The Good Doctor

His true calling lay in not only treating the poor, but also offering quality care at no cost or low cost. The mission made the surgical oncologist leave Chennai and join a small charitable cancer hospital in Silchar, Assam. His seminal work has won him many awards and accolades, including a Padma Shri and the Ramon Magsaysay Award for 2023. Dr Ravi Kannan speaks to Renu Sud Sinha about his inspiring journey…

You have had a long journey in establishing subsidised cancer care. What have been the challenges?

There have been quite a few — the cost of treatment, drugs and equipment. The major challenge, of course, has been treating patients who are unable to pay even that subsidised cost. A much bigger challenge is the cost of human resources. In order to take care of the poor and sick, we need to reduce the cost of treatment, both in terms of equipment and drugs. We also need to cut the cost on human resources.

We need experts willing to take lower pay without compromising on the quality of treatment. Just because you treat the poor, it doesn’t mean you provide poor quality care

Many private hospitals are also part of the National Cancer Grid. As they add to the purchasing power, we are able to get better prices while negotiating with vendors, and that ultimately helps the poor

How do we reduce the cost on human resources?

To treat the poor, we need doctors, nurses, supporting staff, technology and drugs. All this needs money that we can’t generate or ask from the poor patients. So, we need to find people who are willing to take home lower pay packages without compromising on the quality of treatment and care. Just because you treat poor people, it doesn’t mean you provide poor quality care. And to provide quality care, you need to get good professionals, which remains a tough task.

It has become comparatively easy to negotiate the cost of good quality drugs, equipment, etc, because of the National Cancer Grid (NCG). The NCG is a huge network of major cancer centres, research institutes, patient groups and charitable institutions across India with the mandate of establishing uniform standards of patient care for prevention, diagnosis and treatment of cancer. Over 300 institutions are part of it. Because of this huge number, we are able to negotiate better prices with vendors. This number will only increase in future.

When I joined the Cachar Cancer Hospital and Research Centre (CCHRC) in Silchar (Assam) in 2007, I called a company about the cost of contrasts for CT scan and the local representative would not even come and meet me. Two years later, when our patient volumes grew, he came to meet me. And now everybody wants to sell to us. Also, with the NCG, we have a much larger purchasing capacity and can drive down the cost of drugs and equipment. We can purchase generic drugs. The cost of human resources remains a different story though.

How did the NCG come about?

The NCG started about 10 years ago with Dr CS Pramesh, director, Tata Memorial Hospital, Mumbai, taking the lead. Various hospitals started linking under the NCG. The aim was to provide uniform and high standards of cancer care, follow uniform evidence-based guidelines for treatment, whether it is Chennai, Chilika or Chandigarh, and develop adequately trained human resource to fulfil the cancer healthcare needs of the nation.

Private, government, charitable hospitals, all kinds of institutions are part of NCG. These private or for-profit institutions when they participate in group negotiations, they also add to the purchasing power. They may not lower their profit margins, but it benefits charitable institutions like ours as their participation in negotiations helps drive down the cost and that ultimately helps poor patients.

For charitable institutions, funds always remain a challenge. How do you manage to overcome it?

Before I joined CCHRC, I was working at Adyar Cancer Institute, Chennai. The institute’s philosophy was that whoever comes, it will provide treatment whether they could pay or not. That’s where I learned and imbibed this thought process. When I came to Silchar, I started with the same idea that all patients should get no-cost or low-cost treatment as well as board and lodging. To lower the cost, we started many initiatives, from buying generic drugs to having attendants participate in the care of patients. But we found out that not even a third of our patients were completing the treatment.

What were the hindrances and how did you overcome these?

The poor were scared of coming to hospitals as they thought it will bring them financial ruin. We also realised that many daily-wagers could not afford to lose a single day’s work. We decided to provide ad hoc employment to caregivers of the patients. We also started chasing them on the phone for appointments. We started home visits. We also started satellite clinics. Bit by bit, we tackled the problems as we faced them. About 70 per cent of patients complete the treatment now. It is still not 100 per cent. It is a continuous struggle because the poor need to be reassured all the time that we will deliver on our promise of quality care at no or low cost.

