ISSUE NO. 17
The magazine for healthcare administrators and policy makers
Display to 31 October 2022
MODELS FOR DIGITAL HEALTH TRANSFORMATION INDONESIA’S PONDOK INDAH GROUP HOSPITAL ACHIEVES HIGHEST ASSESSMENT IN DIGITAL MATURITY
SINGHEALTH DUKE-NUS INVESTS IN ‘THE SEEDS OF THE FUTURE’ ONEONCO ALLOWS PATIENTS TO KICKSTART CANCER SUPPORT SYSTEM FOR $1
INTERNATIONAL AIDS SOCIETY TARGETS HIV’S ‘ACHILLES HEEL’ MALAYSIAN EYECARE CLINIC ELEVATES SERVICES WITH AI
Pondok Indah Hospital
FROM THE EDITOR
roviding high-quality healthcare in this day and age requires the latest health technology. In this issue, we highlight the newest digitisation initiatives in Asia’s healthcare sector, as well as its progress towards achieving net-zero goals.
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Even as the global pandemic persists, Asia’s healthcare pivots back to non-communicable disease, which remains its ‘blind spot’. SingHealth Duke-NUS launches a new institute that opens doors for maternal-child care research (page 14), whilst OneOnco introduces a digital-based solution for patients seeking to kickstart a cancer support system for $1 (page 18). In this issue, we feature Pondok Indah Group Hospital, the only hospital group in Indonesia to achieve the highest level of HIMSS EMRAM validation. See the full story on page 16. We sat down with Adeeba Kamarulzaman, President of the International AIDS Society, to discuss their latest campaign that promotes stigma-free HIV care in Asia. See the full story on page 24. We also talked with Dr. Khaw Hoon Hoon, one of the founders of Malaysia’s OasisEye Specialists, on their clinic’s utilisation of AI machines in remote areas where doctors are scarce. See the full interview on page 28. Best of health to you all.
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FEATURE PROFILE WHAT’S SO SPECIAL ABOUT PONDOK INDAH GROUP HOSPITAL GETTING HIMSS EMRAM
FIRST 04 7 ways to boost Indonesian healthcare’s digital supply chain 05 Health buddy app’s ‘Parkinson’s Care’ feature launched 06 What will drive India’s healthcare investments the in coming years 07 2 SEA hospitals see high-tech future with VR, metaverse 08 Accelerating public healthcare innovation
22 24 26 28
HEALTHCARE INSIGHT ASIA’S HEALTHCARE TOMORROW: PIVOTING BACK TO NONCOMMUNICABLE DISEASE
10 Conquering the hurdles in green 14
HEALTHCARE TECH ONEONCO ALLOWS PATIENTS TO KICKSTART CANCER SUPPORT SYSTEM FOR $1
hospital goals SingHealth Duke-NUS invests in ‘the seeds of the future’ Antibacterial sutures stitch the gaps in SSI care IAS targets HIV’s ‘Achilles heel’ How PairX Bio transforms cancer immunotherapies Malaysian eyecare clinic elevates
30 Moving telehealth from a temporary fix to a pillar of modern healthcare
32 The contract doctor conundrum: Is there a long-term solution?
services with AI
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FIRST costs, and improve the flexibility of the entire hospital network,” the report added.
Digital supply chains are currently fragmented, with different departments in the same hospitals often using different systems
7 ways to boost Indonesian healthcare’s digital supply chain
he problems in Indonesia’s healthcare system with a fragmented supply chain, information gaps, and lack of transparency have become more obvious as facilities struggled to obtain the supplies required amidst the surging pandemic. Thus, the Australia-Indonesia Centre (AIC) has highlighted seven ways for the country to build a ‘smart’ healthcare supply chain. The first is to develop an end-to-end digital platform that provides a central view from supply to procurement. AIC’s report noted that digital supply chains are currently fragmented, with different departments in the same hospitals often using different systems. Further, the applications in use appear to be rudimentary and tend not to be integrated. “Better end-to-end integration of digital supply chains that connect suppliers and upstream processes to a well-integrated internal hospital process is needed. All digital supply chain processes should be handled through this single platform,” the AIC report stated. 4
Further, all stakeholders are urged to integrate through a single platform that enables transparent operations and centralised or joint procurement, with all hospitals able to view it in real-time for planning and demand management. The second way is to have centralised logistics for all government hospitals. AIC found that hospitals in the country currently conduct their own procurement and manage logistics, noting that this is not the most efficient alternative. “If hospitals under the Ministry of Health can cluster together to manage functions through a centralised digital solution, this would be much more efficient. The shared e-catalogue platform facilitates collective bargaining, but a more holistic logistics solution may improve efficiency, reduce
Monitoring and standardisation Third: ramp up the flexibility of the e-catalogue. AIC said that the inflexibility of government procedures and bureaucratic processes has been hampering the effectiveness of hospitals’ supply chains. “Whilst the e-catalogue significantly reduces costs for hospitals, the lack of supplier choice can result in long lead-times. It can mean supply is not always available in regional areas. The system should present more than a single supplier and provide flexibility for hospitals to procure from nearby suppliers,” the AIC report added. Fourth is to make sure there are effective quality and safety monitoring functions. Centrally managed standards are advised to continue being implemented, even when greater flexibility and autonomy for procurement is facilitated in urgent cases. “Whilst greater flexibility of the Ministry of Health procurement platform will help hospitals obtain supplies efficiently, this needs to be balanced with the quality and safety of any resources,” the report stated. Fifth, the system must encourage standardisation and interoperability. “Standardisation of supply chain practices and interoperability of digital technologies across the healthcare sector would facilitate better integration and learning, with hospitals better able to share knowledge. This could also facilitate resource-sharing across hospitals,” AIC said. Sixth, hospitals must ensure transparency and traceability is built into all-digital supply chain solutions, in order to reduce fraud and ensure accountability. “Electronic tagging, robust supplier registration processes and better traceability of the upstream supply chain via systems integration can eradicate counterfeit medication,” the report stated. Lastly is to develop data analytics capability, which is critical for effective supply chain management. “Whilst ‘big data analytics’ can significantly affect healthcare supply chains, current analytics seem to be limited to forecasting at best. Real-time solutions, such as real-time streaming analytics, need to be incorporated as part of the future digital solution,” AIC said.
Standardisation of supply chain practices and interoperability of digital tech across the healthcare sector would facilitate better integration and learning
Health buddy app’s ‘Parkinson’s Care’ feature launched
o mark World Parkinson’s Disease Day (April 11), a care feature was added to Singapore’s Health Buddy app to help patients with Parkinson’s (PwPs) easily track their symptoms. According to National Neuroscience Institute (NNI), the Singapore General Hospital and Singapore Health Services’ (SingHealth) app added a digital tracker at the SingHealth’s Buddy app, which will record key Parkinson’s disease symptoms and complications including when will the effects of medication wear off, uncontrollable
body movements, poor sleep and low blood pressure. NNI, Singapore’s national and regional centre for neurosciences research, also noted that the symptoms of Parkinson’s may differ from day to day and hour to hour, with more complications arising as the condition progresses. This could be difficult for PwPs, caregivers, and health professionals treating this neurodegenerative disease. “When we see a patient in the clinic, we can only assess their symptoms at that point in time but
A digital journal makes sharing of information with caregivers or loved ones much easier
this may not be an accurate reflection of their experience over the past few months,” said Associate Prakash Kumar, senior consultant at NNI’s Department of Neurology. “So tracking symptoms between appointments is an important part of PD self-care, because it gives the healthcare team a much clearer picture of their condition and how it is progressing. This helps us make appropriate treatment changes to help them manage their symptoms,” he further explained. Managing Parkinson’s Whilst there is no current cure for the condition, NNI said treating PwPs focuses on managing symptoms. Teh Choon Ling, centre manager of Parkinson Society Singapore, the app will act as a digital journal for PwPs, which will be easier as patients, who have writing difficulties, usually log their symptoms using a notebook. “A digital journal makes sharing of information with caregivers or loved ones much easier, and the report feature allows for an instant overview of all their symptoms. Medication management with reminders preset is also very useful for both PwP and their caregivers,” she said. NNI, also a member of SingHealth, cited that about three in 1,000 Singaporeans in the age group of 50 years have Parkinson’s disease, which is the second most common neurodegenerative ailment worldwide.
MEDICAL DEVICE PRODUCERS WITH ADVANCED R&D IN CHINA TO OUTPERFORM PEERS: UOB KAY HIAN
ome pharmaceutical firms and other research and development companies with advanced research and development on anti COVID-19 treatments and vaccines in China will outperform their peers, stemming from a demand for increasing availability of effective therapeutics and vaccines, investment banking company, UOB Kay Hian, said. In its research on China’s healthcare sector, the firm sees that the strict lockdown measures will effectively mitigate the new wave of COVID-19 in China. With this, UOB Kay Hian pushed
for increasing the availability of effective therapeutics and vaccines to improve the situation. Due to these demands, UOB Kay Hian said companies with good potential for launching advanced COVID-19 treatments and vaccines will benefit and are likely to outperform their peers. Amongst the Chinese medical device producers that will likely become profitable are WuXi AppTec, WuXi Bio, CSPC Pharma Group, and Mindray. UOB Kay Hian cited that China logged a vaccination rate of 88.1%, with 1.24 billion people receiving 3.29 billion doses of vaccines.
Companies with good potential for launching advanced COVID-19 treatments and vaccines are likely to outperform
FIRST “Additionally, an increase in the prevalence of lifestyle or chronic diseases coupled with higher purchasing capacity will enhance the demand for specialised healthcare. Health insurance coverage is also expected to increase significantly on account of rising income levels and urbanisation,” the report stated further explained.
Although India has the largest youth population, its number of senior citizens are rising
What will drive India’s healthcare investments in the coming years
rends such as the rising income and the dual burden of disease are likely to boost the demand for investing on healthcare in India as well as influence the nature of health services demanded in the years to come, according to a report from NITI Aayog. A rising income could result in around 73 million households becoming part of the middle class over the next 10 years, thereby enhancing their purchasing power. It is expected that 8% of Indians will earn more than $12,000 per annum by 2026. Life expectancy in the country is also expected to surpass 70 years by 2022, and the country’s population is projected to rise to 1.45 billion by 2028, making it the most populous nation globally. Further, the country has the largest population of youth compared to any country in the world, but the number of senior citizens is also growing. The share of senior citizens in the population will double from 8.6% in 2011 to 16% by 2041. The country is also facing a dual burden of disease. Whilst communicable diseases still account for 33% of Disability Adjusted Life Years (DALYs) lost, a rising morbidity and
mortality cost is now attributable to noncommunicable diseases (NCDs) with 55% of DALYs lost. For instance, India currently has around 60 million diabetics, a number that is expected to swell to 90 million by 2025. It is estimated that every fourth individual in India aged above 18 years has hypertension. Nearly 5.8 million Indians die from NCDs, and the rising NCD burden is projected to cost India a staggering $4.58t before 2030. Lifestyle disorders are also on the rise due to a combination of rising incomes, accelerated pace of urbanisation and increased life expectancy. The fat consumption in diets is growing, which alongside reduced physical activity, is leading to an upswing in obesity, cardiovascular diseases and cancer.
Drivers of medical investments Medical value travel (MVT) is also driving the growth in India’s healthcare sector. “India is fast emerging as an attractive destination for medical value travellers from across the globe. In particular, wellness tourism is growing faster than global tourism, as an increasing number of consumers and travellers are incorporating wellness into their travel plans,” the report added. Several recent policy measures are also expected to help drive the growth of India’s healthcare sector. These include a rise in public health expenditure to 2.5% of GDP by 2025 and implementation of several largescale public healthcare initiatives such as Ayushman Bharat. The government also committed to invest $200b in medical infrastructure by 2024 as well as the roll out of various schemes under the Aatma Nirbhar Bharat Abhiyaan. The Performance-Linked Incentive (PLI) Scheme and the Scheme for Promotion of Medical Device Parks is expected to offer significant financial incentives for investors to manufacture in India. Other important drivers of growth include the enhanced adoption of telemedicine and other digital technologies in the postCOVID era as well as the emergence of PPP models in healthcare. Chains of private hospitals are increasingly foraying beyond the metropolitan cities into Tier 2 and Tier 3 cities as well. “More and more private players are seeking accreditation and developing new healthcare models. Further, various states have launched innovative initiatives to attract PPP investments into the healthcare space,” the report added.
