This document discusses the changing nature of healthcare from a faith-based model to a system focused on profits and contracts. It argues that this shift has led to increased darkness, as some physicians and hospitals prioritize wealth generation over patient care. While medicine involves both art and science, it is practiced by imperfect humans. The document evaluates different healthcare delivery systems and their aims, noting that for-profit systems are most openly commercial but can potentially put profits over patient needs. It suggests some healthcare providers have adopted an unethical "ends justify the means" approach. Overall, the document analyzes factors contributing to less ethical practices in healthcare.

1. Why the smallest candle burns brighter on a moonless night
Preface
 Comprehending the darkness, the candle and the paradox
 Comprehending Medicine: is it an art or a science?
 Are doctors & hospitals different or just extensions of each other?
Comprehending why it is getting dark in healthcare
 The changing nature of healthcare: from the faith to trust to the contract model
 Evaluating the three healthcare delivery systems: For-profit, Public & Charitable
What does it take to be a candle in healthcare of present times?
 Reiterating the raison d’etre for healthcare & doctors
 Getting decision making right in healthcare settings
 Congruent planning
 Decentralization: walk the talk
 Identifying strengths and weaknesses in the existing systems
 Feeding on weaknesses of the system & creating powerful solutions
 Creating additional USPs for your own organization through Disruptive innovation
 Twice as strong systems
Sustaining the light:
 Nurturing the first candle
 More candles
 Rome wasn’t built in a day
Defining Value based Leadership in Healthcare

2. Preface
Comprehending the darkness, the candle and the paradox
The thought of darkness brings with itself, perceptions of fear, vulnerability and ulterior
motives. This darkness is actually a metaphor for all that is not right, not ethical, not
transparent & maleficent. At the crux of this darkness is a power relationship where one
individual can gain intentionally at another’s loss because the gainer has or can create a
position that could enable him to exploit the other individual because he is in a dependent
relationship with the gainer. Although such situations are increasingly being observed in various
facets of our life, hardly few are as grave as the manifestation of this power relationship in
healthcare.
As we try to understand the relationship between the healthcare provider and the patient, it
becomes obvious that the latter are in a seriously dependent relationship with the former,
because the state of ill health is the most vulnerable position in an individual’s life. Healthcare
providers form some most erudite groups of professionals we have amongst us. In view of the
fact that their intervention could make a difference of life or death, they are accorded the very
rare status of being ‘life saviors’ that is nearly incomparable to any other group of professionals.
Now, this life savior status can be perceived in two diametrically opposite ways: on one hand it
may be accepted with the greatest humility as a chance to do extraordinary humanitarian work.
On the other hand however, it could be turned into the greatest power one individual could
wield upon the other. This choice of perception of this status is the key to the potential for
darkness in healthcare.
Note that this very choice is also the key to the potential for light. The candle is thus a
metaphor for this light that would dispel the darkness, like the virtue of ethical and beneficent
actions of even a handful of professionals, who would choose to accept this life savior status, as
not just a chance to do extraordinary humanitarian work, but also the responsibility to
safeguard their patients’ interests at a time when they need it the most.
The paradox is that as darkness continues to deepen; even the faintest light of even a small
candle shines brightly, sharply cutting through the pitch darkness around it. In the field of
healthcare, where at stake is life itself; at the darkest point of this power relationship, even the
smallest ray of hope from those few healthcare professionals standing up to their ideals will
shine brightly as a beacon reinstating the faith that there is a righteous way to practice
medicine, only if we choose to follow it.
This essay not only seeks to identify the factors and changes in social environments that
influenced the darkness plaguing healthcare delivery systems today, but also projects why and
how it is possible to do well by doing good* with an in-depth analysis of how healthcare
providers who have chosen the right way, actually work.
Comprehending Medicine: is it an art or a science?
Despite the effort to study or control health scientifically by healthcare professionals, is it
possible to define it completely in scientific terms? Probably not, because the ones studying it,
are humans too! Additionally, medicine intimately involves dealing with emotions associated
with ill health, which widely differ from one individual to another. This essentially involves an
important element of the art of dealing with people. Medicine as such, becomes both an art and
a science.

