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HOSMAC Pulse Vol. 1 No. 5 April, 2011
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Taking Healthcare Beyond The Metros
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w w w. h o s m a c f o u n d a t i o n . o r g
PPP: Is it really the solution? Pg. 29
Cover Story Pg. 11
HOSMAC Pulse is an initiative of HOSMAC Foundation. High-quality standards have been maintained while preparing and presenting the information in this periodical. However, no legal responsibility will be accepted by HOSMAC Foundation or HOSMAC India Pvt Ltd for any loss or damage resultant from its contents. The views expressed are solely that of the authors or writers, and do not necessarily represent the views of HOSMAC Foundation or its consultants in relation to any particular projects. No part of this periodical may be reproduced in any form without the written permission of HOSMAC Fooundation – the publisher.
HOSMAC Pulse is an initiative of HOSMAC Foundation. High-quality standards have been maintained while preparing and presenting the information in this periodical. However, no legal responsibility will be accepted by HOSMAC Foundation or HOSMAC India Pvt Ltd for any loss or damage resultant from its contents. The views expressed are solely that of the authors or writers, and do not necessarily represent the views of HOSMAC Foundation or its consultants in relation to any particular projects. No part of this periodical may be reproduced in any form without the written permission of HOSMAC Fooundation – the publisher.
Editorial Board
Table Of Content Down-to-Earth Healthcare
3
A Revolution in Rural Healthcare
6
Telehealth: The Reinvention of Healthcare
9
Taking Healthcare beyond the Metros
13
To be or not to be — Accredited
19
jonathan.fernandes@hosmac.com
A Bird's-Eye View of Microinsurance in India
21
Advisory Panel
Effective Cost Treatment
26
PPP: Is it really the solution?
29
Just What the Future Ordered
31
Hands-on Nuclear Medicine
33
Vertically Integrated Healthcare Facility Desig
37
Tapping the Opportunity of MES
41
Healthcare For All
43
Editor-in-Chief Dr. Vivek Desai vivek.desai@hosmac.com
Associate Editors Vinay Pagarani vinay.pagarani@hosmacfoundation.org Jonathan Fernandes
Narendra Karkera narendra.karkera@hosmac.com Isha Khanolkar isha.khanolkar@hosmac.com Vishal Dhangar vishal.dhangar@hosmac.com
Creative Consultant Amit Pandya mumbai@shapecommu.com
Editorial Board
Table Of Content Down-to-Earth Healthcare
3
A Revolution in Rural Healthcare
6
Telehealth: The Reinvention of Healthcare
9
Taking Healthcare beyond the Metros
13
To be or not to be — Accredited
19
jonathan.fernandes@hosmac.com
A Bird's-Eye View of Microinsurance in India
21
Advisory Panel
Effective Cost Treatment
26
PPP: Is it really the solution?
29
Just What the Future Ordered
31
Hands-on Nuclear Medicine
33
Vertically Integrated Healthcare Facility Design
37
Tapping the Opportunity of MES
41
Healthcare For All
43
Editor-in-Chief Dr. Vivek Desai vivek.desai@hosmac.com
Associate Editors Vinay Pagarani vinay.pagarani@hosmacfoundation.org Jonathan Fernandes
Narendra Karkera narendra.karkera@hosmac.com Isha Khanolkar isha.khanolkar@hosmac.com Vishal Dhangar vishal.dhangar@hosmac.com
Creative Consultant Amit Pandya mumbai@shapecommu.com
Editor’s Note
Accessible, affordable and available healthcare, as repetitive as it may sound, is imperative for the health of our nation, which is currently one of the fastest growing economies of the world. One of the most important steps in ensuring this is to treat every region of the country equally in terms of quality and magnitude of healthcare services. The Indian healthcare system typically shows a divide between the developed metropolitans and the rest of India. The metros display a greater concentration of healthcare services both in terms of quantity and quality. 80% of healthcare resources are concentrated towards 20% of the country’s population. This divide only accentuates the social phenomenon of the rich getter richer and poor getting poorer. The central and the state governments of our country, however, have shown great vision and effort in bridging this gap by schemes such as the National Rural Health Mission (NRHM), Rajiv Aarogyasri Community Health Insurance Scheme and such others. But like most other development sectors in our country such as infrastructure and power, which have shown remarkable progress and contribution to the growth of our country by the support and involvement of the private sector, the healthcare sector too calls for their support. With more than 75% of the investments in healthcare flowing in from the private sector, it is only natural that without their adequate support, penetration of healthcare services into every nook and corner of this country will be a Herculean task to achieve. This change, however, has begun. Visionaries in the private healthcare sector have not only answered the call for quality healthcare facilities in smaller tier II and III cities of the country, but have also understood the underlying, untapped potential of these regions. With the metros getting saturated in every aspect, growth is shifting towards the tier II and tier III at a multinational level, with foreign investors, too, eying these markets. The path for healthcare to reach these cities and towns is paved by the growth of information technology, manufacturing industries and real estate in these regions. The Government’s fortification strategies such as public-private partnerships, tax holidays, real estate incentives, concessions etc. have further worked to lure the private sector in penetrating newer markets and defining new bottom lines in the healthcare industry. It is therefore an optimal time for the private healthcare sector to plunge into every region in the country with innovative models and customized strategies to enable every citizen of this country to palpate the magnanimous growth of this great nation.