India’s population is projected to rise to 1.45 billion by 2028
FIRST their home, is something that’s going to be very, very powerful.” IHH chief information officer Linus Tham added the quickly evolving digital technologies offer ‘a huge opportunity’ to enhance services and experiences in telemedicine and teleconsultation. “The combination of AR, VR, and the metaverse environment will give that unique engagement opportunity that we can have with our staff and with the patients,” Tham told the Nikkei forum. “I look at further transforming how health care is delivered. We’re not replacing bricks and mortar, but complementing [them]”.
VR, AR and the metaverse will expand beyond video games and into healthcare
2 SEA hospitals see high-tech future with VR, metaverse
alaysia-based IHH Healthcare and Indonesia’s Siloam International Hospitals both saw big opportunities in using virtual and augmented reality to boost their telemedicine services, with patients one day potentially turning to the metaverse to help them recover. The two hospitals have been tapping telemedicine in the face of the COVID-19 pandemic, using technology to reach patients hit by movement restrictions or in remote areas. They have also begun to explore artificial intelligence and data analysis to support diagnosis and improve the quality of care. Now they think virtual reality (VR), augmented reality (AR),
and the metaverse will expand beyond video games and into healthcare. Siloam deputy president director Caroline Riady said, “I think that these capabilities provide new methods to deliver care. One day we hope to have a metaverse hospital, and there are a lot of services that can be provided in that kind of form.” During the Nikkei Innovative Asia forum held in Singapore, Riady cited the example of potentially using such technology in psychiatry and psychology where patients might prefer to have counselling at home. “Being able to feel like they’re sitting in front of a doctor, sitting in front of somebody counselling them, except not leaving
We’re not replacing bricks and mortar, but complementing them
Drone delivery Over the next 10 to 15 years, he expects drones to deliver drugs directly to people in isolated regions where health facilities are scarce. He also expects developments in AI and machine learning technology to help doctors from counselling outpatients to remotely monitoring patients in intensive care units. The e-Conomy SEA 2021 report released from November 2021 by Google, Temasek, and Bain & Company showed health tech in Southeast Asia ‘continues its upward trajectory’ amid the enduring pandemic, citing ‘increasingly bullish’ investor appetite in the sector with a record-high $1.1 billion funding in the first half of 2021 alone, versus around $800 million for the whole of 2020.
MOH TO REVIEW USE OF TRACETOGETHER
s Singapore passed the peak of the Omicron wave, the Ministry of Health said it is also reviewing measures such as TraceTogether, SafeEntry, and Vaccination-Differentiated Safe Management Measures (VDS). The MOH said the Multi-Ministry Taskforce (MTF) will review the relevance and application of TraceTogether as the ministry no longer relies on the app for contact tracing for the general public. “There is really no need to compare the data between self-reporting and TraceTogether, because having vaccinated the vast majority of our population and being determined to live with COVID-19, we have passed that stage of the pandemic where we contact trace every case,” the Ministry of Health said. However, MOH also underscored that the app is being used by agencies looking after more vulnerable sectors, such as schools or pre-schools. The ministry said the MTF will decide on
standing the app down when it is no longer needed whilst maintaining the capability to restart it should Singapore encounter a more dangerous variant of concern. On VDS, the MOH said the measure is still “needed” considering that 3.5% of the country’s adult population is still not fully vaccinated. “The more cautious and correct course of action now is to keep VDS, and not to risk having more non-fully vaccinated patients getting infected and needing hospital care and adding workload to our healthcare workers,” the MOH said. With VDS still in place, MOH said SafeENtry will also be retained as it is the “most convenient way to check the vaccination status of an individual entering a premise.” The government has earlier made relaxations on Safe Management Measures (SMMs), particularly on travel.
The MOH no longer uses the app for general public contact tracing
FIRST towards sustainable development goals. Policymakers can propel wider cloud adoption and unleash even greater innovation by implementing riskbased digital policies like clear Cloud First policies that apply to healthcare, training workers in cloud skills, and collaborating with the private sector to leverage the full spectrum of cloud capabilities for the good of all citizens,” added AWS APJ head of public policy Quint Simon.
MEDICAL TRAVEL IN ASIA REBOUNDING: IHH ASIA
emand for medical tourism is starting to rebound and will grow beyond pre-pandemic levels as border restrictions ease, according to IHH Healthcare. In an interview with Nikkei Asia, CEO Kelvin Loh said vaccination programmes progressing and borders reopening across Asia will make international patients return, and demand for medical tourism will surpass pre-pandemic levels in the longer term. He added that border controls introduced by several countries to combat COVID-19 have dampened medical tourism. The hospital group highlighted returning patients in various countries. In Turkey, where IHH earned 16% of its revenue from medical tourism, patient numbers returned to normal within a month or two after the country reopened its borders. In Singapore, the company’s hospitals received hundreds of bookings within a week of the city-state extending its quarantine-free entry scheme to Indonesia in late 2021. Before COVID, a quarter of IHH’s total inpatient revenue in Singapore was from international patients. Asia’s economic growth The underlying dynamic for medical travel in Asia is the region’s economic growth. Economic development tends to outpace the rate of medical development in certain countries, so anyone who wants and can afford something that they cannot find locally will go abroad to get it. Healthcare in neighbouring countries, such as Indonesia, is improving but is not yet to the point where it takes away the necessity or desire for medical travel by those with the means to pay for it. Amongst other key strategies to tap growing medical demand will be investments in technology, such as artificial intelligence that could improve the speed and accuracy of care. 8
Governments and healthcare organisations must build on the momentum of the rapid digitalisation during the pandemic
Accelerating public healthcare innovation
hink tank ACCESS Health International, in collaboration with AWS Institute from Amazon Web Services (AWS), announced a new report titled Overcoming Barriers to Cloud Adoption in Public Healthcare in the Asia-Pacific. The research shows that policymakers and healthcare leaders have an incredible opportunity to unleash further innovation in the healthcare industry. ACCESS Health International Senior Consultant Simeen Mirza said, “Rapid digitalisation during the pandemic has brought about remarkable advances in disease surveillance, telemedicine, and vaccine rollout. To unlock the full potential of digital health, now is an opportune time for governments and healthcare organisations to build on this momentum and take immediate action to solve the pressing challenges that are facing public healthcare today.” “We encourage policymakers and healthcare leaders to make digital transformation on healthcare a priority, so as to reduce costs, improve outcomes, ensure equity of access to healthcare, and accelerate progress
Establishing clarity in healthcare data governance and a cloud-first policy Where there are existing government cloud-first policies, it should be explicitly stated that these also cover healthcare data workloads. A central digital health authority that prioritises using cloud-based technology solutions over other IT solutions can provide a clear transformation roadmap that allows healthcare organisations to optimise infrastructure costs and access scalable IT resources whilst building a connected healthcare ecosystem. A great example of this comes from the UK National Health Service Digital.
Closing the digital skills gap in the healthcare sector To enable transformative innovation across the healthcare sector, governments need to work with industry to implement educational programs and training to upskill the workforce and to design and build human-centric digital health applications. To accelerate the digitisation drive, governments should empower a designated body to boost capacity building and drive digital initiatives in partnership with the private sector. Training in cloud technology can also improve organisational efficiency.
We encourage policymakers and healthcare leaders to make digital healthcare a priority
Understanding the benefits and security capabilities of the cloud Research respondents in the report also shared that due to a lack of awareness or understanding of the cloud technology, policymakers and healthcare leaders have misconceptions around security and the privacy of cloud-based data. The cloud is secure and can open up opportunities for digital transformation for healthcare systems in Asia Pacific and Japan.
CO-PUBLISHED CORPORATE PROFILE
Delivering hope amidst crisis through unparalleled logistics expertise Moving aid to where it is needed most is crucial to address the healthcare needs of the world’s underprivileged. By Audrey Cheong, regional vice president, Southeast Asia, FedEx Express
hen the 7.2-magnitude earthquake devastated Haiti in August 2021, close to a million people were left in dire need of humanitarian assistance. The quake took a particular toll on the country’s already struggling healthcare system, with ill-equipped hospitals unable to accommodate thousands of injured patients. Relief organisations swiftly mobilised to provide aid. This was easier said than done. Much of the damage occurred far from Port-au-Prince, the capital, away from roads and airports. Still, in less than a fortnight, the International Medical Corps had established a fully functional emergency field response hospital in the hard-hit southwestern town of Aquin through dedicated chartered flights. The field hospital functioned as a self-sufficient outpatient health facility with trained staff, supplies, and equipment needed to provide a wide range of medical services.1 About 79 tonnes of critical medical supplies were also shipped by FedEx to the worst-affected areas through another chartered flight loaded with $8million worth of prescription medications, IV solutions, emergency medical backpacks, and other supplies.2 Behind the smooth operations was a robust logistics system capable of addressing the need for humanitarian aid under intense pressure. This is just one example of how logistics plays a critical role in delivering aid and hope to vulnerable communities around the globe. Bridging the gap In times of crisis, if humanitarian aid serves as a critical lifeline for millions of people worldwide, then the logistics service could be an invisible vein that connects the movement of relief supplies with people in need. The most promising developments in the overland movement were helicopters and vertical-takeoff-and-landing aircraft, along with techniques of rapid airfield construction, which enabled streamlined airmobile forces and their logistic tails to overleap terrain obstacles and significantly reduced their dependence on roads, airfields, and forward bases. Since then, humanitarian aid has saved multiple lives at a faster speed. Over the past two and a half years, however,
FedEx delivered COVID-19 vaccines and antigen test kits to communities
FedEx is committed to continue leveraging its global network, leading healthcare delivery solutions and decades of expertise to help deliver more mission-critical aid to communities the health and economic shocks of COVID-19 have further exacerbated the need for moving aid across the world. Even countries with fewer reported cases have still experienced severe impacts on livelihoods, household income, poverty, and food security. In many countries, the pandemic has also further constrained access to medical care for maternal and child health. Moving beyond the pandemic In 2022, an estimated 291.3 million people will need humanitarian assistance and protection - a significant increase from 235 million people just a year ago,3 which was already the highest figure in decades. The need for humanitarian aid is keenly felt across the Asia Pacific region, which is home to onequarter of the world’s conflicts and several protracted crises.4 Even as the COVID-19 situation eases, many countries across Asia still struggle to procure vaccines and other supplies. An equitable vaccine rollout is the ideal, and developing countries need support in vaccine procurement and life-saving medical supplies. For example, whilst India was in the grips of a crippling COVID-19 resurge back in June 2021, logistics services providers such as FedEx, donated three dedicated chartered flights to deliver tens of thousands of critically needed oxygen concentrators, and hundreds
of tonnes of medical supplies and aid into the country. When Vietnam and South Korea were battling the surge of the Delta variant last year, FedEx was at the forefront, delivering hundreds of thousands of COVID-19 vaccines and antigen test kits to communities where these were needed the most. To date, FedEx has collectively delivered approximately 14,000 COVID-19 related humanitarian relief shipments through close collaboration with governments and healthcare organisations worldwide. This demonstrates how the private sector could be an important ally to the collective cause, mobilising resources and strengthening emergency preparedness and recovery. With Omicron raging worldwide and complex geopolitical shifts, greater collaboration is needed to include the private sector in humanitarian coordination system. Delivering humanitarian aid is about igniting hope and sharing support. FedEx has set an ambitious goal of creating positive impact to 50 million people around the world by 2023,5 and is committed to continue leveraging its global network, leading healthcare delivery solutions and decades of expertise to help deliver more mission-critical aid to communities. Learn more about how FedEx supports humanitarian aid and the healthcare industry on FedEx Business Insights.
https://internationalmedicalcorps.org/story/finding-hope-in-hard- hit-haiti/ https://newsroom.fedex.com/newsroom/fedex-working-with-relief-agencies-to-deliver-critical-aid-to-haiti/ https://reliefweb.int/report/world/global-humanitarian-overview-2022-february-update 4 https://reliefweb.int/sites/reliefweb.int/files/resources/Global%20Humanitarian%20Overview%202022.pdf 5 https://fedexcares.com/50-by-50 1 2 3
Conquering the hurdles in green hospital goals
Procurement is amongst the 10-goal GGHH framework to achieve net-zero by 2050.
ost hospitals spurred medical innovations on saving lives but missed an opportunity to protect the world where patients live. But not Buddhist Dalin Tzuchi General Hospital of Taiwan, which is one of the 1,500 members of the Global Green and Healthy Hospitals (GGHH) community. Ming-nan Lin, vice superintendent and director of family medicine at Buddhist Dalin Tzuchi General Hospital of Taiwan, spoke with Healthcare Asia, to discuss how they followed the comprehensive framework under 10 GGHH goals to improve their greenhouse goal program and could lead them to achieve a net-zero goal by 2050, which seeks to limit global warming to 1.5°C by enforcing strict climate policies and innovations. Amongst the 10 goals that they follow are leadership, chemicals, waste, energy, water, transportation, food, pharmaceuticals, buildings, and purchasing. For Lin, he said their hospital encountered challenges in the procurement of sustainable medical equipment with the absence of a framework that would calculate the carbon footprint of such tools. To prove his point, Lin mentioned that there is a call to replace even inhalers for asthma patients and anaesthetic gas—which contributes to global warming 10,000 more than carbon dioxide—with more eco-friendly options as both hospital care needs emit greenhouse gases that will cause global warming. Although difficult, Lin noted that they learn from hospital practices, such as in the UK, to calculate the carbon footprint from the transportation of patients to medical devices being used for treating their patients. What drew you to joining the GGHH network and realising its goals? In the year 2012, when Taiwan held the Health Promoting Hospital (HPH) international conference, we had a preconference for green hospitals. That is the year we knew about the GGHH initiative that is from Taiwan’s Health Care Without Harm. The GGHH network and Health Care Without Harm released the GGHH 10-goal manual, in which we are agreeing that, as a hospital, we want to reduce the environmental impacts besides taking care of the patients. We also want to work on our environmental impacts; and the GGHH 10 goals let us check up on the 10 greenhouse growth domains. In 2012, our hospital helped our government to write the book. We call it the Taiwan Green Hospital Experience, which is called Green Hospital Green Life in Green Planet. Then, we shared our experiences. But the GGHH 10 goal provides us a comprehensive framework that we can check on our greenhouse goal 10
Ming-nan Lin, Vice Superintendent and Director of Family Medicine, Buddhist Dalin Tzu Chi General Hospital of Taiwan
program so that we can investigate, we can audit what we have done in our hospital and also share our experience to the other hospitals.