3. This gives rise to a complex situation, where we are not only dealing with something that is
significantly difficult and finitely explained by science, but also the fact that it is understood
only by an exclusive group of professionals, who themselves can’t claim to know it perfectly.
It is thus an imperfect science in the hands of imperfect people, so it’s worth remembering that
at any point of time, nothing is black and white, rather in shades of gray…
Are doctors and hospitals different or just extensions of each other?
Both doctors and hospitals offer similarly complex and highly skilled healthcare services. They
invariably depend on patients to remain in business, yet both essentially have the upper hand in
dictating terms since the patient is just as uninformed in either case. They are ideally bound by
the same ethical codes but the outcome practically depends on how ethical they actually decide
to remain. The only difference is in the scale. Simply put, hospitals can magnify either the
benefit they offer or the damage that they can cause to patients.
So a hospital is nothing but a giant doctor!
Comprehending why it is getting dark in healthcare
The changing nature of healthcare: a transition from the faith to trust to the contract
model
What existed before the present day scientific system took roots, was an entirely informal faith
based model that rested on the pillars of unquestioned divine beliefs and the alleviation of
suffering largely by supernatural powers. Just a few chants, drops of elixir from the God’s foods,
or even a healing hand were all that were needed to ‘cure’ suffering. In many cases we can’t
explain today, this actually worked!
As civilizations developed, rational questioning and scientific temper began to take center
stage. A unique breed of learned individuals who took pains to scientifically research and
understand the working of the human body and diseases came to be recognized as the earliest
physicians. One thing that distinguished them from the present day physicians was the fact
that they placed their knowledge and not themselves at the highest pedestal, and strove to
protect its honor. Consequently, despite whatever modest knowledge they had in treating
patients, they were trusted unconditionally by families for generations, and this was the
essence of the trust based model of doctoring.
With the advent of the Industrial Revolution, the World wars and the rise of capitalism & free
market economies; value systems across religions & regions began to change. Medicine too,
wasn’t insulated from these changes for it was essentially operating in those very
circumstances. Given the fact that doctors were essentially groups of professionals who would
need to heavily invest in their education in terms of time, skill and/or money, the returns on this
investment not only started becoming very important, but also getting quantified in terms of
wealth and success. The spirit of service to the suffering was replaced by a quid pro quo basis,
where doctors were transforming into businessmen, out to sell their wares for a good price.

4. Interestingly, this transition wasn’t one sided. Patients knew the worth of their money too
which is how bedside medicine transformed into evidence based medicine and doctors were
brought on the anvil to provide explanations whenever treatments did not work.
In this process, it wasn’t always easy to get rich even if doctors were trying to sell outright, so
by-routes had to be devised, which is precisely where the power relationship came in handy. A
new breed commercial and unethical physicians and hospitals emerged that worked on the
Machiavellian principle that “ends can justify the means” sending tremors down to the very
foundations of Hippocrates’s medicine. This was the real onset of darkness in healthcare that
continues to date, and threatens to worsen with every passing day.
The irony now is also that although the poor are usually worst hit, hardly anybody can escape
this racket irrespective of their financial power or otherwise, because they are still subordinated
by the exclusivity of knowledge that these skilled professionals possess. Whereas the poor are
commonly victims of unethical acts of omission, the rich can be additionally exploited by
unethical acts of commission because of the money that can be extracted from them.
It thus becomes imperative to examine the existing healthcare scenario to understand the crisis
faced by patients who are at the receiving end of this transition.
Evaluating the three healthcare delivery systems: For-profit, Public & Charitable
With the evolution of healthcare delivery systems, broadly three types of systems are in place
today, based on their purpose and costing patterns namely:
1. For profit (corporate and private healthcare)
2. Public (government hospitals)
3. Not for profit (charitable hospitals)
We examine the proposed aims and reality in each case.
The for-profit are per se the most blatantly commercial of the lot, as they wear their intentions
on their sleeves. Theoretically, the concept of free for-profit market economy claims this
enhances quality and value for money simply because of competition and consequent cost-
cutting. However, there is one important distinction that it does not make as obviously- as to
what levels hospitals could stoop to, in order to ensure this profitability. Also, competition
occurs in healthcare too, but in the for-profit hospitals, it does not necessarily result in quality
or value for money as is expected and rather ends up escalating costs as a result of marketing,
adding tones of unrelated secondary services under the guise of quality. Hospitals end up with
investing more for gaining more which is why even if they manage to provide very high quality
services, they are priced exponentially. What is more important is that these very hospitals can
maximally exploit the power relationship because eventually, it is easier and quicker to make
more money this way, than to wait for cost effective innovations or intelligent management
policies that can cut costs.
The public hospitals that are operated using tax-payers money are a part of the state’s
obligation to provide healthcare to ALL, at highly subsidized prices or even free of cost
wherever possible. There are different types of issues here. Firstly, not all funds
allocated towards the hospital’s functioning, actually reach the hospital thanks to the
long chain of hands it travels in a typical bureaucracy due to it getting siphoned out in
varying extents at every stage. Given the limited funds it must work with, there is often
lesser scope to bring in newer and state of the art technology. Secondly, with most

