because of the timely referral by the midwife.
When referred patients found that they had a good
experience at the hospital, they referred friends and
relatives for their deliveries too. The midwives
became trusted community members in the eyes of
both the villagers and the hospital. By seeking to
understand the barriers to usage and building
community partnerships, Makunda saw large
growth in the number of deliveries performed,
helping it to achieve its strong reputation within
maternal care as a hospital for everyone, especially
the poor.
In summary, each of these four poor-centric
strategies an ability-to-pay-based pricing
approach, equal services for all, hyper-tailored
charity, and addressing cultural barriers to use
through community engagement play into the
success of Makunda’s high-volume, low-margin
approach.
2. Thoughtful Cost Management
Given its commitment to providing care to the
poor, Makunda Hospital has by necessity always
been intensely focused on cost management the
“supply side” of their operating model. To succeed
in providing low-price services, it has primarily
reduced costs to its patients through two innovative
methods: (a) implementing a “revised gold
standard” of care that reduces unnecessary testing
47 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
and procedures for patients, and (b) recruiting and
retaining individuals who are willing to accept
lower salaries and heavier work obligations because
of the training opportunities it provides or their
commitment to Makunda Hospital’s mission.
These themes emerged through triangulating
comments from Makunda employees with financial
data on workforce and procedure costs.
(a) “Revised Gold Standard.”
Medical students are often taught the “gold
standard” approach to medicine: a broad set of tests
and procedures that should be done to maximize
diagnostic accuracy and patient health in an ideal
world. Unfortunately, physicians in low-resource
settings typically do not have the luxury of running
all of the tests and procedures outlined under the
“gold standard” of care for two reasons: first, their
facility may lack the necessary medical equipment;
and second, the patients they treat may simply not
be able to afford such full-scale services.
To deal with these realities, Makunda Hospital
has developed a set of “revised gold standards” to
provide services that are affordable to its patients.
These standards serve to impact both how
physicians make clinical assessments and what lab
tests, procedures, and drugs they recommend to
patients. Doctors at Makunda think about the cost
versus benefit of a test before asking for it. The
same process is used for prescription of medicine
a patient is more likely to comply long-term with
a set of drugs that the patient can afford.
As another example, Makunda performs
choledochoduodenostomies as an alternative to
endoscopic retrograde cholangiopancreatography
(ERCP) in patients with calculi in the common bile
duct. Drs Vijay and Ann have published several
articles on interventions that are as safe and
effective or nearly as safe and effective as much
more expensive alternatives commonly used today
during their postgraduate studies.14,15,16
Makunda Hospital’s “revised gold standard”
approach has enabled it to lower the cost of
providing health care services so it can in turn lower
prices, which drives greater volume.
(b) Recruitment and Retention of Efficient Labor.
In addition to practicing its “revised gold
standard” practices, Makunda Hospital has lowered
costs for patients by recruiting and retaining
individuals who are willing to accept lower salaries
and heavier work obligations because of the
training opportunities it provides and their
commitment to Makunda Hospital’s Christian
mission.
Government hospitals tend to pay physicians
and nurses nearly twice as much as Makunda
Hospital, and many government physicians work in
their own private practice in the evening after
leaving the government hospital, further boosting
their salaries.17 Employees at Makunda Hospital
noted that the hospital also gets much more
leverage from employees by asking them to
multitask throughout the day and work longer hours
to meet the high patient load. A typical nurse at
Makunda Hospital works eight hours a day, six
days a week, but may also voluntarily work
overtime during a particularly busy shift transition.
Because salaries make up the largest expense
category for most hospitals, being able to reduce
that cost translates to significant savings for
patients and contributes to the hospital’s low-price
approach.
Despite the heavy obligations and lower salary,
many employees choose to work at Makunda
Hospital either because of the training it provides or
their commitment to the mission of Makunda
Hospital. Because Makunda has a nursing school
on site, skilled physicians, and high patient volume,
many aspiring nurses come to Makunda Hospital to
get large-volume, high-quality experience before
moving on to other hospitals. Even more striking,
however, is the strong commitment to Makunda’s
mission that starts with the founding doctors and
extends to employees in both the hospital and the
school system. Most of the people who were
interviewed cited their commitment to Christian
48 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
service and Makunda’s focus on the poor as the
driving force in their decision to work at Makunda
Hospital. Furthermore, despite the heavy
obligations, these employees tend to find great
satisfaction in their work; or in the words of one
supervisor, they leave their shift “tired, but happy
and content,” knowing their work is full of purpose.