In Taiwan, we don’t have quite a comprehensive system to identify the carbon footprint of each product
Amongst the 10 GGHH goals, which were the easiest ones to achieve? As for me, I think that leadership is the easiest because we got very strong support from the hospital and also from the foundation. We belong to Tzu Chi Fund Medical Foundation, and Tzu Chi Foundation is chartered and founded by our Dharma Master Cheng Yen. From the beginning of the foundation, she told us that the mission of our foundation is not only to help people, but reducing the environmental impacts and also cherishing the environment. The various strong support from our foundation and also the hospital, which can lead us to arrange many greenhouse programs, and then also training our colleagues, and also investing in energy reducing facilities, and also the greenhouse buildings. I think that the strong support from the leadership is the way that we think we were, it is one of the easiest goals that we can achieve. Which of these goals were quite difficult to reach? It is the procurement. In Taiwan, we don’t have quite a comprehensive system to identify the footprint of each product so we need more support or more guidelines
INTERVIEW from our government or from other non-government organisations (NGOs) to focus on calculating the carbon footprint of different medical products. We now try our best to procure products with a less carbon footprint, but it is not easy because not all the products have this kind of information that we can buy. How can hospitals address this procurement issue? There are so many ways that we can do to reduce the environmental impact of hospitals. Mostly we focus on reducing the use of energy, recycling the waste, and so forth. But more than half of the carbon footprint produced in hospital services is determined by procurement. According to lifecycle analysis, the carbon footprint of the product we used is decided mostly during the manufacturing process. If we want to reduce the carbon footprint of the medical services, we need to have information about which product is more environmentally friendly. However, currently, in Taiwan and also I think in most countries, we don’t have enough information about which product is better for the environment. The health care sector has to work together using the bargaining power for medical product procurement to solve the issue. At the moment, what assessment can you give your institution in terms of meeting the GGHH and the global goal of net-zero emissions by 2050? Now, we are the first one in Asia to join Race to Zero 2050. We try to study experiences from other countries such as National Health Services (NHS) from the UK because I attended a COP 26 (26th United Nations Climate Change conference) in Glasgow last year, and then they have already done this kind of assessment from there in the NHS. So whilst we learn from them, we also try to assess, we try to audit the carbon footprint of the hospital. Thanks to Health Care Without Harm because whenever we don’t know the exact way to calculate our carbon emission, we ask them, and then they provide us some information and also ask an expert to teach us. Now, there are still some items we still need to work on but I think that we will try our best and then it is quite okay because, with the support of our leadership and our foundation, we think that we can go on to take the challenge of Race to Zero by the year 2050. Can you expound more on what information you learned from UK experts regarding the auditing of carbon footprint in health services? At the WHO conference at United Nations Framework Convention on Climate Change COP 26, the NHS of the United Kingdom shared their experiences in the race to net-zero by 2050. It is not easy to exactly calculate the carbon footprint in health services. Besides the energy used, and medical waste produced, we also need to calculate the carbon footprint from the transportation of the staff, patients, and their families. There are also many greenhouse gases that will cause global warming more than 10,000 times compared with carbon dioxide, such as anaesthetic gas. The inhaler for asthma patients will also produce greenhouse gas. Some pharmaceutical companies try to replace the inhaler with other devices which are more environmentally friendly.
A hospital is one of the organisations that will produce a lot of waste and also use a lot of natural resources
What advice can you give other hospitals that would also like to adopt the GGHH initiative? I think that because most healthcare professionals and hospitals aim to improve the medical quality and also patient safety, the environment or the climate change issue are maybe not their priority. We need to go upstream, we treat the patient and treat the diseases, but we need to keep our patient healthy so we need to improve or reduce the possible risk that is causing our fellow citizens to be sick. A hospital is one of the buildings or one of the organisations that will produce a lot of waste and also use a lot of natural resources. I think that we need to think more because if we don’t do anything about this, then there are more and more patients and more and more diseases we need to cure. From the policy side and from practices side, we need the help of Health Care Without Harm, or from other NGO like Global Climate and Health Alliance, these these kinds of NGOs, who can advocate for the climate change issue, and then let all the healthcare professional and all the hospital administrators, and then all the governments know the importance of climate change and health. What projects do you have in your pipeline that revolve around this agenda? We have a lot of the projects but I think that the Race to Zero by the year 2050 campaign, we know the scope. According to this kind of scope item, we work on each one to reduce our carbon footprint. We also joined the Rise Taiwan Alliance to help our federal hospitals, hospitals around Taiwan, and GGHH member hospitals. Also, we work together because we, in Taiwan, share the same experience, we may face the same problems. We try to push our government to support the green hospital programs. We also joined the healthcare climate challenge. And now, Health Care Without Harm Climate Impact Checkup is a training tool, and then they will hold this kind of training workshop, and then we will also invite our federal hospital colleagues to join this climate impact checkup tool training workshops.
Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan
CO-PUBLISHED CORPORATE PROFILE
Create a single source of truth to improve the quality of care
The true cost of poorly managed data could be holding healthcare organisations back, explains Luciano Brustia, Regional Managing Director, Asia Pacific at InterSystems.
Luciano Brustia, Regional Managing Director, Asia Pacific, InterSystems.
e all know there is value in data. With modern data analytics, healthcare organisations can improve the quality of care by linking data across systems, analysing it in new ways, and using it to inform decision making. But poor data quality is holding many organisations back. Recent U.S. research commissioned by InterSystems found only 20% of healthcare organisation executives fully trust the data they rely on to make decisions. This is also a big problem for Asian healthcare organisations, says Luciano Brustia, Regional Managing Director, Asia Pacific at InterSystems. “Bad data” impacts staffing, business decision making and clinical care. According to 53% of healthcare executives, poor data quality impacts their ability to identify gaps in care, meet quality metrics, and optimise the revenue cycle. It also costs money. For a 2000-bed organisation, a Sage Growth Partners white paper calculated the average cost to be US$12.9m per year. Improving data quality and creating a single source of truth would save organisations money, says Brustia. It could have even more significant clinical and business benefits through data-driven
healthcare approaches, like value-based care, predictive analytics and AI. “One of the biggest trends compounding these issues is the increasing volume of healthcare data, growing faster than almost any other industry,” Brustia explains. “For example, more and more medical devices are collecting data either in the hospital or in the home.” The challenge for most healthcare organisations, he says, is to move from somewhat trusting their data to fully trusting their data. That can be achieved by “harmonisation” or creating a single source of truth for data across the organisation. Inconsistent data is a widespread problem. Data may make sense within the system it was created, but not when compared with data from another system. For example, if the names of medications, consumables or suppliers are not the same across different systems, then the results of analysis will not be trusted. Organisations need to take a holistic approach with a new architectural approach called an “enterprise data fabric,” says Brustia, that speeds and simplifies access to data assets. It can unify, harmonise and analyse data across an organisation far more easily and quickly than manual processes.
Organisations need to take a holistic approach with a new architectural approach called an “enterprise data fabric” that speeds and simplifies access to data assets 12
Data fabric in hospitals A “smart data fabric” takes this approach one step further by adding analytics capabilities like self-service business intelligence, natural language processing, and machine learning.But organisations need more than a technology fix, he says. Technology capabilities like interoperability, data management and data analytics are only part of a smart data fabric approach. Success will also require cultural change in systems adoption, data literacy and collaboration with suppliers. “Talking to executives in Asian hospitals, we have identified several factors reducing trust in data,” says Brustia. “One is the way systems are used. If a system is not fully adopted by staff, or data entry is difficult and people take shortcuts, then its data is not trusted.” Improving data quality requires engagement, he explains. “Clinicians need to see the link between the quality of data captured by their systems and the quality of their outcomes. That means answering the question, ‘What’s in it for me?’, and finding ways to deliver data analysis back to clinicians – using visualisation or AI tools, for example – to help them do their jobs.” People also need to understand the potential of technology. After assessing the data literacy of staff, Brustia suggests that organisations put learning and mentoring programs in place, tailoring their approach to each individual. Healthcare leaders should also look for innovative data-driven solutions from suppliers, including health tech companies and start-ups, medical technology and device companies, and pharmaceutical companies. The take-up of these solutions will be facilitated by modern interoperability standards like HL7 FHIR, which works securely via the Internet. “If products include standards-based interoperability, they can leverage existing infrastructure to make them easier and more costeffective to deploy.” “But technology cannot work in isolation,” concludes Brustia. “Your people and processes need to be aligned with your technology, and healthcare leaders need to recognise that.”
Trends shaping Asia Pacific digital health Asia Pacific’s digital healthcare landscape is evolving rapidly, driven by rising consumer demands, rapid technology advancements, and more complex healthcare needs. Healthcare organisations are under pressure to deliver digital-first, seamless, secure, and connected healthcare experiences to keep pace with digital
Download the full complimentary eBook: www.InterSystems.com/sg/HealthTrendsAPAC
evolution and deliver first-class patient care. There are five major trends shaping the future of healthcare delivery in Asia Pacific that healthcare providers need to be aware of to ensure their organisations are equipped to take advantage of the emerging opportunities.
SingHealth DukeNUS invests in ‘the seeds of the future’ It launched a new institute that opens doors for maternal-child care research.
or SingHealth Duke-NUS, taking care of mothers and their kids should go beyond giving medical treatment by also optimising their mental, socioeconomic, and educational wellness. This goal was amplified after launching the Maternal and Child Health Research Institute (MCHRI) at the KK Women’s and Children’s Hospital (KKH). MCHRI, the culmination of SingHealth Duke-NUS Academic Clinical Programmes for Paediatrics’ and Obstetrics & Gynaecology’s 10th year, is eyeing to advance the reproductive, metabolic, and mental health of women and their children through life-course strategy and creating the latest medical technology that will better manage pregnancies with genetic disorders. Healthcare Asia sat down with Associate Professor Ng Kee Chong, the recently appointed director of the MCHRI and the current medical board chairman of the KKH, to know more about the formation of the research institute, its goals, and what it contributes to the maternal and child health community in Singapore. Ng prides himself on being part of Singapore’s only women’s and children’s hospital, which has a rich 160-yearold history. The hospital also holds a Guinness Book world record with the most deliveries in 1966 at 39,835 births. According to Ng, KKH delivers more than one-third of the deliveries in Singapore every year. He added in the last five to ten years, they have worked through the Ministry of Health and charitable institutions to reach out to the community and develop an ecosystem to care for women and children better.