5. employees being permanent government servants, there is no likely risk of losing one’s
job irrespective of what quality or quantity of performance is delivered, and there are
no incentives for improvements either. Lastly, typical seniority based promotions,
unreasonably rigid and age-old rules for functioning, and a ‘distrust’ approach for
employees, leads to a typically bureaucratic functioning huddled with scope for work
inertia, red-tapism, bribing etc.
The charitable hospitals are a unique concept. It ideally starts with a philanthropist who wishes
to do something for society by providing affordable healthcare to the needy. Such
philanthropy however, may not be everlasting, and in today’s times may not even be
philanthropic in the first place! Charitable hospitals, in many cases, genuinely try to
serve the underprivileged class of society. In the endeavor however, they overlook the
need for effective management of funds, which is why in situations where funds don’t
come in continuously, (which can be pretty common), their functioning suffers and
consequently compromises the quality of care they may be able to provide. Eventually,
they may either be forced to close business or continue functioning like public hospitals
or even shift to a for-profit model. Also, the state, as a token of appreciation of the
efforts of philanthropists, offers various tax benefits to those who contribute to such
ventures. The more sinister issue with charitable organizations is that a lot of profit-
making companies often initiate trusts to use the loopholes for acquiring these tax
benefits or direct the surplus to personal benefits. What has followed over time is a slew
of officials appointed to check on these charities with the effect that in the bargain,
even true philanthropy has unfortunately turned into a punishing experience.
Charitable hospitals in reality can infact actually become the best system of healthcare delivery
if they get the fundamental concepts of sustainability, growth and ethical practice
right.
What does it take to be a candle in healthcare of present times?
It may be difficult, but it is not impossible to create honest healthcare delivery models even in
today’s materially driven times. This is not just a theoretical prescription, because there
are professionals who have begun to do it based on the concept of ethical and
sustainable & scalable charity. They stand firmly on the belief that medicine can only be
practiced ethically, coupled with the realization that patients too, believe that
healthcare providers need to be fairly compensated. It starts with the goodwill of the
generous few, builds on intelligent systems that bridge the gaps left by the other
models and steadily grows on its own strengths without losing sight of its primary aims
and ethics at any point in the journey. It is not a practically ideal model; it is rather a
practical model that preserves its ideals.
Let us try to understand how this actually works.
1. Reiterating the raison d’etre for healthcare & doctors
Lost in the haze of wealth and success, the medical profession is primarily losing track of what
possibly was its fundamental reason for existence. In most cases, as may be obvious

