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Aligning business and healthcare in India

September 2013 • Vol 1 • Issue 12 • Rs50

Published by ITP Publishing India

Diagnostic Special

molecular diagnostics Top industry trends latest initiatives

Ensuring patient safety FUTURE-PROOF PLANNING

Low cost High returns



Dr Sabahat Azim, founder, Glocal Healthcare, on building the largest chain of private hospitals for the underprivileged


28 14

Cover story Dr Sabahat Azim, founder, Glocal Healthcare, on the secrets of building low cost quality healthcare delivery in tier III and tier IV towns of India

bulletin 12 This month’s important news updates

42 Dr Sanjay Arora of Suburban Diagnostics,

Project 22 A glimpse into the upcoming Medipulse

44 Thomas John of Agappe Diagnostics Ltd, on growth in reagent and equipment market

on the group’s state-of-the-art facilities


Hosiptal in Jodhpur

46 Anil Prabhakaran, managing director, 24 10 things you should know about Rockland

Sysmex India, on prospects of the IVD market

Qutab Hospital

47 IPAQT’s initiative is focused on improving Hospital Infrastructure 22 When setting up a new hospital, make sure

access to quality TB testing

that the plan is exhaustive yet flexible

MARKETING 50 Ratan Jalan writes about the five essential

Diagnostic Special 34 Top ten trends in pathology sector

pillars of marketing

38 The rising popularity of molecular

Quality 51 Dr J Sivakumaran on various aspects of


patient safety


Healthcare Radius September 2013


Editor's note

September 2013 • Vol 1 • Issue 12 ITP Publishing India Pvt Ltd Notan Plaza, 3rd floor, 898 Turner Road Bandra (West), Mumbai – 400050 T +91 22 6154 6000

Deputy managing director: S Saikumar

Private efforts, public service


n a country where 22 per cent citizens and half the rural population are below the poverty line, the healthcare needs for such a massive segment cannot be ignored. We all know how miserably the government's healthcare infrastructure and machinery have failed to address the need. And it was high time that private healthcare players stepped in to correct the skewed distribution of healthcare service, not just in villages but in smaller towns as well. And that’s why the epochal effort made by Kolkata-based Glocal Healthcare counts. Founded by two former civil servants, the organisation is providing decent healthcare to the havenots, that too in a corporate set-up. Having tested success with its unique business model with five hospitals in West Bengal, Glocal is now raring to grow. It is setting up 50 more hospitals that would take the group’s bed strength to 5,500 beds. Glocal’s story is not just an fine example in successful social entrepreneurship, but also a study in management. It is a reference point for building and operating a low-cost healthcare model that is sustainable and profitable in the long run. However, much of Glocal’s success can be attributed to the success of RSBY scheme. So, while applauding Glocal's efforts, let’s not forget to give credit to Anil Swarup, a maverick civil servant, under whose aegis RSBY has provided more than 110 million people with heavily subsidised health insurance.

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Rita Dutta Editor

used for the purpose of fair review.

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Healthcare Radius September 2013

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a dv i s o r y b oa r d Our editorial board holds up a mirror to the healthcare industry, helping us underscore the key trends and developments of the industry

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Dr Praneet Kumar CEO, BLK Super Speciality Hospital and chairman, NABH appeals and grievance committee

Dr Girdhar J Gyani Director general, Association of Healthcare Providers

Dr Ravindra Karanjekar CEO, Global Hospital and chairman, NABH accreditation committee

Dr G Bakthavathsalam Dr MK Khanduja

Chairman, KG Hospital & Post Graduate Medical Institute

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Healthcare Radius September 2013

Bulletin Manipal acquires two hospitals in Malaysia The Manipal group, which has runs a medical school at Melaka in Malaysia, has consolidated its presence in the country. The Manipal Health Enterprises (MHE) has acquired an under-construction 200-bed tertiary care hospital and a 70-bed functional hospital, both located in KLANG, a suburb district, close to the Malaysian capital city of Kuala Lumpur. Both the projects are 100 per cent buyouts by MHE. The under construction hospital, earlier known as Arunamari Specialist Medical Centre or ASMC, was being constructed on a vacant piece of land by the previous owners of ASMC. This project would now be completed by MHE by September 2014. According to Rajen Padukone, CEO and MD, MHE, “After complying with local regulations and licensing requirements, we will rebrand ASMC to Manipal Hospitals – Klang.” He added that the entire investment including acquisition and construction is being pumped in by MHE. The hospital will focus on a combination of wellness, prevention and curative care for both the domestic and an emerging overseas patient traffic into Malaysia from neighbouring countries. The facility is being implemented in accordance with the Malaysian healthcare guidelines, MSQHA and also JCI. The MHE has also acquired a 70-bed hospital at Klang, just 800 meters away from the under construction hospital. The hospital was set up by Dr Poraviappan Arunasalam, an eminent obstetrics and gynaecology consultant, about 14 years ago. Today, the hospital has an eminent panel of consultants spread across specialities including ENT, general surgery, pediatrics and gynaecology and is equipped with facilities like 64 Slice CT and 1.5 T MRI. While Dr Poraviappan will continue to provide help and guidance as required to the new dispensation, Ramkumar Akeila, head-global practices with MHE will be relocating to Malaysia to lead the operations of the two hospitals as CEO and MD. MHE will retain the existing employees and doctors of the hospital.

Said Swaminathan Dandapani, executive chairman, MHE, “This acquisition is a part of the company’s evolving strategy to expand its footprint in India and in identified countries of the Middle East, Africa and Asia Pacific. In the near term, significant capacities will be created to add on to the present group capacity of 15 hospitals, 5,000 beds and a patient traffic of about two million annually.” Added Padukone, “Manipal is a well-established name in Malaysia, with over 25 per cent of the doctors in the country being alumini of the Manipal University. The access to this pool of talent, trained in India at Manipal University and at Melaka, has been a key driver for Manipal to venture into setting up hospitals in Malaysia.” Asked about the group’s plans of introducing MCC-type clinics in Malaysia, Padukone said, “GP clinics form an integral part of healthcare delivery network for secondary and tertiary care in Malaysia. We would look at some arrangements with existing GP clinics. At this moment, we are not contemplating MCC types of clinics in Malaysia.”

Rainbow Hospital gets PE investment Rainbow group of hospitals, which primarily focuses on paediatric and maternal care, has attracted investment worth $17.5 million from UK's development finance institution CDC and UAE's Abraaj Group, a leading investor in global growth markets. This is CDC's first direct equity investment in India since the launch of its new strategy in late 2012.


Healthcare Radius September 2013

Rainbow, which started in 1999 as a 60-bed hospital, currently runs six hospitals located in Hyderabad, Vijayawada and Bengaluru. The funding will help the company to scale up its beds from 450 to 1,000 by 2017. The company is also looking at expanding to Chennai, Pune, Visakhapatnam and Kurnool, among other cities.

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A better way.


BSR installs 128 slice CT at Medica BSR Healthcare, which manages the radiology department of Kolkata’s Medica Hospitals, has installed the latest state-of-the-art 128 slice CT at the hospital. Said Dr MK Khanduja, CMD, BSR Healthcare, “In continuation with our endeavour to usher in worldclass diagnostic facility, we decided to install this ultra fast CT scan, which along with its advanced software is the best CT for CT coronary angiography, peripheral angiography, body CT cases, neuro cases and all types of routine CT cases as well.” He added that scanner from Philips Healthcare has ‘I dose’ that substantially increases image quality and reduces the radiation dose to the patient. The CT has powerful 8 MHU tube, 80 KW generator and 0.625 mm slice thickness for excellent resolution. “BSR has been known for the reliability of its reports and quality diagnostic services. These diagnostic facilities will enable clinicians to make fast and accurate diagnosis which will help enhance care,” he added. Earlier, BSR had installed advanced 1.5 Tesla MRI, 16 slice CT, colour dopplers, X- Rays, CR systems and mammography at Medica.

Dr Alexander heads to Chennai

Dr Nitish Shetty Joins BGS Global

Former joint managing director and one of the founder partners of MedicaSynergie Pvt Ltd, Bengaluru-based Dr Alexander Kuruvilla, has taken on the mantle of CEO of the upcoming SRM Institute of Medical Sciences in Chennai. A post graduate in radiology from Bangalore Medical College, followed by an MD in hospital administration from KMC Manipal, Dr Kuruvilla started his career as assistant medical superintendent of St Marthas Hospital, Bengaluru. He has worked with Narayana Hrudalaya as director of medical services, followed by Apollo Hospitals, Ahmedabad as CEO. At MedicaSynergie, other than overseeing each individual vertical of the group, he was keenly involved with its projects and consultancy division and contributed as an expert adviser to its verticals of hospital planning and architecture, quality and accreditation and public health.

Former CEO of Narayana Hrudayalaya Dental Clinic, Dr Nitish Shetty has joined Bengaluru’s BGS Global Hospital as CEO. Having post graduate qualification in MD Hospital and Health Care Administration from Kasturba Medical College, Manipal, Dr Shetty started his career with Narayana Hrudayalaya Hospital in 2000. Between 2006 to 2010, he was CEO of Narayana Hrudayalaya Hospitals and in the year 2010, he tied up with Narayana Hrudayalaya as an entrepreneur for conceptualising, planning and deploying Narayana Hrudayalaya Dental Clinic in the twin cities of Bengaluru and Kolkata. He recently exited the dental business after its strategic sale.


Healthcare Radius September 2013

V P Kamath Takes Charge as Group CEO of Nova Former COO of Wockhardt Hospitals, VP Kamath has taken charge as Group COO for Nova’s Surgical Centers and Infertility Clinics. For this role, he has relocated to Bengaluru from Mumbai. Kamath has over 25 years of leadership, general management, operations, marketing and sales and business development experience across premier organisations, such as Wockhardt Hospitals, Apollo Hospitals, Nicholas Piramal and Johnson and Johnson. He is a post-graduate in management and microbiology from the University of Mumbai.


First Liver Transplant in South Kerala

Cochlear Implant surgery milestone for Apollo

By successfully performing the 700th cochlear implant surgery, the Apollo Health City, Hyderabad has created a new record. Off the 700 patients treated till now, 300 were supported by Arogyasree and 350 others got support from SAHI (Society to Aid the Hearing Impaired), Apollo Hospitals, donors etc. Said Dr K Rambabu, senior ENT surgeon, Apollo Health City, though cochlear implant is an expensive treatment, it gives an opportunity for the child to lead a normal life like anyone else post cochlear implantation.

KIMS Hospital, Thiruvananthapuram has successfully completed its first liver transplant surgery, thus becoming the first hospital in south Kerala to perform this procedure. KIMS is also the second hospital in the state of Kerala to offer liver transplant, with Kochi’s AIIMS being the first one. For the 43-year-old patient from Tirupur, who was suffering from chronic liver disease, the liver was harvested from a 30-year old patient who died in a private hospital in the city. The information regarding the availability of the healthy liver was shared with the Kerala Network of Organ Sharing, which identified Sundarmurthi as undergoing treatment at KIMS and seeking a B+ve liver.

After the legal formalities for approving the transplant were promptly carried out, the patient was admitted at KIMS early on the day of the operation and KIMS’ team of experts under the leadership of liver transplant surgeon, Dr B Venugopal, travelled to the hospital where the donor had been prepared for organ harvesting. The liver was successfully harvested and the team returned immediately to KIMS where in the meantime the recipient had been fully prepped for the surgery. The patient underwent the 12-hour surgery, being led by liver transplant specialists- Dr Venugopal and Dr Shabeer Ali. The patient was discharged on the 10th day following the operation.