MCHRI aims to advance the reproductive, metabolic, and mental health of women and their children (Photo: Associate Professor Ng Kee Chong)
What are the medical highlights you can share for KKH, leading to the formation and launch of MCHRI? KKH has the largest child development unit in Singapore that helps improve care for child development and children with special needs such as attention deficit and learning disorders. We also work very closely with the community to try to improve care in the whole continuum. The second highlight is in psychosocial trauma support. We partnered with [the Temasek Foundation] to help improve psychosocial trauma support care for children in the community by working with the family service centres. We are also proud of the region’s first human milk bank, which opened two to three years ago. It currently provides pasteurised breast milk for babies who are unable to get breast milk. That helps to improve general health and prevent things like necrotising enterocolitis. How does KKH contribute to the MCHRI, and what will you continue to provide to meet the goals and mission of the MCHRI? What we are adopting is what we call a life-course approach to this whole continuum of care. Essentially, we are looking at maternal and child health as a whole continuous circle of life. The woman grows up to be healthy in society, marries 14
We want to optimise the value of people by optimising their health
and sets up a family, becomes pregnant and gives birth to a child. Then, the child goes up healthy, becomes an adult, and then contributes back into the family life. The life-course approach refers to how we manage the health of the mother, the child, and the rest of the family. The husband-father is also important in the whole unit, as elements of health can affect them through various social and cultural issues also, not just medical parts. What we do not want to do is just “medicalise” health. Health is not just giving medicines but is also revolving around social aspects, economic aspects, and educational aspects, which are very important to consider. We want to look at it in the different dimensions so that we can appreciate the complexities of the health of the mother and child, and see how we can then improve and optimise the maternal-child health through these various aspects. We are not just working with the Ministry of Health as a hospital, but we also engage with social agencies. The key ones we work with are the Ministry of Social and Family Development, as well as the Ministry of Education. They are important elements if we want to optimise the health of mothers and children. In the end, our key goal is to essentially do three things: be Asia’s centre of excellence for maternal and child health, translate research to improve general health for mothers and children, and strengthen human capital. Singapore is not very rich in resources, but it has its people. So, we are aiming to optimise the value of people by optimising their health. The three arms of the SingHealth Duke-NUS MCHRI
MCHRI aims to advance the reproductive, metabolic, KKHand looks at maternal child health as a whole continuous circle of life mental healthand of women and their children
are, first, to establish a multidisciplinary research community to conduct high-impact clinical, translational, and population health research to meet maternal and child health needs. The second is to establish strong, synergistic partnerships with our partners and key stakeholders; not just healthcare professionals but also sociologists, psychologists, educationalists, and other people in the Singaporean and international community. The last area that is very equally important is to attract future talents and groom the next generation of maternal and child health investigators and researchers for Singapore and beyond. We want to collaborate with everybody as we move forward. What do you see as areas of development needed for the field of maternal and child care in Singapore and Asia? If we look at the area of needs, it can be divided into four key domains: preconception and reproductive health; metabolic health; neurocognitive, developmental, and mental health and wellness; and cancer and critical diseases. It applies to us both in Singapore and internationally. Of all these domains, I think the two things that are very important for maternal and child health, especially in this day and age in Singapore, are mental and metabolic health. We are very competitive and all caught up in a rat race. Our women are marrying later, having children later, and having a small number of children because both parents are working very hard. No longer is family support usually two adults and there’s not much social support. The self-efficacy of parenting and being confident as a parent, especially for first-time parents, is quite lacking. We want to see how we can optimise this. Parents themselves are stressed because of various economic issues, whether they are bringing up a child correctly, COVID-19, and so on. What we want to do is address some of the mental and emotional well-being of mothers. We have a very high rate of prenatal and postnatal depression, so we want to see how we can improve screening and also help them in the early phase. Children are also very stressed with schooling and we want to see how we can better improve their emotional well-being. With the internet and social media, there is also increased pressures like cyberbullying that must be monitored. As for metabolic health maternal pregnancy-wise, up to 20% of our pregnant women have diabetes and metabolic diseases. We need to address how they should learn to take nutritious, metabolically good food and how they can continue to exercise and keep themselves fit. Meanwhile, children tend to have more and more screen time with less exercise. When I ask my patients what games they play, they tell me what latest computer game they are playing, which is not what I asked them. I am asking what physical games
Other factors affecting maternal-child health are the 3 Cs: cyber wellness, COVID, and climate change
they play, but they tell me they are addicted to this latest computer game. All these are not good things that we should try to address and see how we can help our next generation grow up stronger. Another way of looking at factors affecting maternalchild health is the three C’s. The first C is cyber wellness, the effects of digitalisation, computers, and social media. I mentioned cyberbullying and the effects of social media on the general health of women and children. Health information in social media is also not necessarily good. There is so much fake news out there in the media regarding health. It also affects all four of the domains I enumerated. The second C is COVID-19. We are now at the endemic phase. We need to live with COVID, like [Prime Minister Lee Hsien Loong] said. But, what is the impact of COVID on maternal-child health? Parents are stressed mentally and economically. The virus is a generational change affecting us. It will leave our whole way of living our lives and how we remain healthy for them in the maternal-child health field. The last C is climate change. It is relevant to maternal and child care because climate change affects the food supply, which mothers and children need to be healthy. What upcoming plans or projects from MCHRI can you share at this point? What can consumers, patients, and healthcare partners expect from MCHRI soon? From what was shared, one of them was the memorandum of understanding for an ongoing collaboration that we signed with Menarini Biomarkers Singapore. We want to develop technology to identify foetal cells in the first trimester of pregnancy to better manage pregnancies with chromosomal or genetic abnormalities. We also have piloted the [Integrated Maternal and Child Wellness Hub] in Punggol, where we bring in a very focused developmental assessment of the young kids to oversee their development. Another project we are working on is looking at how we can improve parenting self-efficacy by sending out nudges and guiding parents through the first 1,000 days of pregnancy up to two years of age. We hypothesise that having those very targeted nudges can help improve their parenting self-efficacy and can help make them more confident as parents. Lastly, we are collaborating with the UN Foundation and other agencies on this project called Healthy Early Life Moments or HELMS, which is looking at how we can improve the whole metabolic and mental wellness of women from preconception to giving birth through behavioural modifications and timely health advice. If we succeed, we plan to build this into our national system in a very calibrated way. Do you see any partnerships or collaborations with anybody outside of Singapore? We have a rich history of collaboration from KKH, and we want to use the MCHRI to collaborate further. One collaboration is the Integrated Platform for Research in Advancing Metabolic Health Outcomes of Women and Children or IPRAMHO. We have a network consisting of ASEAN countries where there is a conference held every year to share and support one another in terms of medical collaboration. HEALTHCARE ASIA
What’s so special about Pondok Indah Group Hospital getting HIMSS EMRAM It is the only hospital group in Indonesia to achieve level 6 validation, the highest level of assessment.
The level 6 validation is an achievement of the hospital’s commitment to patient satisfaction
o date, only three hospitals in Indonesia have successfully achieved Healthcare Information and Management Systems Society’s (HIMMS) Electronic Medical Record Adoption Model (EMRAM) level 6 validation, namely: Pondok Indah Hospital - Pondok Indah, Pondok Indah Hospital - Puri Indah, and Pondok Indah Hospital - Bintaro Jaya, all three are under the umbrella of the Pondok Indah Group Hospital. Meanwhile, in the whole of Southeast Asia, there are only four other hospitals that are validated with levels 6 and 7. Two of them are located in Singapore and the other two are in Thailand. The HIMSS EMRAM has become a global standard for the implementation of digital health transformation. Once a healthcare institution is given this accreditation, patients are assured that the hospital is digitally mature; therefore, they 16
can focus on their healing processes without worrying about doctors making inacurate medical findings and decisions, as well as their medical history being comrpomised. HIMSS is a non-profit organisation that aims to reform the health ecosystem worldwide through the power of information and technology. For more than 60 years, HIMSS has operated in North America, Europe, the UK, Middle East, and the Asia-Pacific with the EMRAM methodology used to assess the digital maturity of hospitals with the aim of building and optimising digital work environments, improving the performance of health services, and providing the best experience for every patient. In an exclusive interview with Healthcare Asia, Pondok Indah Group Hospital CEO Yanwar Hadiyanto said that HIMSS EMRAM level 6 validation is a form of achievement
The point is how we can provide a better solution than others
of the hospital’s commitment to increasing patient satisfaction through continuous improvement of service quality. “The point is how we can provide a better solution than others.” Pondok Indah Group Hospital was able to get this nod from HIMSS by providing access to important data and information when needed, which would help doctors make decisions regarding patient care plans based on their medical history, minimise the risk of errors in patient care, and maintain confidentiality and security of patient data. Digitisation carried out The first digitisation carried out by the Pondok Indah Group Hospital is the integration of patient medical information, which allows data to be accessed at any time by doctors, nurses, or other authorised medical personnel, through the electronic medical records. The results of patient
FEATURE PROFILE diagnostic examinations, such as laboratory and radiology, can also be accessed in real-time in the system. “The history of vaccination and administration of drugs is also recorded digitally in the electronic medical record. Patients can seek treatment at the three hospitals under the auspices of the Pondok Indah Group Hospital because their medical records can be accessed from the three hospitals,” said Yanwar. Then all requests from healthcare providers for prescribing drugs and supporting examinations (laboratory and radiology) are also carried out digitally through the system, thereby reducing the risk of multiple inputs significantly. “Similarly, the patient’s medical history, current condition, and risk assessment scores—such as risk of falls, risk of skin abrasions, decreased consciousness—will be recorded in the system, making it easier for doctors to determine a patient’s treatment plan,” Yanwar added. The hospital also uses RFID/ QR code scanning technology for drug administration, storage and administration of breast milk (ASIP) in the nursery and NICU, as well as blood transfusions to reduce the risk of human error and improve patient safety. Finally, they provide notifications for patients with certain conditions, for example, those with drug allergies or the pregnant are alerted of the risk of contraindications. Mature digitisation Yanwar said that his party was not only focused on being mature in terms of digitisation but also in responding to technological developments and innovations, both related to information technology and medical technology. “We want to really make sure to present the most appropriate technology, not just the latest technology,” said Yanwar. Pondok Indah Group Hospital carries out digital transformation on an ongoing basis and adopts a digital hospital information system, and integrates hundreds of medical equipment and technology into patient information systems and electronic medical records.
“In its digital transformation process, Pondok Indah Group Hospital has integrated supporting services, such as laboratories, pharmacy, and radiology with patient medical records integrated in various kinds of software and hundreds of medical devices; and it implemented IT security to ensure 95% to 100% of medical documentation is carried out automatically, digitally, structured, and supported by clinical decision that has been systematiszed,” said Yanwar. More technology launched When COVID started to subside, Pondok Indah Group Hospital is again thinking about how to further its innovations. Therefore, this year they introduced optical coherence tomography orOCT, which is usually used for angiography patients for coronary arteries. “This technology can produce better diagnostics before and after the procedure. We can find out what is the most appropriate course of action. For example, what is the shape of the plaque in the heart, how big is it, where should it be placed, and so on,” explained Yanwar. Then they also introduced endoscopic ultrasound—an imaging technology through a small camera that enters the digestive tract. “Ultrasound is on the endoscopic camera for diagnostics and treatment of disorders or small tumors that are usually cancerous,” said Yanwar. For example, cancer in the bile or pancreatic ducts, which so far cannot be reached by ordinary technology. Recently, Pondok Indah Group Hospital has also launched a robotic prostate biopsy, the latest biopsy technology with a high detection rate and accuracy. This technology is able to detect prostate cancer with significantly more precision than conventional biopsy methods. Another advantage is that this technology is also able to increase the accuracy of taking the right tissue according to the biopsy target up to 89.4% accuracy. In the process of taking tissue samples, the biopsy technique will be guided by images from MRI imaging. “Snippets of MRI images suspected of having indications of cancerous
We want to present the most appropriate technology, not just the latest technology
tissue will be contemplated into a robotic platform that will perform digital scanning and combine them with real-time ultrasound images, and automatically determine the biopsy locations,” said Yanwar. In contrast to conventional biopsy techniques using ultrasound imaging, the robotic MRI/US fusion-guided prostate biopsy technique can better differentiate abnormal prostate tissue. Yanwar said that this certainly contributes greatly in increasing the patient’s chances of survival, because most cancer lesions often cannot be visualised on ultrasound examination. In addition, the procedure with robotic prostate biopsy is also an action that has minimal risk of infection when compared to conventional biopsy techniques which have an infection risk of around 3% to 5%. The lack of accuracy of conventional biopsy techniques in determining the point of biopsy location can also lead to a 30% chance of false negative, as well as the risk of bleeding and sepsis. “With this robotic technique, doctors can also reduce or eliminate tissue trauma in patients. In addition, real-time ultrasound images for biopsies become more focused, so the wound becomes smaller and the risk of infection is reduced close to zero,” said Yanwar. Lastly, Pondok Indah Group Hospital will soon launch a sports medicine and injury center this year. This facility will not only be used for injury, but more broadly, for example, for post-operative rehabilitation.