6. from the issues discussed above, crucial priorities are not in place, because they are
displaced by unrelated priorities like ‘bottom lines’ and ‘apparent success’.
There are only three primary aims for healthcare providers to exist, in that order of importance:
1. Best possible treatment for patients at a cost they can afford
2. Stable careers with steady growth and fair compensation for doctors
3. Commensurate benefits to the rest of the employees of the hospital
2. Getting decision making right in healthcare settings
Internalizing these aims of the medical profession are a pre-requisite to getting decision
making right in healthcare settings. This is because the cost of decisions is not just in
terms of money, but in terms of the patient’s life. Consequently, decision making must
proceed in the order of the aims. A simple rule is to reject the activity even if any one of
the condition is not being fulfilled, and to accept the activity only after it completely
fulfils the first condition and reasonably fulfils the other two. Most importantly, this
approach needs to be ingrained from the top management downwards to the lowest
rung of staff.
3. Congruent planning
Congruent planning at every stage is a must to ensure that the framework of ethical systems
does not weaken or collapse.
Policies must be in line with the mission statement of the hospital, and must again follow the
order of priorities listed above. Strong and tight policies that safeguard interests of
those who are most vulnerable are the fundamental to ethical organizations, especially
hospitals. Not compromising on quality, while finding intelligent ways of cutting costs
to keep prices of services low, is an example.
Strategies, like policies need to be intelligent enough to benefit those who need them the
most, without hurting the organization. Offering discounts on pharmacy drugs to
senior citizens is an example that not only benefits people who are most likely to be
chronic patients, and also creates loyal customers for the hospital. One time OPD fees
for a week of follow-up consultations is another bright idea that benefits the patient
first by letting choose any other doctors from the department. Also, doctors and the
organization benefit as the better the doctor, better the practice he builds, while the
hospital only benefits in the bargain.
Procedures and processes at ground level too, must follow inline with the policies and
strategies for the end result to be achieved. Free ambulance service for emergencies
upto a reasonable distance for example, is both a very good policy and an honest
strategy for getting patients to the hospital. It must be supported however, with the
fact that hefty deposits or complex paperwork are not a part of the admission
procedure for such acutely ill/injured patients or the entire purpose of reducing the
suffering for the patient is lost!
4. Decentralization: Walk the talk
One of the most important pre-requisites for decentralization is the level of trust amongst
employees. Most hospitals forget the fact that their employees are first their own internal

7. customers. How you treat them, is how they will treat your external customers i.e. patients. A
hospital is a unique organization which entirely depends on trust through the entire span of
hierarchy of employees. Decentralization here; is akin to trusting them that they would do their
jobs honestly and effectively without you demanding proof from them, just like they would
treat patients as though they were their own kith and kin. It needs to be developed by
constantly reiterating the mission of the hospital, and living it by leading through example, for
them to reflexely follow suit.
5. Identifying strengths and weaknesses of existing systems
Most people merely crib or complain about the problems and weaknesses in the system as
hindrances to their functioning and growth. Intelligent planners identify these very weaknesses
as opportunities to work on. When we examine the transition from faith to trust to contractual
model of medicine, we realize for example that the faith model simply cannot work in today’s
world. The trust model is infact the most rational model of medicine that needs to be restored.
However, to maintain a practical perspective, the concept of evidence based medicine from the
contractual model if implemented without significantly increasing costs, can be put to good use
to bring in better accountability and transparency in the system as it helps to weaken the power
relationship by reducing ambiguity and standardizing medical protocols.
6. Feeding on the weaknesses to creating powerful solutions
Retaining employees for example, is a challenge for most hospitals, even more so in case of
charitable hospitals because salaries may be less than industry standards. Most hospitals incur
serious costs in terms of money as well as diminishing performance in the process of holding
back key employees. That identifies a weakness. A powerful solution is letting go of even key
employees when they genuinely have better prospects somewhere else. They will retain their
loyalty to the hospital in many other less obvious forms, and it is less expensive to train a new
candidate than retain an unhappy one.
Working on targets is another common trend in most organizations that has been adopted into
hospitals too. That it merely creates pressure to manage quantity of performance makes it
prone to finding short cuts to achieve them, identifies a weakness in the system. Correctly
identifying and offering incentives for those who actually work harder and discouraging those
who don’t- is a simple and powerful solution!
7. Creating your own USPs for your own organization through disruptive innovation
In this process, we have so far only developed a day-to-day sustainable organization.
For the organization to grow, we need to have our own distinct strengths apart from the
weaknesses we built on, to be to get an actually competitive edge in the field. Hence, the need
for atleast some special service that we can become pioneers in, using a combination of highest
quality of that service at affordable cost. Again, the key is affordable cost, as many others may
offer the same quality at higher costs.
An example is Hyperbaric Oxygen Therapy (HBOT) at subsidized costs in a charitable hospital.
This therapy is available at very few places in India and its demand is being increasingly
recognized. This will not only give the hospital an edge in terms of exclusivity of the service, but
also brings the hospital into focus amongst all leading competitors who could refer patients to
this hospital for this specialized treatment. Patients obviously gain, whether they were
primarily taking treatment at the charitable hospital or even at any other private hospital,
because the cost cannot be matched by those private hospitals even if they happen to start
offering the service themselves.