The Government’s fortification strategies such as public-private partnerships, tax holidays, real estate incentives, concessions etc. have further worked to lure the private sector in penetrating newer markets and defining new bottom lines in the healthcare industry.
Dr. Vivek Desai Managing Director, Hosmac India Pvt. Ltd.
1
Editor’s Note
Accessible, affordable and available healthcare, as repetitive as it may sound, is imperative for the health of our nation, which is currently one of the fastest growing economies of the world. One of the most important steps in ensuring this is to treat every region of the country equally in terms of quality and magnitude of healthcare services. The Indian healthcare system typically shows a divide between the developed metropolitans and the rest of India. The metros display a greater concentration of healthcare services both in terms of quantity and quality. 80% of healthcare resources are concentrated towards 20% of the country’s population. This divide only accentuates the social phenomenon of the rich getter richer and poor getting poorer. The central and the state governments of our country, however, have shown great vision and effort in bridging this gap by schemes such as the National Rural Health Mission (NRHM), Rajiv Aarogyasri Community Health Insurance Scheme and such others. But like most other development sectors in our country such as infrastructure and power, which have shown remarkable progress and contribution to the growth of our country by the support and involvement of the private sector, the healthcare sector too calls for their support. With more than 75% of the investments in healthcare flowing in from the private sector, it is only natural that without their adequate support, penetration of healthcare services into every nook and corner of this country will be a Herculean task to achieve. This change, however, has begun. Visionaries in the private healthcare sector have not only answered the call for quality healthcare facilities in smaller tier II and III cities of the country, but have also understood the underlying, untapped potential of these regions. With the metros getting saturated in every aspect, growth is shifting towards the tier II and tier III at a multinational level, with foreign investors, too, eying these markets. The path for healthcare to reach these cities and towns is paved by the growth of information technology, manufacturing industries and real estate in these regions. The Government’s fortification strategies such as public-private partnerships, tax holidays, real estate incentives, concessions etc. have further worked to lure the private sector in penetrating newer markets and defining new bottom lines in the healthcare industry. It is therefore an optimal time for the private healthcare sector to plunge into every region in the country with innovative models and customized strategies to enable every citizen of this country to palpate the magnanimous growth of this great nation.
The Government’s fortification strategies such as public-private partnerships, tax holidays, real estate incentives, concessions etc. have further worked to lure the private sector in penetrating newer markets and defining new bottom lines in the healthcare industry.
Dr. Vivek Desai Managing Director, Hosmac India Pvt. Ltd.
1
Down-to-Earth Healthcare 'Why treat people without changing what makes them sick?' Ms. Sonali Sinha puts it right.
3
The World Health Organization defines health as ‘a state of complete
of human waste; sufficient drug distribution centres to ensure timely
physical, mental and social well-being’ and not merely the absence of
availability of preventive and curative drugs for diseases like malaria
disease or infirmity. The traditional view point directly links
and diarrhoea; functional primary health infrastructure to access
healthcare or improvements in health to the advancements in
vaccination services, family planning devices: maternal and child
medical science. In fact, the medical model of health focuses on the
health; and the availability of primary education facilities are a few
eradication of illness through diagnosis and effective treatment.
services to name. These, along with their ready accessibility, health
However, the social model of health emphasises on changes that can
seeking behaviour, lifestyle and availability of livelihood
be made in society and in the lifestyles of people to make the
opportunities define the public health status of the population in the
population healthier; it defines health from the point of view of the
respective area. This in turn is manifested in terms of public health
individuals functioning within the society rather than by monitoring
indicators like life expectancy, infant mortality rate, maternal
for changes in biological or physiological signs. Healthcare is thus a
mortality rate, total fertility rate and the disease burden for that
social institution and, as a social philosophy, it represents the primary
population or area.
means by which people improve the overall quality of their lives.
The study of these public health indicators across nations, different
Given this perspective, health is more or less about the social
regions within a country, the rural and urban divide within the
determinants like safe drinking water, sanitation, nutrition, literacy
regions and the different social classes therein shows a distinct
and primary education, income, social relationships, prevalent
health gradient. For instance, the public health indicators in the
lifestyles, and partly about clinical structure. Thus, speaking more
South Asian and African countries are dismal in comparison to those
specifically, the essence of public health can be explained as
in the US and Japan. The health indicators of the nine EAG states in
protecting and improving the health of communities through
our country, which make about 47% of the population, clearly depict
education, the promotion of healthy lifestyles, lowering the disease
the regional skewedness in the public health status. On a pan-India
burden and research for prevention of disease and injury.
basis, these indicators are comparatively poor for the disadvantaged
Ergo, public health is a social phenomenon with consequent social
classes like SCs and STs. The foundation of adult health is laid during
ramifications. It implies to improve the health and well-being of
early childhood, and social milieu plays a very significant role in it.
people in local communities around the globe, preventing health
However, the outstanding health indicators of Sri Lanka show that
problems before they occur. It entails all the integrated and readily
things can be corrected even in not-so-favourable conditions by
available gamut of public health services on all health determinants.
adopting the right approach and putting in sincere effort.