Yanwar Hadiyanto, CEO, Pondok Indah Group Hospital
OneOnco allows patients to kickstart cancer support system for $1
It is a digital-based oncology solution for those looking to begin their medical care.
here are a lot of stigmas attached to cancer. Many people may say that it is an illness caused by smoking, unhealthy sexual relations, or even a curse. Scientifically, a doctor will explain that it is a genetic mutation or a hereditary disease. There are several other interpretations, which is why, in the field of medicine, the study of cancer or oncology is seen as something multidimensional and multifactorial. This is also the reason why, in Indonesia, almost every oncology treatment is separate from each other. PT Kalbe Farma, therefore, took the initiative to launch OneOnco, an integrated oncology service that aims to unite all stakeholders in the oncology field in Indonesia. “The goal is that when these stakeholders work together, the output given to these patients will be detailed, comprehensive, and of course, better. Stakeholders, in this
case, include academics, doctors, communities, hospitals, insurance, patients, patients’ families, and caregivers,” Selvinna, Head of OneOnco, PT Kalbe Farma told Healthcare Asia in an exclusive interview. Surfing at OneOnco Patients who surf at oneonco.co.id will go through four phases. The first is teleconsultation, a collaboration between Kalbe and Klikdokter, that enables the patient to consult through chat services. The second phase is early cancer detection. Kalbe has partnered with hospitals and health facilities to enable more affordable prices, starting at IDR 15,000 ($1.01). “Our ecosystem makes it possible to order the screening service, of course, it’s easier because the website is already connected to the health facility, you can make a booking, you can even pay directly without having to come
When stakeholders work together, the output given to patients will be detailed, comprehensive, and better
OneOnco creates an ecosystem for doctors and patients, because not all have an access to each other
to the hospital in person, which of course makes your expenses less,” Selvinna said. The third is the doctor directory feature, which allows patients to choose amongst 743 Kalbe’s partner doctors who specialise in oncology, including 175 referral hospitals. Finally, the availability of information about cancer that is completely valid and non-hoax. OneOnco not only provides guidance from reliable sources, such as oncologists and cancer psychologists, but also from cancer survivors through the testimonials they leave on the platform. One thing that Selvinna clarified is that they did not find the need to make OneOnco’s chat service available for 24 hours. This is because cancer is not an emergency disease, Selvinna said. “It’s like if you’re itching now, you don’t need to scratch right now. So if you are sick right now, you can take medicine
OneOnco strives to be the most accurate reference in Indonesia
first but the examination can be done on the next day.” But, how quickly do they respond to their consulting chat service? Healthcare Asia tried to surf on its own and created an account at oneonco.co.id and started looking for online doctors. The time spent from searching to getting the first chat response from the doctor was approximately three minutes. During the chat, waiting for a response to each question took approximately 1 minute. The doctor that Healthcare Asia spoke to in the service revealed that his shift online is for three hours, after which, another doctor would replace him to cater patients who are sending messages. Answering doubts OneOnco creates an ecosystem for those who want to serve, i.e. doctors, and those who need to be served, i.e. patients, because not all have an access to each other. Even for the doctors and other medical service providers, collaborating and getting partnerships is not an easy thing, Selvinna said. “That’s why we created a platform where service providers, service recipients, and many other parties can meet. How did they meet? First of all through information first.” According to data from The Independent, fake news about cancer on Facebook is one of the 20 most shared hoaxes. In Indonesia, one of the problems of oncology is also the deluge of false information and the lack of valid and correct ones, Selvinna said. This causes a lot of anxiety about cancer circulating in
society. OneOnco, therefore, strives to be the most accurate reference in Indonesia. “Many people are afraid when he feels there are signs of cancer in his body. Early detection at OneOnco is an easy initial solution for these people, for example, to get a second opinion of what they are worried about,” Selvinna said. OneOnco also has a channel where cancer survivors can share inspirational stories. Through this, patients and survivors can relate to each other. According to Selvinna, this is one of the important features of their service because it is important for patients to feel motivated and that they are not alone—this becomes a crucial supporting factor for healing. “There is no hope that does not mix with fear, there is no fear that does not mix with hope,” said one of the inspirational story headlines on the OneOnco platform. The platform also has special vaccinations information for cancer survivors who are confused whether, for instance, they can get their COVID vaccine. “They revealed that they are often rejected for vaccines because the vaccinator is unsure about the results of the screening,” explained Selvinna. Collaborating Kalbe has four business units— the Prescription Pharmaceutical Division (with 23% contribution to the group’s revenue), Consumer Health Division (17%), Nutritionals Division (30%), and Distribution and Logistics Division (30%). OneOnco has been around since 2018, but the platform was only
OneOnco has a channel where cancer survivors can share inspirational stories
officially launched in 2021 and has recorded a compound annual growth rate of 20%. From 2018, the company started collaborations both within and outside the Kalbe Group. Internally, the company partnered with organisations that sell chemotherapy, import specialty products, and suppliers of kits for early detection of cervical cancer. The kit has now been produced domestically. Kalbe also tapped a laboratory that specifically examines genes for cancer. Externally, Kalbe also collaborated with communities such as the Indonesian Cancer Foundation (Yayasan Kanker Indonesia/YKI), Cancer Information and Support Center (CISC), and Lovepink Indonesia. There is also a non-profit organisation related to cancer called Knitted Knockers Indonesia, which makes knockers or bra plugs for breast cancer patients which are distributed free of charge throughout Indonesia. Kalbe also works with a mental health application called Relief and, finally, collaborates with insurance companies. OneOnco has now been able to reach around 10,000 viewers and users and targets an eight-fold increase this year. “[We are committed] to provide comprehensive solutions, especially for cancer sufferers when surfing our platform,” Selvinna concluded.
OneOnco is committed to providing comprehensive solutions for cancer sufferers
HEALTHCARE INSIGHT: NCD CARE
Asia’s healthcare tomorrow: Pivoting back to non-communicable disease
Despite NCDs accounting for 41 million deaths annually, they are still healthcare’s ‘blind spot’, expert says. for cancer, many of the therapies that happen in a hospital setting are being delayed. Breast cancer is a highly prevalent form of cancer in the region, particularly in Hong Kong, Singapore, Korea, and the Middle East. Worldwide, at least 1 billion people have a vision impairment that could have been prevented or still needs to be addressed. Indonesia, according to Sudoyo, is the fourth-largest economy with a sprawling area, even pre-pandemic, which poses a geological problem: water. “The amount of islands and the sheer numbers of our population is a very big barrier in disseminating [in general] here.” He added that cancer was not generally thought of as a major problem in the country. The big problems that Indonesia has been facing include mother and child mortality, malnutrition, and environmental health.
The progress made on NCDs during the last couple of years has ground to a halt
bout 77% of all noncommunicable disease (NCD) deaths are in developing countries—and those deaths, particularly in the 30 to 69 age bracket, have often been described as premature. With the recent global health crisis, experts now argue that the progress made on NCDs during the last few years has been backtracked. The ‘Bringing NCDs back into the spotlight’ panel during the recent Future of Healthcare Week Asia focused on the extent to which NCDs were prioritised and tackled as a global health priority set by the World Health Organization, the United Nations General Assembly, and the Sustainable Development Goals 2030. The panel consisted of Indonesian Cancer Foundation Chairman Aru Wisaksono Sudoyo, SingHealth Patient Advocacy Network CoChair Ellil Mathiyan Lakshmanan, Malaysian National Cancer Council 20
(MAKNA) General Manager Farahida Mohd Farid, and Novartis Pharmaceuticals - Patient Engagement and Communications Region Head Ruth Kuguru. NCDs are usually associated with ageing, cardiovascular diseases, cancer, respiratory diseases, and diabetes. The latter being particularly prevalent in the Asian region. NCDs account for about 41 million or about 71% of deaths globally every year. It has become more steadily prevalent due to increasing life expectancy, urbanisation, sedentary lifestyles, and changing diets, amongst many other issues and causes. NCDs amidst a global health crisis Kuguru said Novartis prioritises three disease areas: cardiovascular diseases, cancer, and vision impairment. Around 520 million people are living with cardiovascular diseases globally and have been disproportionately impacted over the last two years. As
NCDs account for about 41 million deaths globally every year
Interrupted screening Meanwhile, in Singapore, scheduled treatments and follow-up appointments have not been that much affected because of all the hospital protocols set. However, there was a lost opportunity for early detection because of the shutdown of screening services, particularly for cancer, noted Lakshmanan. “The [SingHealth Patient Advocacy Network] worked closely with the Singapore Cancer Society to do several screening programs. Given the long-running nature of the pandemic, they are now putting in place different ways of getting people to come down for screening. For cases like rectal cancer screening, we mail the kits from pharmacies and patients can collect the specimen and mail it back outright,” he explained. Malaysia has two scenarios, stated Farid. “The first lockdown was before vaccines were available. All the patients’ treatment appointments were on hold, people were not sure what to do, most of the hospitals were
HEALTHCARE INSIGHT: NCD CARE
Ellil Mathiyan Lakshmanan
Only through collaboration can there be a difference in healthcare
inundated with cases, and there was a near-collapse of the hospital system.” After June, when the vaccine was made available, most Malaysian patients’ treatments resumed. With the lockdown and interstate travel very restricted, they used technology to assist patients, so treatment is uninterrupted and timely. Most of the 75 hospitals that collaborated or referred to MAKNA increased by 48%, and the number of patients that were referred to MAKNA increased by 28%. If they did not have the technology, Farid said, they would not be able to get the kind of support at that particular time. They have three mammogram trailers that were repurposed to become mobile vaccination centres and went to the rural areas to cater to through an outreach program. Re-escalating NCD services in developing countries When Farid looked at the recent Malaysian 2021 budget and the 2022 budget presented by the new government, he saw it was reduced by more than 50% in terms of healthcare costs. “We were not part of the compensation when the policy was made or when the budget was presented. They’re still looking at trying to get a grip on how to handle the pandemic. As you know, our government is going to have a general election in 2022, so they are trying to look good. It doesn’t look like a long term solution for us.” He added that the country is in health, economic, humanitarian, and political crises. The progress being made around NCDs before the pandemic has ground to a halt. He
worries it is going backwards and they are looking at several years of trying to restore and recover that progress. Singapore shares the problem of case backlogs because of the focus on dealing with the pandemic, Lakshmanan said. “We are now beginning to take measures to leave the pandemic. More hospitals are also improving their protocols so that they can get back to business but the priority of lessening the burden of COVID on the healthcare system remains. For the disease, several clinical trials are being done for the COVID pill to address the symptoms. If this thing can be accelerated, we can get back to where we were as soon as possible. There is a Multi-ministry Task Force working on this.” Sudoyo remarked how Indonesia was recovering quite well, although the sheer number of the population made it a daunting task. “We are already 52% vaccinated at this first activation. We are now bracing for our third wave which might or might not happen at the end of this year due to the holiday season. Maybe after this, we will be able to think more clearly. But in many places like in our capitals, we are already on the first level of house protocol. There has not been any talk about it in the media.” Role of patient organisations in NCD care Lakshmanan suggested that patient advocates and leaders of patient organisations must go to the ground and get patients and caregivers to get involved. “They need to put up a united front to the healthcare authorities and institutions to focus on the commonalities and have these
Farahida Mohd Farid
Aru Wisaksono Sudoyo
The role of pharmaceutical companies is to be catalysts or enablers for NCD care
conversations with the regulatory bodies and healthcare institutions.” “The role of [pharmaceutical companies] is to hopefully be catalysts or enablers for this. If there could be some framework set up where they can come in and help create the capacity and capability for the patient organisations to come together and to present this united front, I think it will go a long way in helping us improve outcomes, not only doing this pandemic but beyond it.” Novartis, according to Kuguru, believes that it is only through collaboration that there can be a difference in healthcare. As a global organisation, they have committed to working with patients and caregivers across the life cycles of medicines. One of the partnerships they have funded in the Asia Pacific region is called the Asia Pacific Patient Innovation Platform. It is a collaborative partnership with the patient community with patient leaders co-created to support the evolving capability needs of patient organisations and drive sustained improvements in health care outcomes. Kuguru shared they had a summit in March of this year, which brought together close to 900 patient representatives across 300 patient organisations, representing 36 countries. The other part is the ongoing collaboration with other patient groups such as Rare Cancers Australia. The third part is research and survey. ‘The blind spot’ Sudoyo closed the panel by saying how non-communicable diseases have been a blind spot, and it will take a village to bring them back from the blind spot to the spotlight. “We saw what COVID did to people with other comorbidities, When I talk about the ‘village,’ it’s [compose of pharmaceutical companies], government payers, healthcare professionals and its healthcare system, and us consumers. [We must be] diligent at taking the learnings of the past two years, not forgetting them, and making some important shifts, such as seeing healthcare not as a cost focus system, but as a driver of [gross domestic product] and growth.” HEALTHCARE ASIA
Antibacterial sutures stitch the gaps in SSI care Plus Sutures are reducing the risk of surgical site infections by 28%.