8. 8. Twice as strong systems
This is the key to actually challenging the status quo squarely, because the lack of either one,
will not sustain the initiative long enough to make an impact. No matter what is the initial scale
of the impact, given the enormity of unethical practices in healthcare today, even the smallest
effort will create a great impact on those affected the most. This is why the smallest candle
burns brightly…
Sustaining the light
Nurturing the candle
The journey for this initiative is bound to be turbulent especially in the beginning as it will have
to break many new grounds. Infrastructural growth would be gradual & people would be
difficult to find and retain as employees because funds will be scarce. The management would
constantly have to be on the lookout for innovative cost-cutting measures that would help
them reduce their input costs so as to maintain affordable prices for their patients. Patients,
who have been largely disillusioned by the existing systems, may take time to believe the
hospital’s mission, so trust will have to be continuously built and maintained. Authorities would
ridicule or even oppose the attempt as it could unsettle many established nexuses. For-profit
competitors will soon start recognizing the threat and try to malign the hospital, grab patients,
staff and so on…
This period would infact be a test of the hospital’s commitment to its own mission. Once it
manages to tide over the initial steep curve, the flame will become more resilient, shine
brighter and start inspiring more candles…
More candles
One of the best things about this type of an approach is that you would like to encourage others
to imitate you!
Primarily, this is because the rigor and ethical commitment needed for the effort itself will
retain only those who truly want to make a difference. Also, it is a larger cause to serve, and
there is room for as many helping hands as possible. An important step is to target as many
healthcare professionals by catching them young, to show them that there are ethical means to
growth and wealth. Infact they need to be explained why this is the only way that won’t
backfire!
Rome wasn’t built in a day
We are unfortunately living in an age where everyone seems to be in a hurry to make it big, by
hook or crook. There is a need to redefine the very perceptions of ‘values’, ‘ambitions’ and
‘achievements’ in healthcare. Such paradigm shifts however, are not meant to be achieved
overnight.
They will happen gradually but steadily, because there are really no short cuts to the top.
Sustained efforts would be required and as they get compounded over time, once they reach
the acme, they start paying back exponentially in outcomes far greater than money.
What we wish to achieve here, is to create an ever-increasing team of healthcare providers who
will restore the fading trust in Medicine, by building systems that are transparent yet absolutely
sound in business principles.

9. Defining value based leadership in healthcare
Taking the path less traveled certainly calls for inspiring leaders who can pave the way for other
professionals to follow. Leadership in healthcare, much less value based leadership has been a
scarcely attended necessity. The need for trained management personnel in healthcare is being
increasingly recognized, and many doctors as well as allied healthcare professionals are training
to take up administrative roles in healthcare settings. There is tremendous scope to mould
these budding healthcare managers and senior management for striving towards ethical and
affordable healthcare, before unethical material aspirations become an inseparable way of their
professional lives. These professionals need to specially review and experience how such
sustainable & scalable charity hospital models can work successfully and progressively reinstate
the essence of medical service.
This type of value based leadership that defines the ideal vision, mission and objectives for
healthcare organizations is the need of the hour.
The essay ultimately seeks to appeal to institutes and students pursuing healthcare
management to help sustain and light more candles in this overwhelming task of eradicating
the darkness of unethical practices in this phenomenal business of saving lives - called
healthcare.