Availability of safe sources of drinking water, toilets with flowing
In India, issues related to public health are dealt with mainly by the
water; proper sewerage and drainage systems for the proper disposal
Ministry of Health and Family Welfare, the Ministry of Women and
Child Development and the Ministry of Drinking Water and
aanganwadi centers with safe drinking water facilities. Total
Sanitation. The Ministry of Health and Family Welfare is concerned
Sanitation Campaign (TSC) is a programme that provides latrines for
with public health infrastructure, besides reproductive, child health
individual households, schools, aanganwadi centers as well as builds
and disease control programs. Since 2005, they all have been brought
community latrines. Right of Children for Free and Compulsory
under a broadband flagship program, namely, the National Rural
Education Act was enacted on April 1, 2010. It puts this responsibility
Health Mission (NRHM). Issues of nutrition particularly focused on
on the respective governments and local authorities to ensure that
children up to 6 years of age, adolescent girls, pregnant women and
all the children of 6 to 14 years compulsorily go to schools and
lactating mothers are addressed by the Ministry of Women and Child
complete their elementary education. It also provides a framework
Development. The Ministry of Drinking Water and Sanitation looks
for bringing the aspect of quality to elementary education. School
after the creation and maintenance of drinking water infrastructure
Health Program as a component of NRHM is an intervention to
and sanitation issues. Public health thus is a multi-control sector that
conduct regular health checkups of children in schools. Aside from
requires a consistent and sustained convergence amongst all
that is the Rashtriya Madhyamik Siksha Abhiyan (RMSA), which
concerned so that health services may be made available readily to
intends to improve the secondary education scenario. Though
the people in an integrated way.
individually all these programs have their own objectives,
There exists a pyramid of public health networks in the country, right
collectively they aim to improve the socioeconomic conditions of the
from the apex at the national level down to the grassroots
people and hence also contribute in one way or another to improving
community level. From the total organisational structure, we can
the health status of the communities.
slice the configuration of the healthcare system into the national,
NRHM, in its bid to escalate the effectiveness of the service delivery
state, district, block, sub-block and village levels. The large public
at all levels of healthcare, framed a number of strategic interventions
health network has been established with an objective of providing
that would enable and enhance the reliability and accessibility of
accessible, affordable, effective and reliable public health facilities to
these facilities. Despite this, the scenario remains grim at the lower
every citizen across the country.
level due to reasons which are deep-rooted, and looks for a critical
But all’s not well with the huge, extensive public health system in
paradigm shift. The pertinent reasons for the crisis may be
India. It suffers from many problems including insufficient funding,
enumerated as follows:
deficient facilities and a severe shortage of optimally trained human
Critical non-availability of doctors and paramedical staff at
resources. The complex processes and procedures involved in
all levels, particularly at the PHC level
seeking sanctions and approvals for spending available funds, for
Apathy towards the perception of quality care
upgrading the facilities and the procurement of goods and services
Irrational deployment of the available manpower
also adds to the inertia. Moreover, the system is also plagued with a
Inadequate physical infrastructure and basic facilities for a
lack of accountability. The lack of convergence and coordination
decent work environment in terms of water, toilets,
among the different components and controls of public health also
electricity, communication, transport facilities etc.
contribute to the non-deliverance of integrated public health facilities to the people.
Lack of accountability in the public health delivery system Non-existence of community participation
However, there are many flagship programs that directly or indirectly address the issues of public health in the country. The National Rural Health Mission (NRHM) is a major player in bringing architectural corrections to rural health infrastructure and services. It aims at progressively improving the indicators of Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR) and Total Fertility Rate (TFR), thereby enhancing the life expectancy and achieving population stabilization. The Integrated Child Development Services (ICDS) program provides six major services including supplementary nutrition to children of up to six years, pregnant women and lactating mothers, routine vaccination, health education and preschool education through ‘Aanganwadi Centres’ (AWCs). The recent impetus on the universalization of ICDS has helped in opening of AWCs in hitherto uncovered areas also. AWCs also serve as point of convergence for health and nutrition programs at the village or habitation level. National Rural Drinking Water Program (NRDWP) is to ensure availability of quality drinking water to every rural household. The programme provides for a drinking water security plan to be developed at the local level only with the help of locally trained personnel. It also provides to cover all the elementary schools and
4
Down-to-Earth Healthcare 'Why treat people without changing what makes them sick?' Ms. Sonali Sinha puts it right.