arying climates, cultures, religions, demographics, and healthcare funding landscapes in the Asia Pacific region are the reasons why the distribution of microbial pathogens responsible for surgical site infections (SSI), its prevention, and control within in-patient and post-discharge environments vary. Realising this, Johnson & Johnson gathered an expert panel of ten stakeholders from the various medical fields across the region and North America for the standardisation of evidence-based practices to improve the surgical outcomes of patients in the Asia Pacific. Johnson & Johnson’s solution to reduce SSI is its range of Plus Sutures by Ethicon, which contain triclosan, an antibacterial agent which prevents the formation of a biofilm, a known risk factor for SSI. Plus Sutures inhibit the bacterial colonisation of the suture for seven days or more against the most common organisms associated with SSI and reduce the risk by 28%. “Meta-regression analysis demonstrated that the effect of Plus Sutures in reducing the risk of SSI did not vary by Centers for Disease Control and Prevention wound classification or suture type,” Johnson & Johnson said. Healthcare Asia had a conversation with Johnson & Johnson Singapore and Southeast Asia Medical Devices Portfolio Lead Guillermo Frydman on the prevalence of SSIs in the region, and what Plus Sutures can do in order to improve outcomes for surgical patients. Based on your case studies and consumer feedback, how much has SSI affected patient outcomes, economic burden (cost for patient and hospitals), and healthcare processes (hospital care and home care)? We found that SSI is the most common postoperative complication through the session conducted with the Antimicrobial Resistance & Infection Control expert commentary. This means that infections at or near the surgical incision are prevalent following an operation, impacting a patient’s ability to recover completely and improve their quality of life. Additional costs are also incurred for both patients and hospitals to treat the infections, putting a strain on healthcare resources to look after patients with SSIs. Research we supported found that for hospitals in Asia, additional costs incurred due to SSI can vary anywhere between US$396 to US$5237 per patient due to prolonged hospital stays, and increased morbidity and mortality following surgery or operation. However, we noted that half of all SSIs could be prevented by implementing standardised SSI prevention guidelines. This will help reduce the risk of infection for patients,
Guillermo Frydman, Lead, Johnson & Johnson Singapore and Southeast Asia Medical Devices Portfolio
length of stay in the hospital, and additional costs incurred due to hospital readmission.
Infections are prevalent following an operation, impacting a patient’s ability to recover
Have standards for SSIs changed during the COVID-19 pandemic, and how? The pandemic has accelerated the adoption of stricter measures to prevent SSI throughout healthcare systems. Established international guidelines (World Health Organization, US’ Centers for Disease Control and Prevention, the American College of Surgery) have focused on the implementation of continued surgical services and the prevention of SSI in the current climate. These measures are also concurrently implemented with training to differentiate between surgical site infection and COVID-19 infection. In line with our commitment to support healthcare personnel in the world, we focus on innovative tools such as sutures to help surgeons and patients prevent SSI. Plus Sutures play a vital role in hospital infection prevention measures and help to free up hospital beds with lower readmissions and length of stay. What difference do Asian patients with surgical site infections have from their global counterparts that affect their wound-healing processes?
INTERVIEW The challenge in Asia is due to the lack of consistent guidelines for SSI prevention
The use of Plus sutures is reducing the risk of surgical site infections by 28%
Asia’s reported incidence of SSI varies widely within the region due to the diverse nature of its countries and their healthcare ecosystems – anywhere from 2% to 9.7%. This is significantly higher than in the US, where the incidence rate is just 0.9%. The challenge in Asia is due to the lack of consistent guidelines for SSI prevention across the region. Some common barriers to adoption include manpower constraints that leave little or no time for training and protocol modifications, limited funding that results in inadequate support for implementing new guidelines, and poor patient awareness and responsibility, leading to increased risk of SSI post-operation. These are just some challenges that surfaced from the discussion with the expert panel that also recommended that hospitals work actively towards implementing guidelines that apply to them by embedding the relevant SSI prevention programs within their work processes. What factors and statistical data led you to your innovation of Plus Sutures? At Johnson & Johnson, we understand the ongoing challenges healthcare professionals face and are committed to improving patient outcomes whilst reducing the strain on healthcare systems. Patients with SSI are twice as likely to spend time in an intensive care unit and five times more likely to be readmitted after discharge. This is a significant strain on both patients and hospitals. SSIs arise when bacteria colonise the suture material, creating a biofilm as it passes through the skin. This biofilm establishes immunity from both antimicrobial treatment and the host immune system. Once this biofilm develops, there is an increased chance of SSI developing. Research so far has shown that bacteria can colonise monofilament and braided sutures. However, sutures with triclosan can help prevent bacteria colonisation, infections and wound healing disorders.
So far, what results, or outcomes have come from the utilisation of Plus Sutures? Plus Sutures are recommended by several evidence-based organisations, including the World Health Organization, Centers for Disease Control and Prevention, and the Surgical Infection Society due to their triclosan coat. The National Institute for Health and Care Excellence in the UK has also issued guidance that recommends the adoption of Plus Sutures due to their ability to prevent infections whilst saving costs for patients. In addition, the use of Plus Sutures provides potential environmental benefits to the NHS as a reduced rate of SSIs, in turn, reduces greenhouse gas emissions, freshwater use, and waste generation. In Singapore, evidence and medical analyses show that Plus Sutures reduce SSI risk by 28% and provide cost savings of $258 per patient compared with using standard non-Plus Sutures. This translates to lower hospital admissions for SSIs following a procedure and more efficient use of hospital resources that can be prioritised for other medical surgeries. What upcoming plans or projects can you share at this point? What can consumers, patients, and healthcare partners expect from Johnson & Johnson in Asia soon? Specific to the conversation around surgical site infections, we have recently published two papers developed by a multidisciplinary team of key opinion leaders across the Asia Pacific including surgeons, infection preventionists, and C-suite executives. Both publications show a regional consensus on approaching SSI prevention and look at surveillance programs as well as evidence-based guidelines. We hope to reduce surgical site infections in Singapore and the Asian region, to improve patient outcomes whilst reducing strain on healthcare systems.
The use of Plus Sutures is recommended by WHO, CDC
IAS targets HIV’s ‘Achilles heel’
Me & My Healthcare Provider promotes stigma-free HIV care in Asia.
part from vaccines and cures, the stigma attached to the human immunodeficiency virus (HIV) world is its ‘Achilles heel’ or vulnerable point, International AIDS Society (IAS) President Adeeba Kamarulzaman observed. This is why Me & My Healthcare Provider campaigned to promote the best practices in healthcare service delivery by recognising frontline healthcare workers who deliver quality HIV prevention, treatment, and care—often in the face of discriminatory laws and regulations, as well as stigmatising traditions and beliefs. The International AIDS Society (IAS) recently announced its partnership with Gilead Sciences to expand the Me & My Healthcare Provider campaign to three locations in Asia: Hong Kong, South Korea, and Taiwan. They will also renew the programme in Brazil and Mexico. Healthcare Asia had a conversation with Kamarulzaman and Gilead Sciences Asia 5 Vice President and General Manager Andrew Hexter to know more about what the Me & My Healthcare Provider entails. What factors led to the inception and the formation of the Me & My Healthcare Provider campaign? Kamarulzaman: The campaign was launched in 2016 and champions celebrated on the Global Village main stage of the 21st International AIDS Conference (AIDS 2016) in Durban. That predated me becoming president of the IAS. I think it’s always been known that stigma within healthcare settings, even after 40 years of the HIV pandemic, remains a big problem. The impact that it can have on people living with HIV or people at risk is huge. So, the idea was to highlight best practices and get people within the healthcare settings who show good examples. Hexter: Since IAS commenced the programme, Gilead has been a huge fan and watched with excitement, so the opportunity for us to participate is exciting. Working together with IAS to reduce stigma, highlight the incredible work of healthcare professionals in different countries worldwide, and highlight best practices is crucial to how Gilead sees the totality of HIV prevention and treatment. Working, partnering, and collaborating is a natural extension of the great work that IAS already started with this programme. How will the Me & My Healthcare Provider campaign help alleviate the stigma of HIV, particularly in Asia? Kamarulzaman: The Asian program sponsored by Gilead is just beginning. Previously, the focus has been on a few countries in Africa, Latin and America. In Asia, except in Indonesia, the campaign hasn’t taken off yet. What we do know is a concerted effort in raising awareness and giving healthcare providers the right information to bring either people living with HIV or 24
Adeeba Kamarulzaman, President, International AIDS Society (IAS)
Working together to reduce stigma and highlight best practices is crucial to how we see the totality of HIV prevention and treatment
members of the key population in contact with medical professionals at a very early stage. Some of my students, for instance, have not met anyone living with HIV. When they get exposed and get to meet and talk to a person living with HIV, that’s often quite powerful. Hexter: Healthcare professionals like Professor Kamarulzaman and other healthcare professionals throughout Asia play an important role in stigma-free services. There are a lot of positive stories we can uncover or shine a light on and share with others. We’re doing that through the program with community-based organisations (CBOs) that we’ve been heavily involved with over the ten years that we’ve been in Asia. There are a lot of opportunities for HCPs to be exposed to and have a positive impact on reducing stigma or stigma-free services. By highlighting positive stories, you end up with these role models and these great stories that can be shared with others. By helping them understand the impact that they can have and getting it shared, you get a multiplier effect in stigma-free healthcare services. It’s even more important now during the COVID-19 pandemic because HIV treatment and services have been hampered. I think it’s a perfect time to generate that noise about how important it is for stigma-free services and the great work HCPs are doing.
INTERVIEW What experiences do you remember the most since the inception and implementation of the campaign? Kamarulzaman: One of the things we do is highlight some of these programmes at the annual IAS conferences where the visibility and reach are big. People with inspiring stories get invited to provide training or speak at other venues and other conferences, as well as national-level programmes. The ripple effect is quite strong. One example that we have had were the champions in Brazil. After their good work was highlighted, they were invited to speak at the XI UNGASS-AIDS Forum. You amplify what is potentially a local program with the platform that we give at these international AIDS conferences. Hexter: Since 2018, we’ve launched an HIV-specific Gilead Asia Pacific Rainbow Grant, which has made over US$4.5m in donations to 112 projects across the Asia Pacific. The projects were focused on stigma and discrimination, which has always been a pillar of our focus in our grantmaking. We’ve launched a series of community masterclasses, which are virtual Zoom workshops, to connect CBOs from around the region to each other. With a lack of travel, the response of being able to continue that education has been overwhelming. In addition to that, we continue to connect CBOs within the region and internationally to support their capacity building and learning from each other, so we can take these local cases and amplify them throughout different areas of the world. In the same way, like Me & My Healthcare Provider, the Gilead Asian Rainbow Grant was made to ensure that they’re not isolated because there’s so much that we can share between what physicians are doing and what CBOs are doing. That is how we will achieve success and have a stigma-free service for people living with HIV. What were the criteria that you considered for Taiwan, Hong Kong and South Korea to be included in the list of areas included in the campaign? Hexter: From the Gilead perspective, we’ve chosen to implement in Korea, Taiwan and Hong Kong because that’s the geographic area that we cover. There are certainly many criteria and geographic areas that could be expanded to in the future. But for us, this was the starting point. When we think about the need to reduce stigma or provide stigma-free services, it’s not just limited to these countries. The more that we can do to impact countries around the world, the better. If you look at the great work that Me & My Healthcare Provider has done so far, they’ve been in 17 countries and have 36 champions. With these locations being eligible for this campaign, are there any incentives that they will get once they are included among the champions or are nominated? Kamarulzaman: With inspiring stories and programmes, HCPs will certainly be included as champions and will be highlighted at future meetings. Not only do we have the International AIDS Conference and the science conference, which are both huge platforms to showcase to the world, but we also have the IAS Educational Fund. The fund goes to countries in the region to potentially be able to showcase progress.