Makunda Hospital leaders constantly reinforce
the culture of commitment by challenging the
predominantly Christian staff all Makunda’s
professional staff are Christians to live by
Biblical principles of service (such as “walking the
second mile”). The hospital’s efforts to develop the
school system have also helped to retain young
professionals with families who might have left
sooner but now have viable local educational
opportunities available for their children.
Transferability of the Makunda Model
There are some factors that may limit the
transferability of this model to other hospitals in
low-resource settings:
1. Makunda Hospital’s ability to use scale to
reduce costs is possible because of its high
volume of patients. The hospital is located in
a remote area which is moderately populated
with little competition for the services offered
by the hospital. Hospitals facing intense
competition or situated in less-populated areas
may not be able to achieve the same
advantages of volume.
2. Hyper-tailored charity only works if a mix of
incomes exists in the region so that the
wealthier subset of patients who pay their bills
fully can subsidize those who cannot.
Hospitals located in places where everyone is
poor may not be able to use this internal cross-
subsidy model.
Despite these potential limitations, we believe
that mission hospitals can successfully adopt
elements of the model including some of the
poor-centric strategies and thoughtful cost
management techniques to expand access to
much-needed healthcare services throughout the
world.
Conclusion
Many of the principles identified above can be
used by mission-focused healthcare providers in
low-resources settings around the world. For
example, hospitals can drive volume by utilizing
poor-centric strategies such as setting prices
according to ability to pay, creating equal services
for all patients, tailoring charity according to
observable indicators of true need, and engaging
with the community to overcome cultural barriers
to usage. They can also reduce costs (thus
enhancing their ability to lower prices and
virtuously drive up volumes even further) by
creating customized “revised gold standards” and
decrease labor costs by providing a work
environment conducive to training and a strong
commitment to service.
Factors such as low population density and the
presence of closely situated competition may limit
the transferability of this model. The absence of a
variation in income levels of patients will also not
permit internal cross-subsidy. Additional research
and study are needed to understand how much these
factors play a role in Makunda Hospital’s success
and how well the model can be transferred to other
settings.
Nonetheless, we believe that this study
illuminates several extremely promising and
innovative approaches to providing high-quality,
accessible care in low-resource settings that can be
applied elsewhere. We invite others to engage in
additional research and study to substantiate and
refine the claims made in this paper. Indeed, some
of the general principles warrant further evaluation
in the context of discussions about healthcare costs
around the world. In conclusion, we believe that
the “Makunda Model” developed by Drs Vijay and
Ann offers encouragement for those seeking to
provide high-quality, accessible healthcare in low-
resource settings across the world.
49 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
References
1. Makunda Christian Leprosy and General Hospital
[Internet]. Available from:
http://www.makunda.in/
2. Emmanuel Hospital Association. Hospital location
map. Makunda Christian Hospital [Internet].
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location-map/87-eha-locations-across-india/22-
makunda-christian-hospital
3. Ismavel VA. Sparrow’s nest. early days at
Makunda [Internet]. Available from: https://the-
sparrowsnest.net/2018/05/12/early-days-at-
makunda/
4. Makunda Nature Club. Opening our eyes to the
biodiversity around us [Internet]. Green Hub
Festival 2018. YouTube. 2018 May 20. Available
from:
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5. Flint C, Fernandez K, Parikh A, Ridge S, Sammut
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accessible healthcare in low-resource settings
[Internet]. Wharton Health Care Management
Alumni Association. 2019 Spring. Available from:
https://www.whartonhealthcare.org/the_makunda_
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6. Emmanuel Hospital Association 2017-18 Annual
Report [Internet]. Available from: https://eha-
health.org/downloads/annual-reports
7. Based on analysis of EHA Annual Reports [Note].
https://eha-health.org/downloads/annual-reports .
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stays in rural hospitals, 2007. Statistical Brief #85
Healthcare Cost and Utilization Project [Internet].