HealthKart Launches Store in Chandigarh, India’s pioneer online health and fitness store, has launched HealthKartFit in Chandigarh, their first offline store in Punjab. This is the second store of the country after its flagship store in New Delhi. Facilities like body composition monitor machine to analyse the need of an individual based on the BMI, with nutrition experts at the store to provide professional advice makes this store unique for health and fitness enthusiasts and body builders. The product range at HealthKartFit store is wide and the provision of sampling - ‘tasting before buying’ helps in suitable decision making. The store focuses primarily on sports nutrition, body-building supplements, and weight management products.

Meenakshi Mission Introduces Retrograde Angioplasty

Madurai’s Meenakshi Mission Hospital and Research Centre (MMHRC) has introduced retrograde angioplasty, a Japanese method of doing coronary angioplasty. In this technique, the blockage is approached from the reverse end, against the flow of blood. The first patient undergoing this procedure at the hospital was a 55-year-old man who suffered chest pain. The four-long procedure was led by three interventional cardiologists – Dr R Sivakumar, Dr S Selvamani and Dr N Ganesan. The hospital had also introduced a bio-vascular scaffold by replacing the conventional metal stent implanted in the patient’s artery.

20,000 liver transplants are required in the country, while only 1,000 are done.


Healthcare Radius September 2013

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DCDC Kidney Care ties up with Soni Group

Odisha signs MoU with six private hospitals Extending specialised treatment to the poor people residing in remotest part of the state, the Government of Odisha has tied up with private hospitals. It took the decision as highly specialised treatment is not available in remote areas and when available, the waiting list is long. Empanelling good private hospitals, both within and outside the state, as referral hospitals for specialised treatment was an option to facilitate such treatment. The Government has inked an MoU with six private hospitals: Care Hospital, Vishakhapatnam; Apollo Hospital, Vishakhapatnam; SevenHills Hospital, Vishakhapatnam; Escort Heart Centre, Raipur; Narayana Hrudayalaya Hospital, Raipur and Ramkrishna Care Hospital, Raipur.

DCDC Kidney Care, North India’s largest chain of dialysis centres, has tied up with Soni Group to open 12 units in Rajasthan. Under the partnership, it has opened its first centre in Jaipur at SK Soni Hospital and will be starting its second unit at Soni Hospital, JLN Marg next month. The modern unit at Jaipur consists of 15 dialysis machines with 24 hours service facility to patients from Jaipur and adjoining towns. The machines have advanced technology with latest international standards like online KT/V, NIBP and are backed with a super sophisticated RO plant.

Said Aseem Garg, founder & MD, DCDC Kidney Care, “Rajasthan has always been in our focus for expanding our footprint in Northwest India. With the opening of our first centre in Rajasthan, we are one more step closer to our commitment of supporting medical tourism. With Rajasthan being a tourist hot spot we do recognise the need of quality dialysis in Rajasthan.” He added that the partnership plans to support over 2,000 patients on a monthly basis in Rajasthan to eventually become the biggest dialysis providing chain in Rajasthan, with estimated over 2,50,000 lakh dialysis sessions per year.

OMNI Hospital raises PE funding Mumbai-based private equity investment advisory company ASK Pravi, which is a JV between ASK Group and Pravi Capital, has announced an investment in Hyderabad’s OMNI Hospitals. The investment of Rs 60 crore is against a substantial minority stake. The funding will enable OMNI Hospitals to expand its network of hospitals across India, especially south and east India. OMNI Hospitals is promoted by INCOR Group, which is founded by Anand Reddy Gummadi and Surya Reddy Pulagam. The group operates two hospitals in Hyderabad and Visakhapatnam, offering over 20 specialties. Anand Vyas, managing partner of ASK Pravi Capital Advisors, will be joining the board of directors. Spark Capital acted as the sole financial advisor to OMNI Hospitals for the transaction.


Healthcare Radius September 2013

Efforts to re-open AMRI Almost two years after the Advanced Medical Research Institute (AMRI) Hospital, located in Dhakuria area of Kolkata, was forced to down shutters, as a consequence of the massive fire that killed over 90 people, there are talks about re-opening the hospital. The hospital, a joint venture of FMCG behemoth Emami and real estate group Shrachi, was started in 1991. The devastating fire that broke out in on 9th December 2011, led to arrest of six directors of the hospital and revoking of license of the hospital. It is reported that the five-storey hospital is undergoing renovation work, with special attention being paid to fireprevention arrangements. Some of the measures adopted are new flame detection system, fire-proof doors and sprinklers. On the sidelines of a seminar, RS Agarwal, joint chairman, Emami Group of Companies, had highlighted on-going efforts and talks with the Government to re-open the hospital.


2/21/2013 10:51:47 AM


Wockhardt Hospitals, Goa receives NABH Nusi Wockhardt Hospital, Goa has received accreditation from NABH, making it first hospital in the state to be NABH accredited. With this recognition, Wockhardt Hospitals Ltd received their fifth NABH accreditation, making them the only hospital group with the highest accreditations in the west zone. Wockhardt Hospitals, Goa, is a dedicated super specialty hospital offering comprehensive, end-to-end care in cardiology, cardiac surgery, neurology, neurosurgery, orthopaedics and joint replacement surgery.

Nova’s workshop for bariatric patients Nova Specialty Surgery, leading short-stay surgical centres, hosted a patient awareness workshop on obesity and bariatric surgery at its Tardeo unit in Mumbai. This workshop was specifically designed to address the needs of the patients who have undergone bariatric surgery or those considering surgery. The workshop focused on the variety of topics like post surgery weight lost strategies, misconceptions about surgery, medication myths, surgical and nutritional myths. With an aim to help each patient achieve his or her healthy weight and lifestyle goals, post-surgery issues including motivation, challenging negative and self-sabotaging behaviours, body image, depression and addiction issues were addressed in the workshop. Said Dr Ramen Goel, senior consultant, Nova Specialty Surgery, “Such patient support groups provide an inclusive opportunity to patients to acquire in-depth information on the surgery and allow them to share ideas with fellow patients to surpass the challenges in reaching their weight loss goals.”

Seminar on patient safety and cost reduction The Association of Health Providers (India) is organising its first seminar at Jacaranda Hall, BIEC, Bengaluru, on September 5 and 6, 2013. The theme of the seminar is ‘Improving patient safety and reducing cost of healthcare’ and it is aimed at helping healthcare professionals develop competence and confidence, monitor and assess the cost of healthcare delivery and patient safety in hospitals. The seminar would be addressed by experts of repute, based on their experience of patient safety and governance for efficiency and effectiveness. The seminar is aimed at a diverse set of healthcare professionals, be it policy makers, clinicians, administrators, quality professionals and nursing supervisors, among others. Further details are posted on its website,


Healthcare Radius September 2013

Distinguished Jury for Annual India Healthcare Excellence Awards Frost & Sullivan has announced its distinguished jury for the 5th Annual India Healthcare Excellence Awards 2013, to be held on 27th September 2013 in Mumbai. Said Sandeep Sinha, director, healthcare and life sciences practice, Frost & Sullivan, “The jury members consist of eminent thought leaders, senior experienced doctors, and industry veterans from various healthcare segments.” The jury members are: Dr Alan Almeida, consulting nephrologist and transplant physician, Hinduja Hospital; Dr Amit Varma, founding managing partner, Quadria Capital Investment Advisors Private Limited; Dr Bhavin Jankharia, president and consultant radiologist, SRL Diagnostics; Dr Chander Bhasin, CEO, healthcare, Sahara India Pariwar; DG Shah, secretary general, Indian Pharmaceutical Alliance; Dr Harish Ahuja, chief head of Pathology, Jaslok Hospital; Manish Mehta, managing director, Samara Capital; Nitin Deshmukh, founding member and CEO, Kotak Private Equity; Suresh N, group editor and senior vice president, Biospectrum; Tester Ashavaid, HOD, laboratory medicine, Hinduja Hospital; Dr Uday Patil, advisor to MD and CEO, Medall Healthcare Pvt Ltd; Dr Umesh Khanna, consultant nephrologist, chairman - Mumbai Kidney Foundation and Vamesh Chovatia, managing director, New Enterprise Associate India Pvt Ltd.

You know your hospital can generate twice the revenue. It’s time you did something about it.

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Medipulse Hospital

Fortifying healthcare in Jodhpur Project name: Medipulse Hospital Location: Basni, Phase II, Jodhpur, Rajasthan. Type of hospital: Private and super speciality. Promoted by: Navneet Agarwal, director, JIET Group of Institutions, Jodhpur in partnership with Shashikant Singhi, director general, Poornima Ggroup of Colleges of Jaipur. This is their first healthcare project. Bed strength: 300 in the first phase and 450 when fully complete. Number of floors: Ground plus six in first phase and an additional two floors in the second. Type of project: Greenfield, to be built ground up. Project status: Construction started last December. To be commissioned by end of 2014. Land area: 4,2517 square feet. In-built area: 2,05,052 square feet.


Healthcare Radius September 2013

Project consultant: Hospaccx India Systems, which is doing turnkey architecture and design. Total cost of the project: More than Rs80 crore, inclusive of land, construction and equipment. Type of funding: Mix of equity and debt. USP of the hospital: A state-of-the-art super speciality hospital planned as per NABH norms. The hospital will be backed by eight major OTs, two minor OTs with a flat panel cath lab backed by 60-bed ICU. It will have 18 OPDs and cutting-edge technology like 64 slice CT and 1.5 T MRI. Major specialities of the hospital include cardiology, orthopaedics, medical and surgical oncology, intervention neurology, nephrology and organ transplant. Types of rooms: General wards, twin sharing, deluxe and suites. Number of doctors: 25 to 30. Catchment area: Within 180km of Jodhpur.


10 things you should know about... Rockland Qutab Hospital

16 27 38 49 510

Rockland Qutab was started by Rajesh Srivastava along with his two brothers— Prabhat and Rishi —all of them first generation entrepreneurs.

Rockland Qutab was the group’s first step towards creating a chain of tertiary care hospitals in Delhi-NCR (whose valuation today stands at over Rs1,000 crore) and then connecting them with smaller hospitals, nursing homes, and clinics.

The hospital was formally inaugurated by Sheila Dikshit, chief minister, Delhi, in June 2004. Much impressed by the grandeur and plush décor of the hospital, she had famously said that the interiors will encourage patients to recover faster.

It was one of the first corporate hospitals in South Delhi that set a new benchmark on the way new-age hospitals should look. And believe it or not, the interior was designed by a student of architecture with no prior experience.

The hospital started with only 80 beds having basic specialties. Today, it has all major super specialties and expanded to a total of 200 beds.

Right at the inception, the Srivastava brothers managed to rope in former director of AIIMS, Padamshri Dr PK Dave as chairman of its advisory board and HOD of orthopaedics. It was Dr Dave who roped in the best clinical acumen from several reputed hospitals, thus giving the hospital the much-needed buoyant start.

In 2008, IFC announced an investment of Rs550 million in the group for expansion, which also benefitted Rockland Qutab.

In 2007, Rockland doctors in a collaborative effort with a team of Korean doctors performed a unique procedure on a 46-year-old woman suffering from osteoarthiritis of the knee. For the surgery, known as autologous chondrocyte, the cells were flown to Korea, cultured and flown back to Rockland.

The hospital has launched Sankalp that work towards creating social sensitivity in the minds of the youngsters and trains them in handling medical emergencies.

Like many of its unique cases, the hospital helped a patient who could not get out of the bed, to resume normal life, by using an arthroscopic procedure that harvested cartilage from the knee joint.

Healthcare Radius September 2013


Hospital Infrastructure

Hospital planning should focus on patient care, economic viability, sound architectural plan and medical technology.