3
The World Health Organization defines health as ‘a state of complete
of human waste; sufficient drug distribution centres to ensure timely
physical, mental and social well-being’ and not merely the absence of
availability of preventive and curative drugs for diseases like malaria
disease or infirmity. The traditional view point directly links
and diarrhoea; functional primary health infrastructure to access
healthcare or improvements in health to the advancements in
vaccination services, family planning devices: maternal and child
medical science. In fact, the medical model of health focuses on the
health; and the availability of primary education facilities are a few
eradication of illness through diagnosis and effective treatment.
services to name. These, along with their ready accessibility, health
However, the social model of health emphasises on changes that can
seeking behaviour, lifestyle and availability of livelihood
be made in society and in the lifestyles of people to make the
opportunities define the public health status of the population in the
population healthier; it defines health from the point of view of the
respective area. This in turn is manifested in terms of public health
individuals functioning within the society rather than by monitoring
indicators like life expectancy, infant mortality rate, maternal
for changes in biological or physiological signs. Healthcare is thus a
mortality rate, total fertility rate and the disease burden for that
social institution and, as a social philosophy, it represents the primary
population or area.
means by which people improve the overall quality of their lives.
The study of these public health indicators across nations, different
Given this perspective, health is more or less about the social
regions within a country, the rural and urban divide within the
determinants like safe drinking water, sanitation, nutrition, literacy
regions and the different social classes therein shows a distinct
and primary education, income, social relationships, prevalent
health gradient. For instance, the public health indicators in the
lifestyles, and partly about clinical structure. Thus, speaking more
South Asian and African countries are dismal in comparison to those
specifically, the essence of public health can be explained as
in the US and Japan. The health indicators of the nine EAG states in
protecting and improving the health of communities through
our country, which make about 47% of the population, clearly depict
education, the promotion of healthy lifestyles, lowering the disease
the regional skewedness in the public health status. On a pan-India
burden and research for prevention of disease and injury.
basis, these indicators are comparatively poor for the disadvantaged
Ergo, public health is a social phenomenon with consequent social
classes like SCs and STs. The foundation of adult health is laid during
ramifications. It implies to improve the health and well-being of
early childhood, and social milieu plays a very significant role in it.
people in local communities around the globe, preventing health
However, the outstanding health indicators of Sri Lanka show that
problems before they occur. It entails all the integrated and readily
things can be corrected even in not-so-favourable conditions by
available gamut of public health services on all health determinants.
adopting the right approach and putting in sincere effort.
Availability of safe sources of drinking water, toilets with flowing
In India, issues related to public health are dealt with mainly by the
water; proper sewerage and drainage systems for the proper disposal
Ministry of Health and Family Welfare, the Ministry of Women and
Child Development and the Ministry of Drinking Water and
aanganwadi centers with safe drinking water facilities. Total
Sanitation. The Ministry of Health and Family Welfare is concerned
Sanitation Campaign (TSC) is a programme that provides latrines for
with public health infrastructure, besides reproductive, child health
individual households, schools, aanganwadi centers as well as builds
and disease control programs. Since 2005, they all have been brought
community latrines. Right of Children for Free and Compulsory
under a broadband flagship program, namely, the National Rural
Education Act was enacted on April 1, 2010. It puts this responsibility
Health Mission (NRHM). Issues of nutrition particularly focused on
on the respective governments and local authorities to ensure that
children up to 6 years of age, adolescent girls, pregnant women and
all the children of 6 to 14 years compulsorily go to schools and
lactating mothers are addressed by the Ministry of Women and Child
complete their elementary education. It also provides a framework
Development. The Ministry of Drinking Water and Sanitation looks
for bringing the aspect of quality to elementary education. School
after the creation and maintenance of drinking water infrastructure
Health Program as a component of NRHM is an intervention to
and sanitation issues. Public health thus is a multi-control sector that
conduct regular health checkups of children in schools. Aside from
requires a consistent and sustained convergence amongst all
that is the Rashtriya Madhyamik Siksha Abhiyan (RMSA), which
concerned so that health services may be made available readily to
intends to improve the secondary education scenario. Though
the people in an integrated way.
individually all these programs have their own objectives,
There exists a pyramid of public health networks in the country, right
collectively they aim to improve the socioeconomic conditions of the
from the apex at the national level down to the grassroots
people and hence also contribute in one way or another to improving
community level. From the total organisational structure, we can
the health status of the communities.
slice the configuration of the healthcare system into the national,
NRHM, in its bid to escalate the effectiveness of the service delivery
state, district, block, sub-block and village levels. The large public
at all levels of healthcare, framed a number of strategic interventions
health network has been established with an objective of providing
that would enable and enhance the reliability and accessibility of
accessible, affordable, effective and reliable public health facilities to
these facilities. Despite this, the scenario remains grim at the lower
every citizen across the country.
level due to reasons which are deep-rooted, and looks for a critical
But all’s not well with the huge, extensive public health system in
paradigm shift. The pertinent reasons for the crisis may be
India. It suffers from many problems including insufficient funding,
enumerated as follows:
deficient facilities and a severe shortage of optimally trained human
Critical non-availability of doctors and paramedical staff at
resources. The complex processes and procedures involved in
all levels, particularly at the PHC level
seeking sanctions and approvals for spending available funds, for
Apathy towards the perception of quality care
upgrading the facilities and the procurement of goods and services
Irrational deployment of the available manpower
also adds to the inertia. Moreover, the system is also plagued with a
Inadequate physical infrastructure and basic facilities for a
lack of accountability. The lack of convergence and coordination
decent work environment in terms of water, toilets,
among the different components and controls of public health also
electricity, communication, transport facilities etc.
contribute to the non-deliverance of integrated public health facilities to the people.