Agency for Healthcare Research and Quality. 2010
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Association Annual Survey data, 2014, for
community hospitals. US Census Bureau: National
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10. Ellison A. Average hospital expenses per inpatient
day across 50 states. Becker’s Hospital CFO
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50-states.html .
11. National Accreditation Board for Hospitals &
Healthcare Providers [Internet]. Available from:
https://www.nabh.co/.
12. 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].
13. Narayan R. Robbing Peter to pay Paul. Christ Med
J India. 1993 Jan-Mar;8(1): 8-9.
14. 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
15. 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.
16. Miriam A, Korula G. A simple glucose insulin
regimen for perioperative blood glucose control:
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Peer Reviewed: Submitted 29 April 2019, accepted 16 June 2020, published 29 June 2020
Competing Interests: None declared.
Acknowledgements: We acknowledge the help provided by the staff of the Makunda Christian Leprosy and
General Hospital, especially Dr. Roshine Mary Koshy (Medical Superintendent) for all logistics and support
50 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
provided during the site visit. We thank staff of other institutions who provided time for interviews and site
inspections as well as community members for their time.
We also acknowledge the assistance provided to this project by Alomi Parikh, Kerianne Fernandez, and
Shannon Ridge, all MBA students at the Wharton School of Business who were part of this study and based
in the USA. We also thank Dr. Stephen Sammut, faculty member at the Wharton School of Business, for his
insight and comments on the final report.
Correspondence: Dr Ann Miriam, Assam, India. dr.annanand@gmail.com
Cite this article as: Flint C, Ismavel VA, Miriam A. The Makunda Model: An observational study of high
quality, accessible healthcare in low-resource settings. Christ J Global Health. June 2020; 7(2):37-51.
https://doi.org/10.15566/cjgh.v7i2.389
© Authors. This is an open-access article distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original
author and source are properly cited. To view a copy of the license, visit
http://creativecommons.org/licenses/by/4.0/
APPENDIX I: MAKUNDA HOSPITAL MISSION STATEMENT
Makunda Christian Leprosy & General Hospital aims to provide high quality
medical care at costs that are affordable to the people of North-East India through
development of appropriate health care models
The hospital also aims to provide comprehensive services to all, irrespective of caste, religion, race or
sex, with the assets at its disposal and through collaboration with other like-minded agencies to
improve the social, economic and spiritual lives of our target people.
The hospital further aims to create and sustain a pool of trained manpower and inculcate in them the
values of Christian service as exemplified by the life of our Lord Jesus Christ.
APPENDIX II: INTERVIEW LIST OF MAKUNDA HOSPITAL STAFF
Serial Number
Designation
1
CEO / Pediatric Surgeon
2
Anesthesiologist, Correspondent (Training Programs)
3
Medical Superintendent, Physician
4
Deputy Medical Superintendent, Pediatrician
5
Psychiatrist
6
Resident MD (Global Health) from Netherlands
7
Vice-Principal Nursing School
8
Principal Community College
9
Nursing Superintendent
10
Nursing School Tutor
51 Flint, Ismavel, Miriam
June 2020. Christian Journal for Global Health 7(2)
11
Principal Higher Secondary School
12
School Teacher
13
School Teacher
14
Civil Engineer
15
Biodiversity Project Staff (ex-student of School)
16
Hospital Manager
APPENDIX III: SAMPLE SURVEY QUESTIONS
Initial List
1. What is your role at Makunda Hospital?
2. What are some of Makunda Hospital’s strengths?
3. What are some of Makunda Hospital’s weaknesses?
4. What are some of the challenges you have seen at Makunda Hospital?
5. What are some of the major changes you have seen in the hospital and in the community
during your time here?
6. What is unique about the Makunda Model versus other hospitals?
7. Do you see any challenges with transferring the Makunda Model to other hospitals?
Additional Probing Questions
1. What are some ways that you have seen Makunda Hospital cater to poor patients?
a. How do Makunda Hospital employees identify those who need financial help?
2. How does Makunda Hospital keep costs down for patients?
a. What are some examples of the “revised gold standard” practices you have seen at
Makunda Hospital?
b. How does Makunda Hospital attract and retain quality employees?
... Since it is the only reliable referral center for a large area, many rare conditions are seen. [6,7] All deliveries between 2010 and 2020 were included. The details of patients with advanced primary abdominal pregnancies were taken from their hospital records after getting informed written consent, and the data are anonymized. ...