Plan to succeed When setting up a new hospital make sure that the plan is exhaustive yet flexible By Team HR


hile planning a new hospital, one must consider the changing paradigm and adopt the best practices, be it in design, architecture, finance or equipment. Experts say that hospital planning should focus on patient care, effective community orientation, economic viability, sound architectural plan and medical technology. The whole phase of hospital planning starts with inception, feasibility studies, outline proposal, scheme design, detail design, tender action, construction, commissioning, shake down and ends with smooth functioning. According to Col BP Singh, managing director, global healthcare integrated business solutions, Chandigarh, “Hospital planning should consider site and land requirements, master plan, circulation routes, project costs, inter department relationships, equipment planning, project management and commissioning.” However, there are multiple factors that need to be looked into before planning. “The factors are socio economic profile of community, existing medical facilities,


health profile of the region, vernacular architecture, local regulations, source of finance, choice of technology and climatic zones,” said Col Singh, while speaking at HospiArch, a conference on hospital planning, design and architecture. The conference, organised by AMEN in association with Hospaccx, had Healthcare Radius as a media partner. While freezing in on land and site, one must consider the hospital type and size, the terrain (plain/hilly), climate, scope for future expansion, local regulations and liaison with town planning authorities. According to Dr PH Mishra, medical superintendent, Indian Spinal Injuries Centre, New Delhi, the key aspects in design and planning are market survey and feasibility analysis (ROI), facility planning and architectural design, future developments, medical and non-medical equipment planning, human resource planning, healthcare information technology management, project management and commissioning, accreditations and operational management. The planning should be done with the outcome of clinical excellence, revenue growth and market capitalisation in mind.

Healthcare Radius September 2013


oday, hospital architecture is undergoing a paradigm shift, driven by factors like advancement in medical sciences, enhanced clientele expectations, demographic and lifestyle changes, enhanced standards and norms. Hospital architecture is a synergy of scientific, creative, innovative and artistic principles. According to Col Singh, the hospital architecture brief should be a written document with type of services, inter-relationships, operational policies giving client’s need in consultation with clinicians, professionals inclusive of architect and engineers. The content of the brief should include information on site facilities such as beds, major equipment, schedule of accommodation, zoning–grouping of departments, phasing and financials. The key planning and design parameters of medical architecture include: the planning team, demographic profile, health statistics, local regulations, local cultures and practices and macro and micro planning, flexibility, convertibility and expandability–modular approach. It should also consider needs of beds, wards, departments, resources/funds, landscaping

Hospital Infrastructure

Financial planning begins with market research that should look into demographics, performance analysis of a few corporate hospitals, availability and identification of major specialist doctors, financial feasibility and project report.” — Dr Inderjeet Singh, Deputy medical superintendent, Sahara Hospital, Lucknow

and electric load, HVAC, hospital equipment. The architecture should also take into consideration things like hospital infection control, utilisation of natural light /resources and eco friendly materials. According to Col Singh, the best practises in hospital architecture are: design that follows function, scientific planning, optimum utilisation of space and user-friendly and focussed architecture. Hospital design should not only be functional but should also be safe, comfortable and barrier-free. There should be a seamless integration of clinical requirements with building planning, flexibility and expandability. The master plan of the hospital should have overall site plan, section plan, departmental boundaries, major entry and exit points, vertical transportation such as stairs and lifts, main inter department corridors and areas for future changes/expansion. And the area requirement for the hospital should be decided depending on whether it is a general, multi speciality / or super speciality. Manpower planning is key in project planning. It should also include staffing to avoid over staffing. The planning should be for medical (OPD, diagnostic, IPD, medical and surgical), paramedical (lab services, physiotherapy) and non-medical (support, administrative and security).

financial feasibility and project report. Then, the hospital needs to consider cost for getting statutory approvals like building permit, trade license, labour license, drug license, fire compliance, NOC from pollution control board, lift license, food license, PNDT license, blood bank license, excise license and VAT. Utility planning should entail planning for power, water, AC, generator, STP and ETP, biomedical waste management, medical gases, elevators and access control system. Preparing a project report is crucial to success. The project report should contain cost and means of finance, projected cash flows, projected profitability, projected balance sheet, breakeven analysis, loan repayment and others. The main project cost involves the cost of the land, building and medical equipment. “The cost of land would depend on the location, legal formalities and statutory approvals. The cost of the building involves building plan-


inancial planning is another crucial facet of planning. According to Dr Inderjeet Singh, deputy medical superintendent, Sahara Hospital, Lucknow, financial planning begins with market research that should look into demographics, performance analysis of four to five leading corporate hospitals, availability and identification of major specialist doctors,


Healthcare Radius September 2013

ning, cost of construction, which ranges from Rs2,000 to 5,000 per square feet, approvals, space for parking and landscaping and floor area ratio (built-up area per bed -1:400 to 1:1,000 square feet),” says Dr Singh. The means of finance can be contribution from promoters (equity, unsecured loans and debt/external funding) and funding from banks/financial institutions whose interest rate ranges from 9 per cent to 13.50 per cent. One needs to also take into consideration the rates of depreciation for electronics as per, which is 60 per cent for computers and software, 15 per cent for office equipment, medical equipment and vehicles and 10 per cent for buildings, vehicles.


ith a 40 to 50 per cent of project cost being allocated for medical equipment, its planning is extremely crucial for cost optimisation. Medical equipment planning should include cost of medical equipment, latest technology adoptability to change and upgradation, lease/buyout, annual maintenance cost and credentials of suppliers. The departments requiring large equipment are diagnostics, emergency unit, physiotherapy, autopsy and central labs, central pharmacy, surgery, cath lab, cardiology, ICU/ICCU, in-patient area and OT (ceiling hung, more height required). Equipment may be classified as building service equipment (such as heating, ventilation, AC, filtration equipment, chillers, boilers, fire pumps), fixed equipment (like sterilizers, communication systems, built-in casework, kitchen equipment, serving lines) and mov-

At a glance Planning for water • Water conservation, rainwater harvesting • Re cycling water • Average requirement is 500 litres per bed per day excluding gardening Planning for energy • Building designed for energy efficiency • Solar & wind energy • Direction • Materials

Planning for indoor air quality • Indoor air quality has direct relation to • Occupant health & productivity • HVAC • Natural ventilation Planning for plumbing • Proper water supply • Drainage system • Quality of piping/

plumbing systems • Ease of inspection/maintenance • Preventive maintenance Planning for flooring • Long lasting / resistant • Safe –non skid/non slip • Minimum noise • Dept specific • Easy to clean • Seamless –OT, ICU Source: Col BP Singh

Hospital Infrastructure

able equipment (like portable x-ray, EEG, ECG, etc). Hospital equipment can also be broadly classified into biomedical equipment, laboratory equipment, ward equipment, service support equipment and utilities and hospital furniture. According to Dr Pranav Sharma, nonvascular interventional radiologist and CEO, Top Brass, New Delhi, “It is important that an equipment list is included in the contract documents to assist in overall coordination of the acquisition, installation, and relocation of equipment. The equipment list shall specify whether the items are new, existing to be relocated, owner provided, or not-in-contract.” He suggested that the development of equipment plan involves preparing a preliminary budget, developing alternate specifications to obtain competitive bidding on equipment, making recommendation for new equipment specifications and obtaining utility requirements for all existing and new equipment. The four key aspects of equipment planning are clinical effectiveness, cost of ownership, strategic medical technology direction and perception of client and medical personnel. The clinical effectiveness should consider

Design and planning should be done with the outcome of clinical excellence, revenue growth and market capitalisation in mind.”

— Dr PH Mishra, Medical superintendent, Indian Spinal Injuries Centre, New Delhi

availability (mean time between failures) and downtime duration. The cost of ownership should consider consumables consumption (cost, volume and usage frequency), medical expenditure limit and second-hand resale value or trade in price.


common requirement in the development of an equipment plan is to evaluate the current equipment. Equipment audits needs to be done to evaluate what should be kept in service (and for how long) versus what should be replaced. According to Dr Sharma, one must also conduct assessment of existing equipment, like identifying master list of existing equipment, on site evaluation of each equipment item, evaluating condition/functionality of equipment and

make recommendation for maintain or replace existing equipment. Maintenance is an extremely important work schedule that is required to keep any plant and machinery in a near original state of functioning for as long a period of time as possible. This is different from repairs, which is the restoration of such an asset to a condition as close to its original, by replacements of parts and overhauling of the asset. “A decision to replace a system should be based on the following factors: replacement due to either inadequacy, getting obsolete, high failure rate, excessive repairs / maintenance. Every maintenance has a cost comprising spares and manpower forming the direct cost, followed by additional costs and penalty costs,” said Dr Sharma.

Cover story

Low cost High returns

Having drawn up the blueprint for a network of 55 secondary care hospitals in small towns, founder of Glocal Healthcare, Dr Sabahat Azim unveils the secret of building low cost quality healthcare delivery

Interviewed by Rita Dutta


Healthcare Radius September 2013

Cover story

In the year 2010, Glocal Healthcare rolled out its first hospital at Sonamukhi in Bankura district of West Bengal. After commissioning four more low cost hospitals at Dubrajpur, Khargram, Bolepur and Behrampur, it’s now reaching out beyond West Bengal. It is pumping in Rs 400 crore towards building a network of 55 hospitals in tier III and IV towns of UP, Bihar, Assam, Odisha, Chhattisgarh and Jharkhand. From five hospitals at present to 50 more hospitals in the next one year. How will you manage to pull off such an ambitious feat? Since we started three years back, we have built five secondary care hospitals in West Bengal. That’s no mean achievement for a team that had no prior experience of building any hospital or were remotely connected with such a task. But all of those hospitals were our pilots. Even before the first unit in Sonamukhi was commissioned, we had the larger picture of creating a country wide network of hospitals. So after testing the pilot, which now stands at 500 beds, and making some alterations in our approach, it’s time to scale up at a faster pace. In the next two years, we would be commissioning 50 more hospitals in the states of UP, Bihar, Assam, Odisha, Chhattisgarh and Jharkhand. Being 100 bed each, we would add 5,000 beds in the next couple of years. This would total our bed strength to 5,500 beds. Our 10-year plan is to set up hundreds of such hospitals, becoming the number one hospital chain in the country. Lands for the projects have been identified in most areas, and by September this year, we will start constructing four more hospitals at Krishna Nagar in West Bengal, Siwan in Bihar; Jeypore in Odisha and Sitapur in UP. Are funds in place? The funding requirement is about Rs400 crore, out of which Rs280 crore is coming as debt. The remaining is equity, which is being pumped in by our PE shareholders, LLP partners, and SIDBI Venture Capital is adding Rs25 crore.