Lack of accountability in the public health delivery system Non-existence of community participation
However, there are many flagship programs that directly or indirectly address the issues of public health in the country. The National Rural Health Mission (NRHM) is a major player in bringing architectural corrections to rural health infrastructure and services. It aims at progressively improving the indicators of Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR) and Total Fertility Rate (TFR), thereby enhancing the life expectancy and achieving population stabilization. The Integrated Child Development Services (ICDS) program provides six major services including supplementary nutrition to children of up to six years, pregnant women and lactating mothers, routine vaccination, health education and preschool education through ‘Aanganwadi Centres’ (AWCs). The recent impetus on the universalization of ICDS has helped in opening of AWCs in hitherto uncovered areas also. AWCs also serve as point of convergence for health and nutrition programs at the village or habitation level. National Rural Drinking Water Program (NRDWP) is to ensure availability of quality drinking water to every rural household. The programme provides for a drinking water security plan to be developed at the local level only with the help of locally trained personnel. It also provides to cover all the elementary schools and
4
2008.
A Revolution in Rural Healthcare
The CSDH’s aim was to stimulate action to reduce the health
Madhuri Umeshchandra, Project Coordinator, divulges the story behind Vaatsalaya, with words from its founding healers.
inequalities that exist between countries and within countries. According to the CSDH, in situations where health inequalities are preventable and avoidable, but are not avoided, they are inequitable, and taking action to reduce them is a matter of social justice. CSDH’s recommendations are based on three principles for action: To revive the conditions of daily life – the circumstances in which people are born, grow, live, work and age. Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally and locally. Gauge the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public Lack of established standards for monitoring quality of care Inadequacy/unavailability of proper accommodation
awareness about the social determinants of health. Crucial to the social determinants of health approach is that where
facilities at the facility level (especially in rural areas)
differential health outcomes are linked to social inequalities; the
Unavailability of quality laboratory services at the block
action to improve health outcomes must include the action to reduce
and sub-block level
social inequalities. Seen in this light, every sector is in effect a health
Although these have been perennial problems, there can be few real-
sector, because every sector, including finance, business, agriculture,
time alternatives to mitigate them through:
trade, energy, education, employment and welfare, impacts on
Incentivisation/professional motivation to the health
health and health equity.
professionals who stay and serve at the block level or who
Action needs to ensue at global, national and local levels. The
Healthcare is one of India’s largest sectors, in terms of revenue and
“In India, the patient-doctor ratio is around 1/30,000. Of course, it
provide compulsory rural service for a minimum of two years
national level policy environment needs to empower grassroots
employment, and the sector is expanding rapidly. During the 1990s,
will be higher in Uttar Pradesh and Madhya Pradesh due to non-
Rationalising utilization of paramedical staff or
community participation in identifying what needs to be done, in
Indian healthcare grew at a compound annual rate of 16%. Today the
availability of doctors as well as lack of health facilities and proper
‘paramedicalising’ the block facilities so that doctors can be used at
developing interventions and programmes and in evaluating their
total value of the sector is more than $34 billion. This translates to
infrastructure,” public health expert S. Sunder Raman told IANS over
higher facilities
effects. The CSDH report is optimistic. The global movement for
$34 per capita, or roughly 6% of GDP. By 2012, India’s healthcare
phone from Chennai.
Ensure multi-skilling of the staff through capacity building to
health equity is growing. Progress may be patchy but it certainly is
sector is projected to grow to nearly $40 billion.
According to a Planning Commission report of 2008, India is short of
address the impact of manpower shortage
evident. The report contains examples of successful action including
The private sector accounts for more than 80% of total healthcare
600,000 doctors, one million nurses and 200,000 dental surgeons. An
Increase awareness in the community and other stakeholders
work in Sri Lanka and India. But there needs to be more innovation
spending in India. Unless there is a decline in the combined federal
official in the health ministry said, “Many doctors are unwilling to
to bring in more accountability amongst the staff
and more evaluation so that promising approaches can be developed
and state government deficit, which currently stands at roughly 9%,
work in difficult and hard-to-reach areas. This could be because they
Enhance public-private partnerships with an effective
and extended to reach more people. Public health workers at the
the opportunity for significantly higher public health spending will be
face accommodation problems in these far-off places. Besides,
monitoring system for efficient service delivery
heart of communities have a pivotal role to play in raising awareness
limited.
general infrastructure in remote areas pose problems (as they come
Accreditation/Certification of the facilities to e s t a b l i s h
and calling for action on social determinants, and in the process of
When it comes to healthcare, there are two Indias: the country that
from cities and towns),” the official told IANS.