People living with HIV were hesitant to go to the hospital for treatment for fear of acquiring COVID
From both the biomedical and healthcare provider fronts, what difference did the global COVID-19 pandemic make towards HIV care? Hexter: Gilead surveyed over 1,265 respondents across 10 countries and territories in the region, which include 667 people living with HIV, 455 individuals at-risk of HIV and 143 HIV care prescribers. From that, we saw there was a considerable disruption in care. Half of all respondents reported a disruption of care. In addition, UNAIDS has found a 41% decline in HIV referrals and treatment decline by 37%. Anecdotally, what we’ve seen is that when countries have had flares or infection spikes, hospitals have closed to patients because they’ve had to keep people out to stop the spread of COVID. Kamarulzaman: As someone who had to continue to provide service for both [COVID and HIV], the urgency of the situation took us away from HIV. Unfortunately, in Asia, there are very few of us as well. Whether we liked it or not, we all had to respond very quickly because of the nature of its spread and the damage it was doing. It’s not to say that from a treatment point of view, at least from my observation in my immediate team and Malaysian doctors, many adapted through telemedicine and multi-month dispensing of treatment. When it came to ensuring that prevention efforts continue, that was a lot tougher. People living with HIV were hesitant to go to the hospital for treatment for fear of acquiring COVID. Despite this, we acknowledge many CBOs, like those in India, who responded by assisting with the delivery of antiretroviral treatments to patients who were trapped at home. Aside from this campaign, what other plans or projects do you have in terms of HIV care? Kamarulzaman: The IAS will conduct a review of the current and previous programmes and see what are the motivations of our champions to try and better understand how inspirational good practice of stigmafree service provision can be scaled up. We hope to use the knowledge from that to make the program better and better and institutionalise some of the best practices. One of my goals is to institutionalise stigma-free practices in the medical curriculum.
One of the goals is to institutionalise stigma-free practices in the medical curriculum (Photo courtesy of IAS)
How PairX Bio transforms cancer immunotherapies
The startup focuses on cancer treatment by targeting shared tumour-associated antigens.
n 2017, two oncology researchers, Dr. David M. Epstein and Dr. Raymond Lee, accidentally discovered that RNA splicing or cutting patterns can be observed across shared groups of cancer patients, not just on gastric cancer patients, which they had previously focused on. This scientific breakthrough, they believed, could be developed into a new approach to cancer immunotherapies that are designed to help larger numbers of patients. Cancer treatment using immune checkpoint inhibitors like Ipilimumab and CAR-T therapies like Kymriah has greatly improved cancer patient survival and recovery. Currently, the benefits of this kind of treatment are most prominent in small groups of patients. Healthcare Asia had a chat with Dr. Lee, now the scientific co-founder of PairX Bio. Founded in September 2020, PairX Bio is a startup that raised several seed financing rounds to help in its mission of developing immunotherapies against cancers, especially tumours, which currently have limited targeted therapy options. In your opinion, how much do you think cancer immunotherapy has changed the landscape of oncology globally, in the Asia Pacific, and Singapore? The global medical community, including those in Singapore, embraces this exciting treatment modality as more immunotherapies such as CAR-T cells, checkpoint inhibitors, and monoclonal antibodies continue to be effective on patients. At PairX Bio, we are developing next-generation cancer immunotherapies that target shared tumour-associated antigens derived from aberrantly spliced proteins. The PairX Bio platform is built upon a deep understanding of mRNA splicing biology, which, when combined with our proprietary antigen and T cell validation methods, yields simultaneous validation of tumour antigen T cell pairs in multiple patient-derived tumours. Growth in cancer immunotherapy is predicted to increase exponentially in the coming years. However, most of the targets currently in clinical trials are targets that have been discovered in the past decade. Using our PairX Bio platform, we aim to accelerate the discovery of these targets that can be exploited. By identifying targets that are present in subsets of cancer patients, we aim to develop treatments that can be rigorously tested. Overall, PairX Bio leverages the understanding of the immune system and capabilities to identify unique cancer antigens and paired T cells to establish the arsenal required to push the capabilities of immunotherapy, especially for hard-to-treat solid tumours. 26
PairX Bio is developing next-gen cancer immunotherapies, built upon a deep understanding of mRNA splicing biology (Photo: Dr. Raymond Lee, Co-founder, PairX Bio)
David M. Epstein
The global medical community embraces this exciting treatment
There are several biotech companies based in Singapore. What do you think makes the country an attractive and suitable suitable place for biotechnology? The Singapore government has invested extensively in biotech for over 20 years and is now reaping the rewards. The country now boasts a solid biomedical infrastructure, stringent intellectual property rights regime, trusted global reputation, connectivity to neighbouring countries, and encapsulated knowledge of the overall biotech industry. Thanks to initiatives that encourage biotech talent development, such as the 2020 Research Innovation Enterprise Plan, more researchers are developing an appetite for branching out to the biotech sector, creating a large pool of talented researchers and developers passionate about biotech. Additionally, besides significant financial backing from the government, we also have the support of local private investors such as EVX Ventures. These factors make Singapore a “city of dreams” for those embarking on innovation and enterprise. PairX is currently based at NSG Biolabs, which is considered a co-working space for biotech startups. What are the advantages of this? NSG BioLabs offers the perfect ready-to-use lab space that allows us to immediately focus on research and product
INTERVIEW Singapore is poised to create expertise and capabilities relevant to building a more robust local biomedical industry
Singapore boasts a solid biomedical infrastructure and encapsulated knowledge of the overall biotech industry
development without building laboratory infrastructure from scratch. This approach is also financially more viable because we need to conserve our spending and prioritise funding for research and development (R&D). Being close to the Biopolis research hub allows us to easily access shared equipment and other facilities critical for our R&D. As NSG BioLabs is a startup incubator, we have the opportunity to interact with like-minded people and learn from one another in various aspects, such as tackling the challenges of building a new company. We are a seedling trying to find our way through these challenges, and it’s great to be in an environment where other people are on the same wavelength and speaking the same language so that we can learn from each other to grow.
healthcare development with both local and global benefits. For instance, the global ageing population requires the medical field to undergo a significant shift to pinpoint what is needed for healthy ageing and to treat chronic diseases. The biomedical expertise that Singapore has built up can help drive that shift by enabling the innovation of solutions that are applicable not just to the ageing population of Singapore, but globally as well. Aside from the pandemic, what other challenges have your company and the biotech industry faced? The local early R&D biotech industry is still in its infancy, and we have to catch up to reach the level of that seen in established ecosystems such as in Boston, USA. We believe that many local biotech companies will have to advance themselves to gain a solid foothold in other locations to further develop their products and innovations, especially during the downstream phases such as CMC (chemistry, manufacturing, and controls), and associating with regulatory bodies to initiate clinical trials. Having said that, Singaporean companies are actively pursuing advanced-stage product development overseas with the eventual aim to bring such know-how into the Singapore ecosystem, so we are slowly and steadily working our way up. The biotech startup had also exclusively licenced its rare and innovative cancer treatment process from Duke-NUS, where the firm continues to scale up the educational institution’s research capacities and developed its foundational technologies. These were further enhanced by the Duke-NUS Academic Medicine partnership with Singapore Health Services (SingHealth). In relation to the Duke-NUS collaboration, the DukeNUS’ Centre for Technology and Development helped Lee work with clinicians all over Singapore to expand their study to other cancers common in Asia, where they focused on head and neck, liver, and colorectal cancers. With this support, Epstein and Lee managed to venture into the “great unknown” that is starting a biotech company.
What kind of assistance did your company get from the Singaporean government? How much did it benefit you? Along with the increased impetus from the Singapore government in accelerating research and development within the science and technology sector, it has been very welcome to support our efforts. We have received support and backing in growing our startup from government initiatives such as Enterprise SG. With their help, we were able to bring in overseas talent to add specialised skills and expertise that was critical to our R&D, which is especially difficult in these pandemic times. Enterprise SG also showed us the ropes and taught us many things about the initial phases of building a company, which went a long way towards helping us find our footing. How do you think focusing on biotechnology research will benefit Singapore and the world? In what other fields of medicine? Singapore is poised to create expertise and capabilities relevant to building a more robust local biomedical industry. It will further propel Singapore to become a major player in
Singapore’s biomedical expertise can help enable the innovation of solutions that are applicable to the ageing population of Singapore and globally
Malaysian eyecare clinic elevates services with AI OasisEye Specialists deployed AI machines to remote areas where doctors are scarce.
hree ophthalmologists from Malaysia set their vision to operate a clinic in January 2020, days after getting a licence from the government. Little did they know that, in just a few weeks, a new fatal virus would infect people globally and interrupt business and healthcare operations. Instead of closing up the shop, the doctors of OasisEye Specialists decided to focus on opening boutique eye centres in northern, southern, and central Malaysia to cater to emergency eye care needs. It currently has three operating centres: OasisEye Kuala Lumpur, which is the main clinic, in Nexus Bangsar South; OasisEye Johor Bahru in Beletime Danga Bay, Country Garden; and OasisEye Seremban at Seremban 2. Since it is a specialty clinic, OasisEye Specialists was able to invest in technology and partnerships specific to the improvement of its eye care services. One of the notable innovations is artificial intelligence (AI) which helps detect risks of patients’ retinal ailments. Here is Healthcare Asia’s interview with Dr. Khaw Hoon Hoon, one of the board directors and founders of Malaysianbased OasisEye Specialists, wherein she discussed their boutique centres and strategies. What are the goals and principles that guide you and your colleagues to give eye care services to your patients? I’ve been practising as a clinician since 2003. For the last 20 years, medical services have evolved. From big hospitals to private hospitals, and now, we have what we call the ambulatory care centre. What we are doing is a daycare centre, where patients come in, get their treatment, and get discharged immediately after a few hours. It’s very much a boutique centre. It is the trend now, in the medical field, if you look around Singapore, Hong Kong, and even worldwide. We are not into bigger hospitals now, where there are multi-disciplines addressing all kinds of ailments from head to toe. We have deconstructed the hospital setting into boutique centres. We at OasisEye Specialists have concentrated on ophthalmology—when the organisation is smaller, customer service becomes the priority. Our centre is patient-centred and comprehensive, where we get the chance to utilise our best technology and be able to provide personalised care to patients at an affordable cost. So how do we do that? It’s very easy: Get a group practice, where within the centre, for example, in Bangsar South, we have 10 practising ophthalmologists. The doctors here, we share all the same equipment and machinery. Therefore, we can afford to buy the best technology that we have. Patients get it at a fraction of the price for every cost for us to recoup back our return on investment. As a group, we offer multidisciplinary care. We have retinal 28
Dr. Khaw Hoon Hoon, one of the founders of OasisEye Specialists (Photo from OasisEye Specialists website)
When the organisation is smaller, customer service becomes the priority
surgeons, glaucoma surgeons, and paediatric, oculoplastic, and refractive surgeons. When we are sub-specialising in various components of our eyes, we are able to serve our patients better. Patients have more quality care, instead of just a doctor or ophthalmologist treating the eye from front to the back so that’s the purpose of our group being subspecialised. What are the innovations, technology, and programmes that OasisEye Specialists are doing right now? We have artificial intelligence, which is replacing a lot of medical services that we have. For us, we also use this artificial intelligence grading software so that we can take a photograph of the patient’s eye and the artificial intelligence software will diagnose the severity of the disease. With this, a doctor does not need to be present. How important is all this? Where there is a large remote area where doctors and ophthalmologists are not accessible, all these machines will be dispersed to all these small remote centres. We can do retinal screening and take photographs of the eye, especially for diabetic patients, glaucoma patients, or age-related macular degeneration patients. These machines are deployed to those areas, then photographs are taken and the AI will ”grade” them, diagnose them, and identify those diseases to be referred to fellow doctors and ophthalmologists.
INTERVIEW It took us three years to start off our main centre, which is currently located in Bangsar, Kuala Lumpur. That’s when we are operational and, after that, the lockdown came in. But because we are in the field of medicine, we are considered one of the essential services, we did not shut down. We were not allowed to shut down because we still had to attend to our patients. What sustained us throughout the pandemic are the number of emergencies that we had to attend to. We were open throughout, we attended to various kinds of ocular emergencies as simple as conjunctivitis. On the other hand, all those patients with most complex emergencies, such as retinal detachment, bleeding, and everything which could lead to blindness, came in. We were still working at a reduced load, but at a comfortable rate throughout the pandemic.
We adapt to the latest cutting-edge technology to provide evidence-based eye services
We also have the subthreshold retina laser treatment for central serous retinopathy, glaucoma, and diabetic macular edema. We are also doing selective laser trabeculotomy and, of course, selective laser trabeculoplasty for glaucoma patients. All these things utilise a type of laser machine. We became a reference centre for these Quantel medical laser machines for the Asia Pacific training region so, we assist all these companies to do the testing of their machines. We do the wide field retinal angiography where we also became a reference centre for this Nikon Training and Research Centre. Nikon is very good at photography. Through the pupil that we have, we can take the photograph of the retina for patient education, academic purposes, and our research, amongst others. You may have heard of radiofrequency therapy. Ours is slightly different. We call it Tixel, high-intensity heat therapy, to be used to treat dry eyes. Oddly, with the pandemic and everything, dry eyes have become very common. Because of intense computer use, a lot of patients are coming in.