What prompted you to start corporate hospitals for the poor? The desire stemmed from a painful personal experience of seeing a family member die in one of the renowned private hospitals in the country due to medical negligence. I shuddered to realise that if being a doctor and a civil servant I could be a victim of an indifferent and lackadaisical system, what was the dismal fate of poor people. While people advised me to press charges against the callous hospital, I realised the futility of such an exercise to compensate my irreparable loss. The episode made me realise that strengthening of healthcare delivery, where it is more protocol-based and less doctor dependent, where it is more transparent and less commercial, was the what the country needed. With 80 per cent healthcare facility be-

What each Glocal Hospital offers Type: 100 bed secondary care hospital Number of floors: G plus two Built-up area: 30,000 square feet Facilities: Medicine, surgery, gynaecology, pediatrics, critical care and emergency, orthopaedics, ophthalmology, ENT and dental departments. Cost: Rs8 crore. Time to build: Six months. Operational breakeven: Six month Staff strength: 100 staff, including 12 full time doctors. Catchment area: People living in a radius of 15 km of the hospital.

ing in the city, while 75 per cent population live in the villages, my idea was to build a healthcare delivery system that could serve the majority of the people. I quit civil service to co-promote an e-governance venture and later quit that to start Glocal along with former SEBI chief M Damodaran, who joined us as chairman of the venture. Our chairman, three team members and I invested Rs one crore as growth capital in the project. That fund was used for research, developing the concept and buying our first piece of land in Sonamukhi. Additionally, for the first five hospitals, Sequoia Capital and Elevar Equity had pumped in about Rs15 crore, while United Bank lent us Rs24 crore. You grew up in Lucknow and later worked in Agartala. So, why you decided to pilot the project in West Bengal? The e-Governance venture that I initiated was based out of Kolkata, so we had built an ecosystem around us and West Bengal is an underserved area. Apart from Kolkata and maybe Siliguri, there is a huge gap in the healthcare infra and service sector in the state. How do you choose the areas? We look at tier III and tier IV towns, which has an urban population of one lakh and rural population of around five lakh. Also, healthcare facility in such areas should be under-served. Considering the non-healthcare management background, how did you zero in on the low cost corporate hospital model? Oh, our ignorance was our biggest asset! Since

Healthcare Radius September 2013


Cover story

we approached the idea without any pre-conceived notion, we were ready to make mistakes and get embarrassed by them. People cautioned us against the difficulties in making a low cost model for rural people — both sustainable and scalable in the long run. But today, we have proved that a low cost model can also be a profitable. While others may take as much as Rs15 crore and more to build a 100-bed secondary hospital project, we do it within a budget of Rs8 to 10 crore, inclusive of land, construction, equipment and doctor’s quarters. Let me share that we did not do anything out of the ordinary to reduce cost. Our secret is nothing but proper planning, zero-based approach to design and costing and excellent implementation. We studied the commonest disease types and decided to build a hospital that would cater to more than 90 per cent of the disease occurrences.

have to make too many modifications in the structure. Third, we have an efficient project management along with in-house construction team. This has not only reduced labour costs by 10 to 15 per cent, but ensured that the project is completed within six months. Yes, you heard it right, just six months. Fourth, optimal utilisation of space is another key to low cost. Our 100-beds units are laid out on 30,000 square feet built up area as against the conventional norm of 50,000 to 80,000 square feet, which shoots up the project cost. Unlike the conventional approach of having the diagnostic facility located closer to both IPD and OPD, we have embedded it within the OPD area. As the usage of diagnostics is higher by OPD patients than IPD ones, bringing it closer to the OPD made sense. It has helped reduce the turnaround time for OPD patients from six hours to two and a half

Please elaborate on the measures... First, as we build hospitals in rural and semi rural areas, the cost of land is low. That reduces the capital cost by around eight to 10 per cent. Second, from infrastructure point of view, we cut out the frills. No glass facade, no Italian marble. We use standard RCC, equipment, pipe line and tiled floors. No cheap Chinese stuff. We use simple modular design of 40 feet by 40 feet, which forms the super structure. Due to its modular design, we can build both vertically and horizontally. It’s what we call our ‘cookie cutter approach’. So, when we expand, we don’t

With capital cost being only Rs8 lakh per bed, low cost of operation and RSBY patients, we make a revenue of around Rs25 lakh per month per hospital

hours and also resulted in lesser crowded lobbies. Fifth, we have leveraged IT to reduce cost. For instance, rather than having full-time radiologist, we depend on tele-radiology services with our tele-radiology unit located at Lucknow. Our cloud-based disease management solution has helped do away with unnecessary diagnostic tests and made treatment cheaper. Why did you feel the need to have disease management solution? It is an outlandish idea to expect doctors to remember about 10,000 diseases and their symptoms, about 4,500 compounds, 60,000 brand names and adverse reactions of drugs. Research tells us that 42 diseases make up 95 per cent of the disease load in rural India. So, we focused on designing LitmusDx, a cloud-based end-toend solution that addresses these conditions. The system helps do away with unnecessary diagnostic tests, helps doctor identify drugrelated risks and choose the right combination. Overall, it will ensure higher quality of care. Against the current trend of asset-light model, all your existing and upcoming hospitals are greenfield. Does it not add up to the cost of the project? Greenfield field project adds up to your debt burden when one takes years to commission a project and then that much time to attain breakeven. That is not true for us. As we follow a simple approach to design, we are able to build

Despite providing corporate type set-up, Glocal hospitals are meant for the poor populace.

Like Glocal’s hospital in Khargram, each hospital is constructed within six months.


Healthcare Radius September 2013

Cover story

each hospital in just six months and we also attain breakeven in that same time frame. Since we use the same design grid everywhere, using a brownfield project that needs due modifications would end up costing more. Did you not look at land from the Government? No, we believe it buying land from the market. That is cheaper and faster than any other source. A C-section and an appendectomy at just Rs12,000 each. How do you manage to provide service at such low cost? Yes, we offer at 20 to 40 per cent less than the market rate. And that was the whole idea of starting Glocal— affordable care for poor patients. Right now, 55 per cent of our patients are cashless due to the tie up that we have with the government of West Bengal for the Rashtriya Swasthya Bima Yojna (RSBY). This scheme has allowed us to provide free treatment to BPL patients. Be it cashless or cash patients, we have managed to offer the same rate due to our low capital cost, low cost of operation, optimum use of technology and a quick breakeven time. The recent award from the Ministry of Labour and Employment for ‘outstanding performance in providing healthcare services through RSBY’ is a vindication of our belief. You charge a paltry amount, but still manage to attain breakeven in just six months. How?

Glocal has acquired Indigram to impart training to nursing assistants and technicians.

Yes, I know, any standard hospital takes a minimum of 12 to 24 months to have operational breakeven. We have been able to achieve it in six to nine months. With capital cost being only Rs8 lakh per bed, low cost of operation and RSBY patients, we make a revenue of around Rs25 lakh per month per hospital. Did you make any modifications in the original blueprint? Yes, in various aspects. First, in recent times, we have strengthened the critical care unit in all our hospitals. Earlier, we had decided for a two to five bed critical unit. We felt as were not a tertiary care hospital, there was no need for focusing on critical care. We were also horrified by reports of attacks on doctors and vandalisation of hospital properties by angry mobs, when critical patients succumb to death. We had decided that we would refer critical cases after stablisation, but soon realised that poor patients turned away by us did not have any hope or option. They would die because the public facilities are not up to the mark in areas we exist and the private ones beyond their means. So, we changed our course by having a 20-bed unit in every hospital. Second, to keep cost in check we refrained from investing in technology not required by majority. So, we did not have CT or MR earlier, but now all our upcoming units would have a CT scanner. Third, believing in the merits of the full-time doctor concept, we did not allow visiting con-

Around 55 per cent of its patients are from RYBY scheme.

Upcoming hospitals Jharkhand Dhanbad, Ranchi, Deogarh, Girdih West Bengal Krishna Nagar Bihar Gaya, Siwan, Purnia, Begusarai UP Sitapur, Amroha, Fatehpur Odisha Jeypore

Healthcare Radius September 2013


Cover story

Regarding our management team, we have an intelligent and diverse workforce. Some of them are from B-schools, some from the Government sector and some from the clinical side. The senior leadership is multi skilled and multilingual. All of them quit better paying jobs to work in an area that brings more than money. It is the sense of achievement to create the country’s largest healthcare enterprise.

Each Glocal Hospital uses simple modular design of 40 feet by 40 feet, which forms the super structure.

sultants. Sooner than later we realised that the output and efficiency of many of the full-time doctors were not what we expected of them. Some of them were working without any sense of accountability. So, we decided to have a good mix of full time and visiting consultants. Fourth, we were against roping in the local medicos— mostly quacks. But soon realised that these not-so-qualified professionals were of great help to critical patients brought to our hospital. They were often found accompanying the critical patients, and would accurately provide details about the patient’s medical history and past medication, better than the family members. So, we no longer alienate them but have built an ecosystem that involves them as well. We regularly train the local health givers in assessment of diseases and in ways of recognising when patients needs to be referred to the hospital. How do you manage to get skilled manpower in the small towns? Yes, indeed that is a challenge. To address that, we have acquired a company called Indigram. It is a partner of the National Skills Development Organisation. We impart training to nursing assistants, emergency medical technicians and others. Under this programme, the students undergo video-assisted training on physical skill required for the job, followed by training on electronic mannequins and then on patients. So far, we have trained about 2,000 students. Additionally, we have inked a five-year MoU with Mt Sinai School of Medicine, New York, which spans collaboration in gastroenterology, GI endoscopy, and internal medicine.


Healthcare Radius September 2013

About Dr Sabahat Azim

How did the experience in the civil service help in your journey as an entrepreneur? As a civil servant, at a young age, you are made in charge of a sub division. You have to take all decisions, with no one else to guide you. With limited resources, you learn to rise up to the occasion, think on your feet and scale up fast. Such learnings acted as a catalyst towards making me an entrepreneur. I have learnt to

Healthcare cost in the country is spiralling out of control. I hope Glocal is able to correct that and provide poor people healthcare in a dignified setting look at the larger picture, and not get deterred by obstacles, be it lack of trained manpower or limited resource. Do you see Glocal foraying into the tertiary care segment? No, not in the near future. In tertiary care, the complexities are too high. Also, you have to set up such a hospital in a fairly populated area, where the land cost is high. That makes the project expensive.

Soon after completing his MBBS, Dr Azim realised that medicine did not fascinate him. After cracking the civil service exam in 1999, he joined the IAS and very early rose to become the Secretary to the Chief Minister of Tripura. In 2006, he left civil service to start an e-governance initiative for people in rural areas. He quit that to start Glocal Healthcare in 2010.

Besides providing low-cost care, what would be the contribution of Glocal to Indian healthcare delivery? To enhance quality of care and reduce chances of error, healthcare should be less doctor driven and more protocol and process driven. We at Glocal are encouraging this protocol-driven approach. Also, healthcare cost in the country is spiralling out of control. I hope Glocal is able to correct that and provide poor people healthcare in a dignified setting.

Embracing modern thinking

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Diagnostic Special

Top 10 Trends A listing of the key trends defining the Indian clinical diagnostic industry By Rita Dutta


he $ 3.4 billion Indian clinical diagnostic industry is on a roll. The industry, dotted with almost 60,000 pathology labs, 90 per cent of which is in the unorganised sector, is slated to reach 6.0 billion by 2017. While the market is growing at a CAGR of about 16 per cent, it is major metros, like Mumbai, Delhi, and organised players that have witnessed a higher growth rate of no less than 20 – 22 per cent in this sector. Such a buoyant growth is propelled by factors such as changes in demographic and disease profile, rising health awareness, and spate of hospitals that have engendered demand for diagnostic facilities. According to Jagruti Bhatia, senior advisor, healthcare, KPMG, “Almost 47 per cent of the


market is in the stand alone lab segment, while the rest is in the hospital-based lab segment.”


ith better consumer awareness, smaller setups are now upgrading themselves with more automated equipments and better infrastructural facility. And even hospitals have also started adopting high-end clinical diagnostic technologies as they recognise its importance from both clinical and commercial perspective. Today, diagnostic services have found applications in overall patient management going up to the treatment level. Newer tests and technologies are strengthening the test menu, offering doctors wider choice to select their tests on various parameters. Even more tests are available to test a single

Healthcare Radius September 2013

disease. Take HIV testing, for instance. It ranges from a simple spot test to PCR. According to Ameera Shah, managing director and CEO, Metropolis Healthcare, “The price and quality variations have different relevance for different locations. However due to multiple options now available to doctors and patients, made possible due to technological advancements, the accessibility and affordability to quality diagnosis can be tackled.” According to her, the rapid growth of various diagnostic segments cannot not be attributed to technological breakthrough. It is due to the increase in application of the same technology in various disciplines. This is a positive tiding, as multiple applications of same technology make them more cost effective.