processes and systems to raise the quality quotient at all
developing and evaluating action at a local and national level. Only
provides high-quality medical care to middle-class Indians and
While 70% of India is living in semi-urban and rural areas, 80% of
then would we be able to create a healthy society and a happy
medical tourists, and the India in which a vast population lives —
India’s healthcare facilities are located in urban/metro regions.
nation.
whose residents have limited or no access to quality care. Today, only
Vaatsalya is bridging this gap by building and managing
25% of the Indian population has access to Western (allopathic)
hospitals/clinics in semi-urban and rural areas, bringing healthcare
levels of service delivery Community Risk Pooling and Health Insurance Harness the support of the big industrial houses as their Corporate Social Responsibility Advocacy and awareness amongst key stake holders India needs to make its public health system operative and effective. Programs are already in operation. The need is to create convergence amongst them, synergize them so that they are able to deliver their services in a more desirable way. A Commission on Social Determinants of Health (CSDH) was set up by the World Health Organization in 2005 to support action on the social determinants of health to improve the overall population’s health, refine the distribution of health, and to reduce disadvantage due to poor health. It published its final report and recommendations in
5
Inauguration of Vaatsalya Hospital, Hubli by A.PJ. Kalam
The author has varied experience in implementing public health
medicine, which is practiced mainly in urban areas, where two-thirds
services where it is needed the most. Vaatsalya is India’s first hospital
programs at the grassroot levels and has served both at the
of India’s hospitals and health centers are located. Many of the rural
network focused on tier II and tier III cities.
Government & non-government sectors. She has worked with
poor must rely on alternative forms of treatment, such as ayurvedic
Dr. Ashwin Naik, 37, and Dr. Veerendra Hiremath, 35, who grew up in
Hosmac Public Health Department as a Principal Consultant.
medicine, unani and acupuncture.
Hubli, Karanataka, went around the world and returned to set up
The next time you walk into a clinic for a cough and cold, spare a
Vaatsalya, a unique model of an affordable hospital network in the
thought for your rural brethren. Latest government data reveals that
under-served areas. “Doctors from rural districts rarely go back to
rural India is short of over 16,000 doctors, including 12,000
their roots,” says Naik. They decided to address this demand-supply
specialists.
gap.
While the situation is often attributed to the unwillingness of doctors
All healthcare stalwarts underscore the importance of making
to work in difficult areas, others say not enough is being done to
healthcare more affordable and accessible, but how many of them
incentivise the postings.
dare to address the lack of healthcare services in semi-urban and
6
2008.
A Revolution in Rural Healthcare
The CSDH’s aim was to stimulate action to reduce the health
Madhuri Umeshchandra, Project Coordinator, divulges the story behind Vaatsalaya, with words from its founding healers.
inequalities that exist between countries and within countries. According to the CSDH, in situations where health inequalities are preventable and avoidable, but are not avoided, they are inequitable, and taking action to reduce them is a matter of social justice. CSDH’s recommendations are based on three principles for action: To revive the conditions of daily life – the circumstances in which people are born, grow, live, work and age. Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally and locally. Gauge the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public Lack of established standards for monitoring quality of care Inadequacy/unavailability of proper accommodation
awareness about the social determinants of health. Crucial to the social determinants of health approach is that where
facilities at the facility level (especially in rural areas)
differential health outcomes are linked to social inequalities; the
Unavailability of quality laboratory services at the block
action to improve health outcomes must include the action to reduce
and sub-block level
social inequalities. Seen in this light, every sector is in effect a health
Although these have been perennial problems, there can be few real-
sector, because every sector, including finance, business, agriculture,
time alternatives to mitigate them through:
trade, energy, education, employment and welfare, impacts on
Incentivisation/professional motivation to the health
health and health equity.
professionals who stay and serve at the block level or who
Action needs to ensue at global, national and local levels. The
Healthcare is one of India’s largest sectors, in terms of revenue and
“In India, the patient-doctor ratio is around 1/30,000. Of course, it
provide compulsory rural service for a minimum of two years
national level policy environment needs to empower grassroots
employment, and the sector is expanding rapidly. During the 1990s,
will be higher in Uttar Pradesh and Madhya Pradesh due to non-
Rationalising utilization of paramedical staff or
community participation in identifying what needs to be done, in
Indian healthcare grew at a compound annual rate of 16%. Today the
availability of doctors as well as lack of health facilities and proper
‘paramedicalising’ the block facilities so that doctors can be used at
developing interventions and programmes and in evaluating their
total value of the sector is more than $34 billion. This translates to
infrastructure,” public health expert S. Sunder Raman told IANS over
higher facilities
effects. The CSDH report is optimistic. The global movement for
$34 per capita, or roughly 6% of GDP. By 2012, India’s healthcare
phone from Chennai.
Ensure multi-skilling of the staff through capacity building to
health equity is growing. Progress may be patchy but it certainly is
sector is projected to grow to nearly $40 billion.