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In this article, we report the different presentations of thiamine deficiency disorders seen at a remote rural mission hospital in Northeast India, including investigations, treatment, and recovery. Two case studies, one of an infant with cardiac beriberi and the other of a nonalcoholic adult presenting with peripheral neuropathy, cardiomyopa- thy, and metabolic acidosis and responding to thiamine supplementation, are described in detail. We share our experience with these clinical entities over the past two decades, including recent research and lessons learned, and suggest ways forward to identify at-risk populations in Northeast India, improve early diagnosis and treatment, and promote preventive public health strategies.
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During the period 1996-98, 5 neonates underwent operative repair of gastroschisis at the Department of Pediatric Surgery, Christian Medical College Hospital, Vellore. While one patient was closed primarily, the other 4 patients underwent silo creation using plastic material cut from a urine drainage bag. Two of these had a successful result and have been followed up for more than 6 months. The other two died of causes unrelated to the repair technique. We conclude that this plastic material from urine drainage bag is a freely available, cheap and effective alternative to other materials in the staged closure of gastroschisis.
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During the period 1994-1998, three patients with bilateral hydatid cysts of the lung (HCL) underwent operative removal of the cysts. In three of the six lungs operated upon the conventional technique was used: after removal of the cyst and suture closure of bronchial leaks, the chest was closed with an intercostal drainage tube. Two of these patients developed bronchopleural fistulae requiring rethoracotomy and prolonged hospital stays. The other three lungs were operated upon using the pneumonostomy technique: after excision of the cyst a separate catheter is fixed within the residual lung cavity and brought out through the adjacent chest wall, effectively marsupialising the residual cavity to the atmosphere. All these patients had an uneventful postoperative recovery. We conclude that the pneumonostomy technique is a very useful method of treating HCL surgically, especially when the cysts are bilateral and complicated.
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In this study, we sought a simple, easily implemented method of intraoperative control of blood glucose in diabetic patients in a large multispecialty teaching hospital. The Vellore regimen, which offers the advantages of a combined glucose insulin and variable rate infusion was evaluated. For every 1 to 50-mg/dL increase in blood glucose concentration more than 100 mg/dL, 1 U of insulin was added to the injection port of a 100-mL measured volume set containing 5% dextrose in water. Hourly monitoring of blood glucose was performed. The blood glucose control was compared with the different existing techniques followed in the hospital in 204 randomized patients: 98 in the study and 106 in the control group. The study group had a mean +/- sd blood glucose value of 156 +/- 36 mg/dL, and the control group's value was 189 +/- 63 mg/dL (P = 0.003). The percentage of patients who were poorly controlled (outside 100 to 200-mg/dL range) decreased from 51% to 28% (no patient less than 60 mg/dL) with this regimen as compared with the control group in which it increased from 49% to 72% (10 patients less than 60 mg/dL) (P = 0.0013). We conclude that the Vellore regimen is simple, effective, and safe for intraoperative blood glucose control.
Sparrow's nest. early days at Makunda
  • V A Ismavel
Ismavel VA. Sparrow's nest. early days at Makunda [Internet]. Available from: https://thesparrowsnest.net/2018/05/12/early-days-atmakunda/
The Makunda Model: a study of high-quality, accessible healthcare in low-resource settings
  • C Flint
  • K Fernandez
  • A Parikh
  • S Ridge
  • S Sammut
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].
Inpatient stays in rural hospitals
  • E Stranges
  • L Holmquist
  • R M Andrews
Stranges E, Holmquist L, Andrews RM. Inpatient stays in rural hospitals, 2007. Statistical Brief #85
Analysis of American Hospital Association Annual Survey data, 2014, for community hospitals. US Census Bureau: National and State Population Estimates
  • Us Census
  • Bureau
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
Average hospital expenses per inpatient day across 50 states. Becker's Hospital CFO Report
  • A Ellison
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/a verage-hospital-expenses-per-inpatient-day-across-50-states.html.
Robbing Peter to pay Paul
  • R Narayan
Narayan R. Robbing Peter to pay Paul. Christ Med J India. 1993 Jan-Mar;8(1): 8-9.