Diagnostic Special

leading players • Metropolis Healthcare It has a network of 105 diagnostic labs and 700 collection centres across India, Sri Lanka, Africa and Middle East. • Dr Lalpath Labs It has a central lab in Rohini in Delhi, and a network of 150 satellite labs and 2,000 collection centres. • SRL Limited It has 12 referral labs, over 244 network labs and 1,255 collection centres. • Thyrocare Technologies Two labs (in India and Bahrain) and over 30,000 collection centre.


o, let’s analyse the trends that have emerged in recent times, trends that are redefining the way the industry is and will function, progress and make its moolah.


Network of labs Gone are the days, when a successful pathologist set up one single lab that carried out all activities- from sample collection, testing to report delivery. The new-age players have segregated the tasks. While sample collection has moved to collection centres, testing is carried out in the satellite or central lab. This has made the groups spread their network faster and cater to a wider patient base. For instance, Dr Lal Pathlabs with its central lab in Rohini in Delhi, and its network of 150 satellite labs and 2,000 collection centres conducts 30 million tests annually. “With investment in a collection centre being one 20th of that of a lab, this model has ensured economies of scale,” says Dr OP Manchanda, CEO, Dr Lal Pathlabs. But no other group has accrued benefit of this model better than Thyrocare, which is the only brand that works with single laboratory for the entire country. As of now, it has one central lab in India and one in Bahrain to cater to the needs of GCC and MENA countries. And that’s it. It caters to 75 lakh patients through its 30,000 plus collection centres. Explains Dr A Velumani, managing director, Thyrocare, “Any laboratory or hospital or clinic can collect blood from patients and send it directly or through another laboratory to our

Most labs are investing heavily in automation.

If mergers and acquisitions trend is combined at the right time with Government regulatory control, it would lead to an excellent opportunity to organise the market” Ameera Shah managing director and CEO Metropolis Healthcare

laboratory in Mumbai.” After that, it is mere logistics management. “Our bar-coded collection kits are at 60,000 locations, and from there the journey of the specimen starts. Air-cargo logistics from 30 airports on same night, every night, helps us logistically to manage the business in many ways,” says he.


PE funding The pathology business has found favour with PE firms. For instance, Metropolis has received two rounds of PE funding. First, from $7 million from ICICI Venture and then $85 million from Warbug Pincus in 2010. And the same year, CX Partners had invested Rs188 crore in Thyrocare. Once again last year, Thyrocare has raised Rs120 crore from Norwest Venture Partners. Additionally, Dr Lal Pathlabs received a funding of $10 million from WestBridge and in July, last year, SRL has reportedly raised $67 million from NYLIM Jacob Ballas and International Finance Corporation. Earlier, SRL had raised PE investment from Avigo Capital Partners and Sabre Partners. And Mumbai-based diagnostic chain, Suburban Diagnostics has raised Rs40 crore from Sequoia Capital. According to Dr Sanay Arora, managing director, Suburban Diagnostics, “Besides being recession proof, what attracts PE funding for the diagnostic market is its fragmented existence. The PE firms see a huge opportunity in

Healthcare Radius September 2013


Diagnostic Special

Increasing your reach through collection centres ensures economies of scale and faster scaling up” Dr OP Manchanda, CEO, Dr Lal Pathlabs

PE funding in diagnostics Player

1st PE Partner (s)

2nd PE partner

Metropolis Healthcare

ICICI Venture

Warbug Pincus

Dr Lal Pathlabs


SRL Limited:

Avigo Capital Partners and Sabre Partners

NYLIM Jacob Ballas and International Finance Corporation


CX Partners

Norwest Venture Partners.

Suburban Diagnostics

Sequoia Capital

consolidation of the market by capital infusion with right-sized players.” So, how did some diagnostic players benefit from PE funding? Dr Manchanda is effusive in his praise. “Besides the access to funds, which create an ecosystem of funding entrepreneurs, the PE funding has ushered in the concept of professional management. It has also encouraged focus on growth and corporate governance,” says he.


Consolidation Grappling with changing market dynamics, capital-intensive technological upgradations and administrative bottlenecks, many small and regional players are getting acquired or giving away the management baton to corporate brands. With the industry getting consolidated, mergers and acquisitions (M&As) are turning out to the preferred growth route for some diagnostic behemoths. For instance, Metropolis finds M&As most useful to expedite expansion and for faster market penetration in newer locations. While it acquired Lister in Chennai many years ago, in the last one year, it has acquired three labs across the country. Consolidation in the diagnostic industry is being witnessed not only in the labs, but also in network creation logics and vendor segment. Hailing the trend, Shah says if M&As is combined at the right time with Government regulatory control, it would lead to an excellent opportunity to organise the market. Others predict that by the year 2020, there


would be 10 laboratories with more than Rs1,000 crore annual turnover. “Volumes would be strength of brands and thus these 10 would handle 50 per cent of the market,” says Dr Velumani.


Preventive Health Checkups A significant trendsetter of the industry is the surge in preventive-based testing- the rise is as high as to 10 to 15 per cent in recent times. This trend is fuelled by rising healthcare aware-

Healthcare Radius September 2013

ness, increased incidence of lifestyle diseases, and over all encouragement of wellness by corporates. The need for these check-ups are personalised for individual industries. Even labs have been found communicating with the consumers and motivating them to go for preventive tests. Says Dr Sushant Agrawal, lab director, south and west India, SRL Limited, “The demand for preventive testing has lead to creation of wellness facilities in diagnostic chains and hospitals, with mediating companies exclusively sourcing these services.” SRL Limited, which has been bullish about the wellness segment, has seen its business growing three times in the last five years in the wellness and preventive testing segment, with most of its labs having facilities for these check-ups. Metropolis has clocked a significant 20-25 per cent growth in recent years in the same segment. Wanting to consolidate its position , SRL now works closely with the clinicians to understand their diagnostic needs for a 360 degree individual disease management. Its PMT experts conduct market surveys with key opinion leaders in various fields and based on the feedback, it introduces not less than 75 - 100 new tests every year. “Check- ups for individual industries are governed through occupational health check-ups. For instance, metal testing in mining industry, audiometry for call centres. Also the packages are

Several diagnostic chain like Dr Lal Pathlabs is strengthening its network by opening collection centres than labs.

Diagnostic Special

Trends to watch out for

tailor made to suit requirement by HR department of individual companies,” says Dr Agrawal.


ICT and Automation Information & Communication technology (ICT) and lab automation are redefining lab services provided to patients. ICT has led to many innovations like ‘any time any where’ concept. Today, one can avail of home collection of tests, books tests on line and even gets the reports on line. Automation has been introduced for all types of tests. “Right from bar coding, sorting aliquoting to testing, automation has ensured better output, efficiency and accuracy,” says Dr Manchanda, adding that at Dr Lal Pathlabs the number of tests done per day has shot up from 3,000 to 30,000 per day due to automation. It has enabled fasters TATs and more standardisation in the lab processes. Metropolis has implemented two major IT projects: extensive laboratory information management system and SAP (material management and financial management). It helped the chain consolidate and streamline its network and lab processes. Also, it has helped enhance overall lab process quality, performance and TAT, significantly and qualitatively. However, according to Dr Velumani, total laboratory automation is yet to pick up. “Of the 60,000 laboratories, only around 6,000 use high-end automated analysers but only 60 of them use IT to make it bi-directional. So, clearly we have to go a long way to go in automation.”


Molecular diagnostics One testing segment that has exceeded all others in growth is molecular diagnostics. The figures say it all. The Indian market for molecular diagnostic is growing at a rate of 25 to 30 per cent, while the global market is growing in the range of 12-15 per cent. At Dr Lal Pathlabs, the segment has witnessed 40 per cent growth, contributing to 15 per of revenue. And at Metropolis, the growth in this segment is 25 per cent. According to Dr Bhuwnesh Agrawal, head of APAC and global chief medical officer, Vela Diagnostics, Singapore, “Molecular diagnostics has a number of benefits in today’s scenario: It is very sensitive, specific, reproducible and fast. It allows the detection of very low numbers of virus particles, which could otherwise not be detected, reliably. It also allows the quantification and therewith monitoring of

• Cytogenetic: Cytogenetic and its clinical utility have a huge growth potential for future. Cytogenetic also has an increasing application in therapies and treatments, especially in cancers. The science is also witnessing some revolutionary changes that could make this segment of diagnostic tests more cost effective and affordable for people. • Genetic testing: Though not commercial at a large scale, genetic testing is going to become a way of life in the long term, thereby moving it further from preventive to predictive testing. • On-line booking: Androids are playing a crucial role in on-line booking. “With the growth in online booking, it makes sense for diagnostic laboratory to make at least make a mobile compatible web pages if they cannot make an app for their clients. By 2020, on line booking will exceed all others and thus laboratories cannot ignore it for too long,” says Dr Velumani.

therapeutic success.” As it detects antigens and not antibodies, which is the alternative method, it can detect an infection much earlier, when the patient is already infectious. While molecular diagnostics first became popular due to the HIV epidemic, today it is more widely used for a wide range of disease.


POCT It ensures quick delivery of results directly to the patient monitor and thus rapid treatment. It rules out chance of error, and reduces the length of hospital stay. We are referring to the benefits of Point of Care (POC) testing that have been beneficial to hospitals. The merits of POCT have made it to useful mainly for diabetes, HIV and hepatitis patients. While today it is more popular in the metros, experts say in the near future, POCT will have a significant role in improving accessibility for the rural markets.


Disease Management With corporatisation of the industry, there is greater focus on disease management and patient satisfaction by the labs. Once diagnosed with lifestyle disease, the patient is required to monitor the disease status regularly through testing. This has led to higher frequency of visits to the lab, drawing focus to patient satisfaction. In addition to improving turnaround time through automation, today most labs provide on-line report facility for enhanced customer services.


Mass Spectrometry In recent times, mass spectrometry has come out of the purview of pharma R&D labs and analytical chemistry labs into the clinical

By 2020, 10 diagnostic chains would handle 50 per cent of the market” Dr A Velumani, Founder, Thyrocare

diagnostic utility domain. “Mass spectrometry technology is regarded as gold standard for diagnostic applications including new born screening tests, immune suppressants, Vitamin D, steroid hormones and drugs of abuse. It is able to provide clinically decisive data specifically for grey zones of the routinely available immunochemistry technology for the specified tests,” says Dr Agrawal of SRL. The only deterrent for many to adopt it is the high initial investment in the equipment and infrastructure required for it.


Accreditation With growing competition and requirement to participate in organised business, including PPP, CGHS, hospital implants, CRO outsourcing, there has been a steady increase in the number of labs getting accreditations, mainly NABL. This trend has greatly enhanced quality standards.