How do you win them over?

Everything matters. The way we look or behave, the way the hospital building looks — it must be clean but not fancy. Our staff, including the doorman, has to adopt an assuring body language and convey the impression that the hospital will take care of them. If we are a poor-friendly hospital, we have to show that every day, at every opportunity. Now we give basic training to all staff members on how to deal with patients. Step by step, it has been a tremendous and tenuous journey. We look at every challenge as an opportunity that how can we do better.

How did you embark on this journey?

I had amazing mentors all through my life — in medical school and later at the cancer institute in Chennai. I became a doctor because my mother, Indumati Rangaswamy, couldn’t become one. Growing up, she would see the family physician in her village visiting homes to treat people. That was her concept and image of a doctor — someone who would take care of the community or people around. My mother drilled this into me. Later, I was just fortunate that my teachers were the kind of people that I could aspire to be.

How do we create more committed doctors like you?

The biggest deficiency that we as a nation face is a lack of role models. We need people who will inspire us to be like them. I was fortunate to have such role models. We need role models like Sachin Tendulkar and Virat Kohli in every profession.

We have taken a stand that we will provide low-cost or no-cost services. We have worked hard to get affiliation with different funding agencies — from the Indian Cancer Society, PMJY, PM National Relief Fund, various state government insurance agencies. We also stretch the money that comes as much as possible. We are very clear that we are not looking at people at the top of the socio-economic pyramid but looking at people at the bottom of the pyramid where there is no competition. It is both good and bad in a way because competition drives quality. It is very easy for somebody working at the grassroots to become complacent. It is very important to constantly keep a watch on our outcomes and our behaviour. We have to persistently self-monitor. Had there been competition, it would have been auto-surveillance.

We have taken a conscious decision that our lowest salary will be Rs 15,000 and the difference between the lowest and highest salary will be 1:10. The highest salary will remain Rs 1.5 lakh. If someone asks for a raise, it will be from bottom onwards. If anyone expects more, he/she doesn’t fit into the organisation’s core values.

What are these core values?

Our most important core value is compassion, followed by a people-centric approach (for patients, caregivers, our own staff), team work, gratitude for all opportunities, evidence-based treatment and frugal innovations. Any time there is a problem, we try to solve it using our core values.

How was the move from one corner of India to another?

People move to Chicago from Chennai and try to assimilate but still can’t overcome the tag of their ethnicity. We only moved across India. It was not difficult at all. We received so much of affection, care. I have had no complaints. Ultimately, life is about people only.

From providing for a small number of patients initially to 5,000 new patients as well as 30,000 follow-up patients every year, and ad hoc employment for caregivers, how do you sustain the process?

We have introduced many interventions on the way. From monthly charges, we shifted to one-time charges. The patients’ compliance improved immediately. We then started ad hoc employment for caregivers. After so many years, I feel each of the interventions was a game-changer, a confidence-building measure. All these helped pushed compliance upwards from 30 per cent to 70. When we first introduced ad hoc employment in 2012, we employed only 30 people but the compliance rate was much higher from 28 per cent to 55 in one year. The ripple effect of every intervention has been much more than the intervention itself.

How do you plan to take this 70 per cent patient compliance rate to 100 per cent?

Many don’t get diagnosed or seek treatment because of distance from home and just die at home. We have introduced satellite day-care clinics in the region around from where our patients come. We want to have OPDs, follow-ups, diagnostics, chemotherapy, palliative care and even simple surgeries at these clinics. We have also started 3-4 one-man-one-room PEP (prevention, early detection, palliative care) centres. We plan to expand these two initiatives. The government of Tripura has also asked us to replicate this model and offered us 15-acre in the state. People keep on joining the movement and ultimately bring about change.