According to a Planning Commission report of 2008, India is short of
address the impact of manpower shortage
evident. The report contains examples of successful action including
The private sector accounts for more than 80% of total healthcare
600,000 doctors, one million nurses and 200,000 dental surgeons. An
Increase awareness in the community and other stakeholders
work in Sri Lanka and India. But there needs to be more innovation
spending in India. Unless there is a decline in the combined federal
official in the health ministry said, “Many doctors are unwilling to
to bring in more accountability amongst the staff
and more evaluation so that promising approaches can be developed
and state government deficit, which currently stands at roughly 9%,
work in difficult and hard-to-reach areas. This could be because they
Enhance public-private partnerships with an effective
and extended to reach more people. Public health workers at the
the opportunity for significantly higher public health spending will be
face accommodation problems in these far-off places. Besides,
monitoring system for efficient service delivery
heart of communities have a pivotal role to play in raising awareness
limited.
general infrastructure in remote areas pose problems (as they come
Accreditation/Certification of the facilities to e s t a b l i s h
and calling for action on social determinants, and in the process of
When it comes to healthcare, there are two Indias: the country that
from cities and towns),” the official told IANS.
processes and systems to raise the quality quotient at all
developing and evaluating action at a local and national level. Only
provides high-quality medical care to middle-class Indians and
While 70% of India is living in semi-urban and rural areas, 80% of
then would we be able to create a healthy society and a happy
medical tourists, and the India in which a vast population lives —
India’s healthcare facilities are located in urban/metro regions.
nation.
whose residents have limited or no access to quality care. Today, only
Vaatsalya is bridging this gap by building and managing
25% of the Indian population has access to Western (allopathic)
hospitals/clinics in semi-urban and rural areas, bringing healthcare
levels of service delivery Community Risk Pooling and Health Insurance Harness the support of the big industrial houses as their Corporate Social Responsibility Advocacy and awareness amongst key stake holders India needs to make its public health system operative and effective. Programs are already in operation. The need is to create convergence amongst them, synergize them so that they are able to deliver their services in a more desirable way. A Commission on Social Determinants of Health (CSDH) was set up by the World Health Organization in 2005 to support action on the social determinants of health to improve the overall population’s health, refine the distribution of health, and to reduce disadvantage due to poor health. It published its final report and recommendations in
5
Inauguration of Vaatsalya Hospital, Hubli by A.PJ. Kalam
The author has varied experience in implementing public health
medicine, which is practiced mainly in urban areas, where two-thirds
services where it is needed the most. Vaatsalya is India’s first hospital
programs at the grassroot levels and has served both at the
of India’s hospitals and health centers are located. Many of the rural
network focused on tier II and tier III cities.
Government & non-government sectors. She has worked with
poor must rely on alternative forms of treatment, such as ayurvedic
Dr. Ashwin Naik, 37, and Dr. Veerendra Hiremath, 35, who grew up in
Hosmac Public Health Department as a Principal Consultant.
medicine, unani and acupuncture.
Hubli, Karanataka, went around the world and returned to set up
The next time you walk into a clinic for a cough and cold, spare a
Vaatsalya, a unique model of an affordable hospital network in the
thought for your rural brethren. Latest government data reveals that
under-served areas. “Doctors from rural districts rarely go back to
rural India is short of over 16,000 doctors, including 12,000
their roots,” says Naik. They decided to address this demand-supply
specialists.
gap.
While the situation is often attributed to the unwillingness of doctors
All healthcare stalwarts underscore the importance of making
to work in difficult areas, others say not enough is being done to
healthcare more affordable and accessible, but how many of them
incentivise the postings.
dare to address the lack of healthcare services in semi-urban and
6
rural areas? Not many! And that’s why the two doctor friends from
the state of Karnataka,” says Dr. Naik.
Vizianagarama in Andhra Pradesh. Vaatsalya's efforts to take
Karnataka Medical College (KMC), Hubli have come in the limelight
As of now, it has built 10 hospitals spread across Hubli, Gadag,
healthcare to the rural hinterland has received acclaim and it has
for pioneering Vaatsalya Healthcare Solutions.
Bijapur, Mandya, Hassan, Mysore, Gulbarga and Shimoga in
been bestowed with a slew of awards ranging from the Frost &
Explains Dr. Ashwin Naik, Founder and CEO of Vaatsalya, “While 70%
Karnataka; Vizianagaram and Narasannapetta in Andhra Pradesh.
Sullivan, India’s Excellence In Healthcare Award, 2010; Rashtriya
of India stays in villages, healthcare services are concentrated only in
The centres are similar, mid-sized hospitals with an average bed
Samman Puraskar in 2010 for Outstanding Contribution in the
urban areas. To bridge this gap and make quality healthcare services
strength of about 70. The Vizianagarama centre is the largest centre
Healthcare Sector; Sankalp Award for Social Entrepreneurship in
affordable and accessible in semi-urban and rural areas, we set up
with 122 beds, 95 of which are operational.
2009 for healthcare inclusion; LRAMP award for grassroots
Vaatsalya.”