Healthcare Radius September 2013


Diagnostic Special

Poised for growth Factors like high sensitivity and specificity as well as faster results have spurred the molecular diagnostics market to clock a phenomenal growth rate of 25 per cent. Watch out for more from this segment... By Team HR


Healthcare Radius September 2013

Diagnostic Special


n the late 1980’s, when a colleague of Dr Bhuwnesh Agrawal at the infectious disease ward at the University Hospital in Berlin said that he could give results of TB tests within 24hours, Dr Agrawal did not believe his ears. The conventional test needed three months for culture. That was the first time Dr Agrawal heard about molecular diagnostics, a segment that is revolutionising the pathology sector. “In contrast to cultures for most bacteria and virus, which take between 48 and 120hours, PCR requires just a few hours,” says Dr Agrawal, now head of APAC and global chief medical officer, Vela Diagnostics. Singapore-based VelaDx, which provides a broad menu of molecular diagnostic tests, is firming up plans to foray into the Indian market. Taking back to where it all began, Dr Pravin Potdar, HOD, molecular medicine and biology, Jaslok Hospital, Mumbai, says, “The molecular diagnostic programme was initiated after publication of complete genome sequences in 2003, by Dr Francis Collins from National Institute of Health, USA. With several national and international companies and laboratories starting work on PCR-based molecular diagnostics tests for diagnosis and therapies of various complicated diseases, molecular diagnostics has become a major platform in clinical medicine.” However, the segment came in the limelight due to the HIV epidemic. Initially, the mainstays for molecular diagnostics were three main infectious tests - HIV, HBV and HCV. Over the years, the usage has expanded to wide number of diseases and this has propelled the Indian market for molecular diagnostics to grow at a phenomenal rate of 25 per cent, while the global growth rate is in the range of 12-15 per cent. The market is well-served by vendors like Roche, Biomerieux, Abott, Bayer, Beckman and BD.


he benefits and popularity of this segment is evident in more ways than one. “Molecular diagnostic tests are very sensitive, specific, reproducible and fast. They allow the detection of very low numbers of virus particles, which could otherwise not be detected, reliably,” says Dr Agrawal, former CMD of Roche Diagnostics, India. The testing can be used for diagnosis as well as monitoring the therapies of various diseases. It requires small amount of blood cells and results are available within 24-48 hours. It can give a quantitative data- copy numbers of viruses or genes present in human body, which allows one to monitor

About molecular diagnostic lab According to experts, molecular diagnostic should be one of the most essential services for every hospital in India. It is essential to have in-house molecular diagnostic laboratory to get the report as early as possible for treatment of patients in time. Says Dr Bhuwnesh Agrawal, head of APAC and global chief medical officer, Vela Diagnostics, “Today real-time PCR testing has become such an integral part of the mainstream, that any organisation having patients with infections (bacterial and viral) or cancer should have a PCR set-up, as it ensures fast result. In the US and Europe, almost all middle to large sized hospitals and commercial labs have PCR technology. In India, it is still limited to few large labs due to the high price of the tests. It is absolutely necessary for following institutions dealing with the following to have a molecular diagnostic lab: • Major diseases such as HIV, HBV, HCV and TB, especially specialised centres. • Infectious disease patients, e.g. diarrhoea, respiratory infections, tropical diseases (dengue, chikungunya) • Children’s hospitals • Hospitals with ICU patients • Surveillance, e.g. govt. offices dealing with infectious disease surveillance like diarrhoea and influenza, including H1N1, H7N9, MERS • Cancer centres, including haematology centres • Transplantation centres • Private labs • Genetic labs Traditionally, a 3 chamber set-up was required to set up an even basic molecular diagnostic lab to avoid contamination. For most routine tests, except for very specific dangerous agents, one require a BSL lab: a bio-safety cabinet in addition to the lab equipment. “Though most companies still require 3 chambers, there are now some which have fully automated systems, which can be run in any lab without a 3-chamber set-up,” says Dr Agrawal From a commercial perspective, it is important for the lab to assess the number of tests and commercial viability. Each test run requires at least one negative and positive control. A good system has other controls as well to ensure that the whole process is working correctly.

In contrast to cultures for most bacteria and virus, which take between 48 and 120hours, PCR requires just a few hours” Dr Bhuwnesh Agrawal, Head, APAC, Vela Diagnostics, Singapore

treatment for infectious diseases and various cancers. “DNA- sequenced based programme find out a specific mutations which is mostly helpful in deciding the therapies for the specific diseases. In recent years, we have seen that several infectious diseases such as HBV, HCV, HIV, CMV and M. tuberculosis and cancers have shown drug resistant to various therapies and it is only possible to detect these mutations by using molecular diagnostic technology,” says Dr Potdar. He adds that due to poor availability of di-

agnosis and treatment for cancer, neurological and genetic disorders, there is a growing need for establishment of genetic testing laboratory in India. “It has been observed that general conventional technologies such as biochemistry, immunology, hematology or microbiology can’t diagnose the exact cause of disease. This can be very well solved by introduction of molecular diagnostics testing for proper diagnosis and therapies of these diseases,” says Dr Potdar. Other growth factors have been increasing

Healthcare Radius September 2013


Diagnostic Special

to diagnostic purposes,” says Dr Agrawal. The technology is also been found useful in understanding drug resistant mutations in HIV and M. tuberculosis patients. Proper selection of drugs can be done by clinicians to reduced toxicity and better response. “It is also useful in finding out mutations in hereditary cancer patients such as BRCA1 & BRCA2 in breast and ovarian cancers. Introduction of Next Generation Sequencing (NGS) will allow us to give quick and large amount of data of respective genome in short time,” says Dr Potdar.


General conventional technologies can’t diagnose the exact cause of disease. This can be very well solved by molecular diagnostics testing ” Dr Pravin Potdar, HOD, molecular medicine and biology, Jaslok Hospital, Mumbai

awareness, inclusion of many guidelines in the US and Europe and increased commercial availability of the tests, as that implied high quality, reliable and reproducible tests. Then, there is the cost factor. According to Ramanathan V, CEO, XCyton Diagnostics, Bengaluru, “With the reduction in the cost of molecular diagnostic assay and several hospitals and labs investing in setting up equipments and instruments, molecular diagnostics have become a viable option in diagnosing critical infections, TB, cancer and other diseases.”


echnology wise, what has given the segment a boost is real time PCR. Earlier, conventional PCR was supposed to be the sensitive assay to detect genes for diagnosis


of various diseases. However, introduction of real time PCR technology which gives exact copy number of viruses and genes gave a fillip to the whole programme like none before. “The technology has been frequently used for quantitative analysis of viruses and bacteria in all infectious diseases programme. There is a further development in identifying several mutational hot spots by DNA sequenced analysis to detect specific mutation caused by the specific diseases,” says Dr Potdar. Real-time PCR has permitted the quantification and also added to growth recently. “The knowledge from the Human Genome Project as well as other such large scale projects, e.g. ENCODE, ICGC (for cancer genome) and many more has helped us apply the knowledge

Healthcare Radius September 2013

o, what’s next? According to experts, the coming years will increasingly see molecular diagnostics encompass areas that one currently considers separate, such as histopathology. Molecular diagnostics will play an important role in personalising medicine. With newer technologies like sequencing becoming more and more simplified, personalised medicine should soon become a reality. “Presently, real time PCR and DNA sequencing used for diagnosis and therapies of various diseases include infectious diseases, cancer, haematological disorders and others. The introduction of NGS Next Generation Sequencing (NGS) will help in analysis of large amount of gene data and help in predicting abnormalities in individuals,” says Dr Potdar. The growth of this segment will be further propelled by knowledge of newer indications of genetics and newer technologies, such as the use of sequencing technologies for diagnostic purposes. “In many diseases, the success rate of treatment is between 2080 per cent. However, this can be improved significantly, if the patients are stratified based on their own specific situation,” says Dr Agrawal. For instance, in cancer, where tests such as BRAF (for papillary thyroid cancer) or KRAS (for colorectal cancer) can help decide the treatment option that is best suited for a patient. Similarly, the introduction of microarray analysis can help in identifications of various biomarkers for these specific diseases and findings of molecular targeted therapies. Also, microchip technology will overcome present karyotyping testing for abnormal chromosomes and would aid detect specific abnormality to go for prenatal diagnosis. In all, molecular diagnostics will help in identifying a mechanism of each and every disease and allow clinicians to treat diseases more successfully.

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Diagnostic Special

>> consumer connect

Cutting edge Dr Sanjay Arora, owner, Suburban Diagnostics, speaks about the state-ofthe-art facilities and the newer areas that the group wants to explore

What is your long-term business vision? We are currently catering to diagnostic services, including pathology, radiology and diagnostic cardiology, and preventive healthcare. Today, after 5 million tests and serving over 1 million patients, we continue to raise the bar to achieve optimum accuracy and precision, besides constantly endeavouring to propagate wellness and preventive healthcare through series of health check up packages and patient care initiatives. Our long-term vision is to be the most admired healthcare company by focusing on a customer centric approach, investing in the cutting edge technology and working with a skilled team to provide best quality and service. To build on these, we would be focus on direct footfalls rather than the referral practice. In the years to come, we would like to be a pan India player with our presence majorly in all state capitals of India.

About Dr SanjayArora Dr Sanjay Arora is an alumnus of Grant Medical College, Mumbai, with specialisation in Cytopathology from Tata Memorial Hospital, Johns Hopkins and Henry Ford Hospital, USA.


Healthcare Radius September 2013

Diagnostic Special

Which are the segments you propose to consolidate your position or enter? We want to be a leader in preventive healthcare and own that space. Soon, we are going to enter the lab-to-lab space with niche products. We will enter initially the areas of histopathology, microbiology, genetic testing, haematopathology and allergy diagnostics. We also want to launch new products in genetic testing.

automated set up and have introduced PAP smear and latest concepts in cytology. Are there any quantifiable criteria for identifying prospective clients for Suburban Diagnostics? Customers who appreciate the benefit of prevention rather than cure and appreciate the value of technology and service with hygiene.

What is the USP of Suburban Diagnostics? Focus on technology, team building, doctor driven approach, focus on systems and processes, customer-centric approach, high quality of results and products, high level of quality control and a vast team of doctors. We have created our credibility of providing quality service over 19 years of dedicated service.

What are the key challenges your business sector is facing? The market is growing, but so is the competition. The market is fragmented with no standardisation. Also, many larger players are consolidating by acquiring smaller players or starting more greenfield centers – geographical spread. This takes away the doctor-centric approach (which builds relationships) needed for word of mouth credibility and growth. But at the same time, not moving ahead with times will result in stagnation. Other challenges are lack of regulation for setting up a lab, lack of legislation for accreditation and dearth of trained manpower.

Which path breaking technology does the group have? We are always at the forefront of technology by being the first among many cases to invest in the latest and best technology, be it Cobas 6000, Olympus AU400, MGIT 320, Architect ci8200 or GeneXpert. We always had a fully

What are the recent developments in your business? They are increase in awareness amongst consumers, penetration of health insurance, consolidation of healthcare industry and shift from curative to preventive and from infectious to chronic disease.

What are the critical factors for success in your business? They are service, accuracy with consistency, quality of products or results, personal approach and convenience of customers.

Are there any opportunities that you want to capitalise on? Yes, they are lab-to-lab business, hospital-lab business, genetic test menu, end-to end wellness solution for corporate, direct to public approach, CRO and medical tourism. What’s in the pipeline? Plenty of initiatives. Some of them are launch of metabolic fingerprinting, allergic diagnostics, blood on call campaign, launch of CRM and a loyalty programme. Then, we will have a centralised lab at Andheri, which would be the first lab for centralised histo-path processing in Mumbai. Additionally, we will launch many new centres, especially on the central line and Navi Mumbai.