Can you walk us through the OasisEye Specialists’ business, when it implemented AI? How did this help increase the number of patients? This is still in a very early stage where we are testing out. We put this machine currently at one of the other centres where we do the screening without the presence of the doctor. The optometrist will be there, handling the patients, and the machines’ software will read out the results of the eye and guide the optometrist to explain it to the patient. If this is successful, we will have plans to deploy this machine to as many places as we can to assist in diagnosing and managing patients, especially with retinal issues, like diabetic retinopathy. Diabetes is a very major issue in our country. Most people tend not to go to the hospitals because of the pandemic, so the only way to help our patients is, we have to bring all this technology to them. We are working towards that direction so we don’t expect patients to come in. We expect to serve the patient, and bring the technology to them, without the doctors having to be present. The clinic was founded in 2018. Why did it only start operations in 2020, three months before the pandemic? We, the founders of the company—Dr. Kenneth Fong, Dr. Manoharan Shunmugam, and I—have been operating since 2018. To construct a big centre like this, you need at least about two years of planning construction licence applications. We officially got the licence on the 31st of December 2019.
We expect to serve the patient and bring the technology to them
OasisEye Specialists received the specialty clinic of the year award in Malaysia, which was given by Healthcare Asia. Did this affect the performance of the clinic and staff? For us, this award is a recognition of the highest standards that we are providing in our centre. We have been using this award to further strengthen, to do our resolve, and to do even better for our patients. The staff are feeling very motivated because of that. We are moving towards this correct goal to achieve what we want. We are further enhancing our performance; maintaining and improving on every step that we can. The award is being felt throughout the centre. Thank you very much for that award. As one of the directors of the clinic, how did you manage to uplift the institution’s operation amidst the pandemic? We took the opportunity to build more centres, we have the time, so people started to approach us, and our fellow colleagues approached us. We managed to build the other two centres all within the last two years. We spend a lot of time building these centres and commissioning them, replicating what we are doing at every boutique centre that we have. As borders and restrictions are loosened, all our centres are growing very well. There has been a rebound or number of patients. Now, we are working on opening up more centres. I believe we are there to capture our international patients when the borders are open. Just like our southern part we are waiting for Singaporeans to come in. We’re waiting for the Indonesians to come in. Moving forward, any future plans for OasisEye Specialists? We always adapt to the latest cutting-edge technology to provide evidence-based eye services. A month or two ago, we acquired a new sixth-generation state-of-the-art excimer laser, to perform refractive laser surgery, which performs very minimally invasive refractive surgery with very high-speed eye tracking, pupil monitoring systems with better customisation of the laser profiles. We are planning to increase the number of centres. We are still moving to reach out to more high calibre doctors who are very keen to join us because they believe in the way we manage our centres, they can see with their own eyes that even in a pandemic situation, we could expand, we still have a good number of patients and we still have doctors and ophthalmologists who are joining us. HEALTHCARE ASIA
DAVE O’SHAUGHNESSY Moving telehealth from a temporary fix to a pillar of modern healthcare
nce reserved for out-of-country patients or those with restricted mobility, COVID-19 has seen telehealth expand to deliver essential services when restrictions limited the number of patients allowed on-premises. Far from a stop-gap measure, these services are set to become one of the standout legacies from the global pandemic. Ernst and Young found a surge in demand for telemedicine services by both patients and physicians across ASEAN, indicating confidence in the method and a lasting appetite for its convenience. Indeed, the benefits offered by teleconsultations are broad and farreaching, and many of them slot perfectly into the gaps that persist across the region’s healthcare sector. Research has identified inadequate physical infrastructure and a lack of skilled healthcare workers as amongst the top issues plaguing ASEAN’s low-income and middle-income countries. With the availability of video-conferencing services, patients no longer need to leave their homes to receive care, and providers can ensure those in inaccessible areas aren’t left behind. In Indonesia, for instance, telehealth consultations have been identified as a way to improve the accuracy and efficiency of medical diagnoses in areas with limited resources, such as remote islands and mountainous locations. They can also address geographical challenges when skilled healthcare workers are permanently stationed in these places. Whilst demand for telehealth services has spiked, there is also a degree of skepticism around its long-term viability. Dr Peter Pronovost, a renowned expert in medical innovation encapsulated this attitude best: “There’s a lot of focus on shiny objects, rather than on solving problems.” It’s true providers cannot rely purely on telephony or simple video-conferencing software and expect it to provide a comparable experience to a traditional hospital or doctor’s office. Given the challenges around in-person availability, patients across ASEAN might avoid seeking healthcare altogether if they find that the telehealth experience is not easy to navigate and free of excessive wait times or interruptions. On the provider side of the coin, a clunky or ineffective solution could increase the administrative workload for staff, exacerbating stretched resources and ultimately driving more people away from the healthcare sector. A dent in the talent pool could seriously escalate the health crisis in Singapore, for instance, where 1,500 staff resigned in the first half of 2021, compared with 2,000 annually before the pandemic. Not just a shiny object Healthcare organisations need to create a telehealth environment from the ground up, one that addresses the specific pain points felt by people across the region. This begins with a unified system that can integrate with existing applications, allowing healthcare providers to seamlessly expand
DAVE O’SHAUGHNESSY Healthcare Business Specialist, Avaya
capabilities, thereby easing the frustration that comes with fragmented encounters between staff and patients. A solution that enables flexible integrations saves staff from trawling through external systems to access patients’ medical histories and referrals, readily drawing upon electronic medical records (EMRs), decision support and diagnostics systems to provide patients with uninterrupted virtual experiences. A pillar of the healthcare sector Research has found a lack of interoperability between healthcare providers in ASEAN is elongating referral processes and causing unnecessary re-evaluations if patients have to move between facilities. A unified system can go a long way toward streamlining this process and saving time. In a practical example, healthcare organisations can reduce the duration of individual consultations by rolling out a secure, virtual waiting room that patients can access with dedicated, private web links. This allows them to be automatically identified, authenticated, and admitted to a virtual doctor’s office, providing visibility over the journey and closely mirroring traditional healthcare visits. Patients should also be empowered to book appointments, receive medical advice and complete payment processes in the one spot. If each step of their journey involves separate applications, with different login credentials and interfaces, administrative staff will expend time and resources explaining each process, hindering the overall impression of care and support. Additionally, this flexibility will allow providers to easily expand upon telehealth solutions when new technologies and processes emerge across the industry. Some hospitals, for instance, have begun creating a telehealth ‘metaverse’, extending healthcare beyond isolated consultations to include pre and post-care, the delivery of medication, and more. Two of Southeast Asia’s largest hospital operators, for example, have begun experimenting with augmented reality as part of their telehealth services, with plans to use artificial intelligence (AI) and machine learning technology to provide outpatient counselling and to remotely monitor patients in intensive care units. To leverage these initiatives with minimal set-up time and disruption to services, a unified system that can seamlessly draw upon historical patient information is essential. Telehealth is poised to become a crucial pillar across ASEAN’s healthcare sector, not only to compensate for scarce resources and navigate pandemic mandates but to ensure the delivery and availability of healthcare is the same for all people, regardless of their location. To elevate the experience beyond simplistic measures and provide services that are on the same level, or even better, than traditional healthcare appointments, these environments need to address the needs of patients and healthcare staff, and be flexible, adaptable, and geared for the challenges of the future.
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HOSPITALS UNDER ATTACK SINGAPORE’S MASSIVE DATA BREACH SHOWS THAT HOSPITALS NEED TO STEP UP THEIR GAME IN ORDER TO WARD OFF POTENTIAL ATTACKERS AZHAR HARUN CEO, UMSCp14
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9/21/2018 2:35:41 PM
DR PRADEEP NAIR
The contract doctor conundrum: Is there a long-term solution?
n 2016, the Malaysian government introduced a contract scheme of employment in its effort to rationalise the employment of doctors within the public sector. This scheme basically ensured two years of housemanship, followed by three years as a medical officer before a decision was made regarding permanent employment. Fast forward to 2021, the COVID-19 pandemic has brought into sharp focus a problem that many of us may have instinctively realised but did not speak about – apart from not having enough doctors and specialists, there is an uneven distribution of the same across the country. With educational liberalisation and in an effort to make Malaysia a hub for education in the 90s, private institutions of higher learning embarked on the expansion of their course portfolios. This was fueled by a genuine lack of adequate places in public universities as well as government policy. Medicine was no exception, and private medical schools were established, albeit with the stringent requirement to meet the standards of the Malaysian Medical Council (MMC) and the Malaysian Qualifications Agency (MQA). Today, we have 31 medical schools, 11 of which are government institutions. Malaysia annually has 5000 to 6000 doctors who need housemanship training, and of these about 50% to 60% are locally trained and the rest are international graduates. We further recognise about 330 international medical schools and we also have Malaysians graduating from unrecognised medical schools, who may seek provisional registration and housemanship opportunities by appearing for an examination run by the MMC. Malaysia’s private medical schools Over the years, private medical schools have become convenient scapegoats for what is claimed to be an excessive number of medical graduates in this country, when it is self-evident that this is only part of the story. Medical schools in Malaysia are very closely scrutinised by the MMC and MQA for accreditation, every three to five years, apart from frequent supervisory visits in between to ensure the gaps that had been identified are closed. In 2017 the Penang Institute in its paper “Housemanship Programme in Malaysia: Availability of Positions and Quality of Training” concluded that whilst there has been a rapid proliferation of private medical schools in Malaysia, competency issues which commonly lead to an extension of housemanship are largely driven by poorer performers among foreign medical graduates, constituting 60% of dropouts from housemanship. It would be worthwhile to compare our recognition of overseas medical qualifications with Singapore which recognises a total number of 158 medical institutions. Since the publication of this report, the number of overseas medical schools recognised in Singapore has been whittled down to 103 to offset the increased number of local graduates. This took effect on Jan. 1, 2020. Whilst similar action has previously been proposed, progress in Malaysia has however been painfully slow. The matter that we need to consider is that with a moratorium in place on the number of medical programmes in the country, as well as limits on intake, should the next steps be: 1. A phased reduction in the number of overseas medical schools and institutions we recognise.
DR PRADEEP NAIR Deputy President , Malaysian Association of Private Colleges & Universities (MAPCU)
A scheduled discontinuance, with sufficient notice, of the provisional registration examination for unrecognised graduates. 3. The introduction of a common competencies checklist for ALL Malaysian medical undergraduates studying locally or abroad. (This is in tandem with the latest MMC undergraduate standards document for medical schools. The implementation has been delayed by the pandemic.) 4. The introduction of a common exit examination for all Malaysians (medical graduates) intending to work in Malaysia was overseen by a regulatory body of stakeholders from MMC, MOH, MOHE and the universities. In 2015, the Global Health Observatory report indicated that Malaysia has a 1:651 doctor to population ratio whilst WHO recommendation is 1:500. The MOH in August 2020 reported that we had an overall ratio of 1:454, however, conveniently ignores the urban rural divide. Quoted ratios in East Malaysia at the same time were 1:856 in Sabah and 1:662 in Sarawak with up to 45.6% of rural clinics in Sarawak were without doctors. In 2009, the housemanship period was extended to 24 months, without proportionately increasing the number of posts required for the extended training period which consequently compounded the shortage of posts available. There were 38 MOH hospitals for housemanship training in 2009 compared to 48 in 2019, excluding UMMC, HUKM and HUSM - an increase of 10 hospitals whilst the number of graduates requiring housemanship places were much more. This is an area that will need to be looked into to ensure more hospitals are gazetted for training of housemen. Malaysia spends 4.4% of GDP on healthcare, compared to a recommended 7% by the WHO, a ramping up of healthcare expenditure may also contribute to easing the gridlock in available posts in the medium and long term. Housemanship training in the private sector Another solution is exploring the possibility of smart partnerships with private medical centers, and medical schools by allowing housemanship training in the private sector. This is in place in Australia, under the Commonwealth Medical Internships Initiative, and is worth exploring. Finally having a temporary oversupply is not always a bad thing. An Australian study in 1980 indicated 5 major advantages: 1. Improvements in the quality of medical care. 2. A renewed emphasis on preventive medicine. 3. Equitable need-related distribution of doctors. 4. The ability to continually train and upgrade skills without compromising service needs. 5. Increased capacity to participate in humanitarian aid programmes in the region and internationally. The recent announcement by the government to increase the contract period of service is a welcome one. It will extend a lifeline for junior doctors and improve th eir morale and as for the government, there will be manpower that can be deployed to areas that need medical personnel. The government could also tie permanent tenure and specialist training to serve in the rural and public health sectors.