Healthcare Radius September 2013


Diagnostic Special

>> Consumer connect

On growth trajectory Thomas John, managing director, Agappe Diagnostics Ltd speaks on the company’s rapid growth in reagent and equipment market in India and abroad, and the road ahead

Thomas John How has the company grown since its inception, in terms of its market strength, product portfolio and revenue? Established in the year 1995, Agappe has grown to a Rs-70-crore company over the years. We have an employee strength of over 350 people with an equal number of distributors spread across India and over 20,000 loyal customers. Today, we are one of the largest manufacturers of clinical chemistry reagents in India and we are the third largest in terms of market share in clinical chemistry reagents. Today, our products are exported to over 48 countries in Asia, South East Asia, the Middle East, Africa, Latin America and regions in Europe. This is a testimony to the quality of products we offer which is on par with the West. We have adequate systems and processes to ensure the quality of our products and seamless delivery systems. We have our own subsidiary at Switzerland which caters to the international market. How has your range of equipment and reagents expanded over the years? Agappe acquired basic strengths to manufacture its own products in the initial years. The need to strengthen the manufacturing base and also to broaden the product portfolio was


identified and addressed. Our new reagent and equipment plant in Kerala was created in the year 2006 as part of this broad plan. This development offered Agappe the much-needed impetus to broaden its base. On the reagent segment, Agappe added new segments like Immuno Turbidimetry and Nephelometry. On the equipment side, the focus was to create niche products using the R&D strength of Agappe. The result has started flowing in with the introduction of a ‘channel shifting technology’ through Mispa i2. Many more are in the pipeline. At Agappe, we draw our priorities and longterm plans based on the international market trends. We are active in clinical chemistry, immuno turbidimetry, nephelometry, serology, coagulation, hematology and system reagents for fully automated systems. The clinical chemistry and serology is expected to grow about 20 per cent (CAGR) while immuno turbidometry, nephelometry and coagulation is expected to grow above 40 per cent. We have international tie ups with some of the leading international players like Toshiba Medical Systems, Japan; TOKYO BOEKI, Japan; Denka Seiken, Japan: Kyowa Medex, Japan, for exclusive marketing of their products. Please tell us about the uniqueness of your manufacturing plant in Kochi. We are an ISO 9001-2008 and ISO 13485:2003 certified Company. We conform to GMP standards and have an FDA approved most modern manufacturing facility spread over 80,000 square feet of built up area in Kochi, Kerala. We have been successful in obtaining CE marking as well for our products. We are undertaking contract manufacturing for a couple of reputed European Companies and these products are exported in their own name and kit box and label. Please share details about your R&D activities. We are committed to enhancing our technical capabilities, infrastructure and compe-

Healthcare Radius September 2013

tency. My view is, technical strength will differentiate companies in various slots. It is our endeavour to bring in new products by constantly upgrading technology through R&D and thus introduce innovative products by keeping pace with dynamic international standards. Our in-house R&D team has developed a unique Protein Analyser Mispa-i 2 with UCS technology. We got the prestigious NGSP (National Glycohaemoglobin Standardisation Programme) certificate for our HbA1c Reagent in Mispa-i2 Protein Analyser. We are the first Indian company to get this certification. Agappe’s innovation on equipment is aimed at offering the much needed competitive edge to pathology by offering precise and trustworthy results. What's in the pipeline? We are the only Indian Company which is developing the latex coating technology for quantitative estimations such as ASO, CRP, RF, etc. and also manufacturing Immuno turbidimetry reagents such as Apo A, Apo B, Cerloplasmin, etc. Our R&D team is working for indigenisation of products and bringing it as a revolutionary product which will change the dynamics of laboratory testing with the introduction of two new equipment. One is slated to be launched in the year end, and another by March 2014. How do you see the company five years down the line? We are thrilled to grow more than the market. We would be entering some of the new segments like microbiology and POC. We intend to be one of the best solution providers. Agappe has its focus areas defined and investments are being made to give Agappe a competing edge on its given areas of strength. In the inorganic areas of development, Agappe wishes to share its strength for reciprocity to achieve its strategic objectives. Emerging markets offer abundant opportunities and Agappe has the obvious advantage of being one with its massive strength in R&D, manufacturing and marketing in an emerging market.

Diagnostic Special

Rapid strides Anil Prabhakaran, managing director, Sysmex India Private Limited, speaks on the company’s steady growth and the prospects of the IVD market unique and innovative values, while building trust and confidence. In the Indian market, our diagnostic business has steadily grown over the last two decades. We are present in this market with our distributor Transasia Bio-Medicals. Sysmex India was established in the year 2006. In the year 2013, we started urine analysis business in India. We plan to grow further in the years to come and bring in newer technologies to help healthcare professionals make faster and reliable diagnosis for better patient outcomes.

Anil Prabhakaran How is the IVD market growing? The last decade has seen many new advances in the IVD market in India, despite the global economic crisis. The market has shown steady progress and is being closely watched by all the MNCs as an ‘emerging market’. From a predominantly capital sale market, the Indian IVD market has evolved into a financial or operational lease market. The growth drivers for this market are population boom, rise in the middle class population, preventive care with a need for better healthcare facility, steady increase in FDI in healthcare facilities, consolidation of hospital/lab networks, government funding and exponential growth of IT infrastructure. However t-here are some dark clouds over the distant sky as well. Factors like high inflation, mediocre infrastructure and depreciating rupee will influence the future of the Indian IVD market. How has the company grown since its forayed into the Indian market? Sysmex was established in Kobe, Japan 45 years ago in 1968. Our corporate philosophy captures the very essence of this change happening in the IVD markets across the globe while demonstrating the passion on which it is surging ahead. Our mission is shaping the advancement of healthcare. Our value is to continue creating


How has your range expanded and evolved over the years? With the advent of new information technologies and state-of-the-art automation, the lab diagnostics fraternity has witnessed a radical change in the workflow and efficiency of laboratories. Keeping this as our driving force, we have brought in technologies like fluroscence flow cytometry for cell counts and urine analysis, aggregation and preanalytical check in coagulometers to help laboratories give reliable and accurate result for clinicians to make that timely decision. We now offer a comprehensive range from small three part analysers to high-end lab automation In the field of haematology, Sysmex is a global leader. In which segments of diagnostics does the Indian arm command a leadership position? Sysmex maintains a clear global leadership in haematology as well as haemostasis, and aims to expand into the other segments in the years to come. This year Sysmex India launched the Sysmex Urine analysis instruments (UX-2000 & UF-500/1000i) into the Indian market with many prestigious hospital and labs opting for automation in urine analysis. Our analysers are known for their robust quality and reliability provides with key information to make faster clinical decision and improve the quality of treatment which remains to be the primary concern of all healthcare providers. One of our core principles is to ensure the scientific support to

Healthcare Radius September 2013

the doctors and lab techs and in line with this principle, Sysmex actively encourages scientific papers and seminars to help advance level of expertise in the labs. We are also proud to be a part of the five papers presented this year in the International Society of Laboratory Hematology (ISLH 2013, Toronto) by eminent Indian doctors, of which the evaluation of (IPF) Immature Platelet Fraction in dengue was selected for the ‘Berend Houwen’ award.

Our analysers are known for their robust quality and reliability provides with key information to make faster clinical decision.” What is the in the pipeline? We are going beyond supplying state-of- theart instrument to the laboratory. At Baddi in Himachal Pradesh, we have established ISO 14001 & 13485 certified manufacturing facility, high quality reagents to support our robust analysers. This was established with the goal of availability of high quality reagents at economical rates to reduce the financial burden. Sysmex also is capable of handling customer needs as a solution provider with global experience rather than an instrument provider. This is a concept with is commonly seen in the developed markets and is starting to become more popular in India. With the launch of the Sysmex immuno chemistry and clinical chemistry analysers in the Japanese market, we are taking steady steps to provide complete solutions for the laboratories in-line with our long-term vision.

Diagnostic Special

A crusade against TB IPAQT is a unique initiative focused on improving access to quality TB testing By team hr


ore than five decade after India started its TB control programme, we are ranked as the worst performer among developing nations in controlling the scourge of TB, with 26 per cent of the global TB burden. Despite a strong Revised National TB Control programme (RNTCP) that delivers free treatment to patients in the public sector, a significant number of TB patients are found seeking care in the private sector, which is plagued by challenges like inaccurate diagnostics and inappropriate treatment. Such lack of access to early and accurate diagnosis leads to unnecessary high costs of care, delayed case finding or misdiagnosis and mistreatment. And such factors contribute to loss of life, generation of drug-resistance, and increased disease transmission. To address these impediments, in 2013, various stakeholders from non-NGOs, academia and private laboratories came together to form Promoting Affordable and Quality TB Tests (IPAQT). Says Dr Navin Dang, who heads Dr Dang path Labs in Delhi and is also a governing council member of IPAQT, “The primary goal of the initiative is to broaden access and accelerate the use of more effective TB tests by making them more affordable, thereby providing higher quality care to millions of patients who seek diagnosis in the private sector.” The objective is being achieved through multiple ways- by ensuring that quality tests are available at significantly lower prices to the patients by lower input costs form manufacturer and smaller margins for the participating laboratories. The member labs are committed to deliver Hain Line Probe Assay at Rs1,600, which is almost a third of its current market price, GeneXpert, a WHO endorsed and widely accepted test at half of its current price and the MGIT liquid culture at lower than the market price. “The hope is that these WHOendorsed tools will replace the inaccurate

Stakeholders The current council comprises: • Ameera Shah, managing director and CEO, Metropolis Healthcare Ltd • Dr Madhukar Pai, associate professor, McGill International TB Centre

serological tests banned by the Government of India in 2012,” says Dr Dang. The initiative currently promotes the use of five WHO endorsed tests namely MGIT Liquid Culture, Hain Line Probe Assay, GeneXpert cartridge-based nucleic acid amplification test, BacT/Alert culture and LED microscopes. The access for the members to WHO-endorsed quality tests such as Liquid Culture, Line Probe Assay and cartridge-based nucleic acid amplification test (Xpert MTB/RIF) at reduced prices, make it possible for patients in the private sector to avail these quality tests at affordable cost. Informs council member Dr Madhukar Pai, who is associate director, McGill International TB Centre, dept of epidemiology & biostatistics, Canada, “The participating laboratories have committed to cease the use of serological tests that have been banned by RNTCP and to supplement the Government’s efforts by ensuring notification of positive cases.”


his self-sustaining initiative supported by the participating laboratories is rapidly growing. From 20 member labs in April 2013, IPAQT is now having 49 labs. These member labs, with over 3000 collection centres all over the country have tested over 9000 samples for TB through WHO approved tests. The laboratories are keen to further spread awareness of better testing practices by educating the private healthcare providers about the benefits of using accurate tests as opposed to tests such as antibody-based blood tests that are banned, and blood-based interferongamma release assays that have no role in the

• Dr Sanjeev Chaudhary, managing director, SRL Limited. • Dr Sarabjit Chadha, director, International Union Against Tuberculosis and Lung Disease (UNION) • Dr Navin Dang, managing director, Dr Dangs Lab, New Delhi • Harkesh Dabas, managing director, CHAI • Brigadier (Dr) Arvind Lal, chairman and managing director, Dr Lal Pathlabs • Dr Nalini Krishnan, founder, Resource Group for Education Advocacy for Community Health (REACH)

diagnosis of active TB and yet are widely used due to commercial incentives. “It is important that quality assured and endorsed tests are the first choice amongst doctors. so that timely and accurate diagnosis is assured. To that end, education of providers through awareness and advocacy campaigns is the need of the hour and all IPQAT laboratories are committed to this,” says Dr Dang. Further, accurate diagnosis must be followed up with proper care and treatment, so as to check the spread of the disease as to also curb drug resistance. All IPAQT laboratories ensure that positive cases are notified in keeping with guidelines so that they could be initiated on free quality treatment through the national TB programme. “We are also hoping that more NABL-accredited labs will join IPAQT. Any accredited lab can join IPAQT provided they agree to not charge more than the ceiling price, agree to notify all cases to RNTCP, and adhere to principles in the charter,” says Dr Pai.

Healthcare Radius September 2013


Diagnostic Special

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or conventional reasons, the use of latex gloves is highly popular in diagnostic industry. This is despite the fact that rubber material used for latex exam gloves is considered as an allergen- it can lead to allergies if worn by people with sensitive skin. Due to the allergen element of latex gloves, the demand has shifted to gloves that were fabricated from materials like neoprene and nitrile as these were synthetic and latex-free. Nitrile Exam Gloves have become the popular synthetic alternative to natural rubber latex, minimising the risk of contact dermatitis caused by an allergic reaction to natural rubber proteins. Nitrile is a unique type of polymer that provides superior chemical and tear resistance. Nitrile gloves are poly acrylate coated from inner side to facilitate easy and smooth donning. Being a powder latex free and powder free glove, nitrile ensures that specimens are not contaminated and assays are not inhaled. Latex is strong, but nitrile is stronger and more tear resistant when formed into gloves. They are also generally favoured because of the latter’s susceptibility to small pinprick holes that are not easily seen by the naked eye. Nitrile protects against contaminants like blood-transfused pathogens and is highly resistant against petroleum based solvents and the like. Not only does nitrile protect you when it comes to pathogens but it also gives you better grip and resists electric charges at the same time. Nitrile forms a skin-tight barrier that is naturally activated by the heat from the hands wearing it. The fit becomes more exact the longer you have the gloves on. For various diagnostic laboratory tasks, dexterity is tremendously important and this is why the synthetic material is best utilised in laboratory or clinical settings. Ansell® a global leader in barrier protection has devised a product – MICRO-TOUCH® Nitrile which meets the barrier protection demands of diagnostic professionals optimally. JKAnsell Ltd, the marketer of MICRO-TOUCH® Nitrile and other Ansell® medical gloves in India, has also received ‘best healthcare barrier protection company of the year award – 2012.’


Healthcare Radius September 2013

outine urine sediment analysis typically involves a number of manual steps including centrifugation, resuspension, microscopy and finally manual documentation of the results. These numerous steps can make the process time consuming, laborious and at risk for transcription errors. Sysmex India has introduced fully automated urine flow sytometers, UF-1000i and UF-500i which employ high performance, laser-based Fluorescence Flow Cytometry (FCM) that give reliable, quantitative results. These systems improve your laboratory turnaround time and offer worry-free urinalysis tool that you can totally rely on. FCM is a Sysmex core competence. It has been employed in the company’s X-class hematology analysers and its accuracy and reliability have been proven for many years. The analysers also offer value-added clinical information of UTI, red cell morphology, and conductivity and is able to accurately detect rbc, wbc, epithelial cells, casts, bacteria, crystals, yeasts and sperm in urine sample by using three different scatters: • Forward scattered light-information on cell size • Side scattered light- information on Internal cell structure • Side fluorescence light- information on RNA / DNA contents. UF series from Sysmex offers excellent capabilities for the best differentiation and quantification of urine particles. It provides standardisation in urinalysis that complies with ISLH guidelines by analysing un-centrifuged native urine sample.

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The pillars of marketing Branding, advertising, PR, sales force effectiveness and social media are the key differentiators for your brand By Ratan Jalan


s we all know, there are 4Ps of marketing- product, price, place and promotion. Let’s talk about the five key elements here that I consider important for marketing. Positioning and Branding: It is critical to understand about product attributes and their positioning. Positioning is all about some of the fundamental attributes of the business model, which would differentiate it from others and which have an inherent service delivery model built into it. Indigo, for instance, is positioned as an on time carrier. This attribute is the key differentiator of the model, a promise that is delivered across the organisation. In healthcare, most of the providers talk about care and compassion which is hardly reflected in the overall service delivery and which is quite subjective. Some of the newer hospitals project themselves as a ‘new dimension in healthcare’ or ‘redefining healthcare’ which to a consumer practically means nothing. As per Jim Collins, ‘Positioning is all about what you decide not to do’. It starts with identifying an opportunity area and creating a precise solution for the opportunity area. The opportunity area could be anything – right from a specialisation to a softer aspect such as patient centricity. Advertising: Any advertising essentially starts with the communication objective of the provider and the target segment for the intended communication. The communication message should be specific, credible, engaging and more importantly, simple to understand. In today’s context, a lot of people talk about revolutionary technologies, for instance ‘CyberKnife’ or ‘the world’s first non invasive


whole body robotic radiosurgery system’ which the patient cannot comprehend. It should be kept in mind that a good ad and a bad ad cost the same. It is for the hospital to think of an ad, which people could relate to. Setting communication budgets and evaluating media options is critical to the success of any marketing campaign, depending on the nature of the hospital. A television commercial may work better in some case, while a hoarding may in some other case. A careful evaluation of shelf life of the ad is also critical. For instance, a print ad in a leading newspaper could be expensive with a shelf life of a single day. Public Relations: There are seven key tenets of any PR strategy, starting all the way from determining a theme, deciding the ‘face’ of the organisation, staying consistent, building credibility, choosing the right media and language and creating a story. Healthcare, being a sensitive segment, managing and handling crisis at hospitals is equally important. In fact, good PR is always free, it is the bad PR that costs! Sales Force Effectiveness: It is pertinent to understand the question: ‘whom to sell’. Selling to everyone never yields expected results. A hospital targeted towards relatively underprivileged segment of the population would need to target patients covered under government health insurance schemes whereas a hospital for relatively affluent people need not necessarily worry about insurance patients. Another area which more often than not has always been compromised is the quality of sales team. Unfortunately the only topic, which is invariably discussed, is the contacts with physicians and the compensation. Issues such as domain/ product knowledge, or even ques-

Healthcare Radius September 2013

tions like ‘how to sell’ are never discussed. Further, performance-based incentives are far too less than the actual contribution by value by the sales team. Last but not the least, monitoring productivity is invariably linked to the conversion of cases by number. Contrary to this, productivity is measured on different parameters: Social Media : Healthcare as a sector is largely driven by word of mouth, which is nothing but conversations. Taking the logic further, social media is all about conversations. In fact a closer look at Facebook would show communities such as pregnancy, infertility, obesity, osteoarthritis, asthma among others where patients continuously engage with each other. However, just creating a Facebook profile does not serve any purpose. Hospitals could target patients based on the user info. It could be age, gender, geography, work, education, common interests or some support groups. For instance, a birthing facility could customise the Facebook search to married women who attend prenatal yoga or who stay in a specific locality. Unlike other marketing activities, social media activities and platforms such as Facebook do not involve exorbitant spending and can be monitored precisely. However, it has to be highly involved relationship with the hospital. Finally, contrary to the common perception, negative comments are a blessing in disguise. They help hospitals understand their problems.

Ratan Jalan is founder, Medium Healthcare Consulting. He spoke about the above topic at ‘Healthcare Marketing MasterClass’, organised by Medium at Bengaluru.


Safety first Right from the entry of a patient in the hospital till his discharge, various aspects of safety have to be carefully monitored and managed By Dr J Sivakumaran


mong all other motives, patient safety is fundamental in healthcare delivery. And right from the time a patient enters the hospital till he leaves, all aspects should be carefully monitored and managed to ensure his safety. On the non-clinical side, safety starts from allocating a safe location for car parking and having a system in place to take care of vehicles. Unfortunately, many hospitals do not have sufficient parking and patients have to park at a private area where safety cannot be guaranteed. Parking contractors concentrate mostly on vehicle management. As a result, safety aspects are often compromised. A hospital’s flooring is another crucial aspect. It needs to be slip resistant, stain resistant, bacterio-static and easy to clean. The incidence of

falls is highest in patient rooms and bathrooms. So footwear provided to patients should be nonslippery with more grips. Another reason for patient falls is the absence of side rails, while in stretcher/bed. It is important that hospital attendants accompany patients when they have to move from one department to another either on foot or in a wheelchair and check that they wear safety belts and wheels are locked. Training and retraining of transport assistants will help in safer transportation of patients. Areas that see maximum patient movement should be well lit. Purified water should be provided at select points, so that patients/attendants do not have to venture far to quench their thirst. The facilities available (right from ATM to photocopy) should be patient oriented, so that

the patient/attendant is not found wandering for such requirements. It is advisable to educate patients/attendants on certain important common activities like wheelchair movement. Communication on various dos and don’ts could be explained either orally or through printed media to educate them. Fire safety, electrical safety and radiation safety also play a vital role in patient safety measures. Keeping relevant and sufficient number of fire fighting equipment as per guidelines of the authorities is important. These equipment need to be checked at periodic intervals. Apart from checking, it is important to have mock drill at fixed intervals in critical/sensitive areas to educate the staff. Installation and maintenance of proper smoke detectors and alarm with sprinkler system is essential. Every patient room and other common patient moving

It is important that attendants accompany patients when they are in a wheelchair and ensure that they wear safety belts and wheels are locked.

Healthcare Radius September 2013



areas should have fire exit, plan marking the escape route in a dark glow colour. No hindrance should be there in the exit route. All electrical equipment and fittings should be of good quality. Proper earthing and load requirements need to be calculated. While patients are undergoing radiation related procedures, proper usage of apron shield will ensure protection from radiation exposure. Any damage noticed in the apron should be replaced immediately. When physically or mentally challenged patients get admitted, an attendant should accompany them 24x7. Prevention of sexual or any other abuse by hospital staff or by other public should be taken care of. Another vexing problem in spite of having various check points and security arrangements is that of abduction of babies. Access control system in the birthing area, checking of ID of mother and baby, video recording system are some of the steps a hospital can take to prevent this. Though hospitals can’t control carelessness on the part of patients/attendants in keeping mobile, cash/ gadgets, cloth, vigilance should be provided by the hospital to prevent untoward incidents.


n the clinical side, many safety precautions could be listed. Incidents of wrong site surgery, wrong side surgery or wrong patient surgery and blood transfusion errors are alarming, even in a developed country like the US. In India, proper regulations/protocols/ preventive mechanisms by authorities are still not in place. As there is no proper reporting system in India, we don’t know the volume of such incidents here. Hospitals should follow reporting protocol to analyse reasons of occurrences and take measures to prevent the same. Equipment-related burns (resulting from hot water bottles and cautery machines among others) or infections due to poor quality of disposables should be prevented. Hospital acquired infection is another safety issue before us. Poor hand hygiene practices or not taking proper care to central lines or catheters could lead to this problem. Proper protocol on hand wash helps arrest the problem. Digital display on hand wash, giving alarm at fixed intervals, identification of hand washing person through ID by the sanitising dispenser and sink are different methods to improve the hand washing compliance. Often patients are restless when various tubes and lines are inserted in their bodies for treatment. One needs to look at avoiding such


Hospitals need to ensure that there is no accidental removal of lines and tubes.

accidental removal of lines/tubes. Some patients due to their altered sensorium could harm themselves or others. Proper restrain protocol should be in place for them. Hospitals need to check and recheck a patient’s history on medication and allergies. While the patient is under treatment, switching patients between different medicines or medical therapies and interchanging them will involve serious safety issues. Proper handoffs will take care of such harms. The Joint Commission International has laid down guidelines for international patient safety goals (IPSG). They are: 1. Identifying patients correctly (name and UHID instead of room number or bed number) 2. Improving effective communication to be in place to avoid error in written orders. In case of emergency, take verbal orders but read back the order to confirm correctness. 3. Improving the safety of high alert medications (look alike/sound alike medicines are to be colour coded and stored separately). 4. Ensuring correct-site, correct-procedure, correct-patient surgery. Following time out procedures, pre-operative verification process.

Healthcare Radius September 2013

5. Reducing the risk of healthcare associated infections by following hand hygiene and standard precautions. 6. Reducing the risk of patient harm resulting from falls: side rails and safety first sign. Another crucial aspect is medication safety, which is to prevent errors while prescribing, transcribing, dispensing and administering medicines. Information safety is making available up-dated, completed and accurate medical records for every patient. Communication safety refers to sharing relevant, real-time information to all authorised/interested parties. Environmental safety is keeping noise level down, keeping distractions to a minimum and less clutter in work areas where medications are prepared. Training, retraining and monitoring the staff is the proven method to make the patients feel safe.

Dr J Sivakumaran is senior vice president of SPS Apollo Hospitals, Ludhiana, Punjab.

Healthcare Radius, Sep 2013  

Aligning Business & Healthcare in India