Model la Revolution
innovation in 2008; and Business In Development Challenge India,
The idea of catering healthcare to tier II and tier III cities did not
One significant aspect of Vaatsalya is its low-cost business model,
2007.
engender immediately after graduating from KMC. Dr. Naik went to
which aims at providing high quality medical services at an affordable
According to the founders, the reason Vaatsalya has been a
the US for his Master’s degree from the University of Houston, Texas,
price. It attains its low-cost model by controlling cost to the
resounding success is not because of the range of services that it
followed by working in a leading genomics company in the US, while
maximum and by optimum utilization of resources. It uses a ‘no frills’
Dr. Hiremath graduated with a degree in Hospital Administration
approach and invests only in high quality medical equipment
from P.D. Hinduja Hospital and was working in Malaysia.
relevant to its specialties — obstretics, paediatrics, surgery and
surgery, diabetology and neuro-surgery are added to the service
“The differentiator is that we are assuredly customer centric
“In early 2004, when we both met after coming back to India, I
medicine. Moreover, it does not invest in land and building, since
portfolio. The doctors range from full-timers to visiting consultants.
compared to other hospitals. We overlay these services with a few
proposed the plan to Hiremath. He believed in it and we got started
they are provided on lease for a long-term basis or partnership with
All of them are local. Currently, all 10 centres put together witness
specialized services such as Neonatal ICU (NICU), ICU, and dialysis
with Vaatsalya,” says Dr. Naik. By the end of 2004, Vaatsalya was
existing nursing homes.
three lakh foot falls in their OPDs, annually.
centres. We don’t overcharge just because we have captive
registered.
“On the operational front, we have very high utilization of our
Marketing Strategies
customers who have nowhere else to go,” adds Dr. Madhuri, Project
Rolling out the First Centre
services which further helps reduce the cost of providing care,”
Since it is frugal with its budget for marketing, it does not engage in
Cordinator.
Setting up low-cost hospitals in semi-urban and rural areas entailed
explains Dr. Naik.
print or TV media. “In fact, we don’t have a separate marketing
Exploring Newer Business Models
multiple hurdles. Initially, the challenges were financing, seeking
The cost of setting up a new centre comes to INR two crore. Vaatsalya
department. The business development team assumes the role of
With an endeavour to reduce maternal mortality and, at the same
good clinical staff and establishing the proof of concept. For
uses two strategies for expansion: green field and brown field. The
marketing when needed. We rely on word-of-mouth and spend our
time, decrease the overall cost of pregnancy care in villages, the
financing, the duo was not sure of getting access to traditional means
ratio of green field to brown field is the same.
money wisely on health camps in and outside the hospital. We think
group is foraying into birthing centres. As of now, two centres are in
— venture capital or bank debt. “We tapped into our network of NRI
In a green field strategy, Vaatsalya rents a space suitable for a
of innovative ways to serve the community, even if it does not have
the pipeline, costing INR 10 lakh - 12 lakh per centre. The first birthing
contacts, who were from small towns and believed in the potential of
hospital, remodels it for hospital purpose, recruits doctors, and starts
any direct gains for us. Basically all our marketing activities are about
centre is coming up at Kotumachigein Gadag district and is located
Vaatsalya. They provided the initial capital to set up our first unit,”
operating. In the brown field project, it partners with an existing
gaining or reinforcing the trust customers have in us,” says Dr.
around 20 km from the Gadag town. The birthing centre is spread
informs Dr. Naik. Getting local doctors to join a start-up and the first
hospital, usually has one or more star medicos having a good practice
Renganathan.
over about 1,500 sq. ft. and will have a labour room for two
privately organized entity in that region was also an uphill task. The
and the building is owned by the doctor(s). As part of partnering, the
Vaatsalya has partnered with the Deshpande Foundation in their
deliveries. The delivery will be attended by a midwife. There is also an
duo had to initially tap into their personal networks to slowly build
hospital is rebranded as a Vaatsalya Hospital.
quest to improve healthcare in and around the Dharwad district of
antenatal programme consisting of consultations, diagnostics, and
the team. Based on this initial funding from NRIs, the first centre was
“It took Vaatsalya three years to attain breakeven for its first centre in
Karnataka. It is also coalesced with nursing homes, wherein their
medicines. The first centre is slated to be operational in the next two
rolled out in the outskirts of Hubli in 2005.
Hubli, primarily because it was still in the learning phase. Today, a
doctors join Vaatsalya’s team and help expand the services offered.
months.
What was the reason for choosing Hubli, a regional town and one of
new centre could breakeven in about eighteen months,” asserts Dr.
“This helps the doctors to focus on their clinical practice, while we
Vaatsalya has also devised a micro-insurance scheme, for which it
the fastest developing industrial hubs in Karnataka? The group felt
Renganathan.
take care of the administration part,” says Dr. Naik.
was seeking grant from the Microinsurance Innovation Facility, ILO,
that Hubli, which was devoid of good healthcare facilities, could be an
While all Vaatsalya hospitals focus on the core specialities of
The Impact
Switzerland. This insurance scheme leverages the Government’s
ideal testing ground for the innovative business model.
gynaecology, paediatrics, general surgery and general medicine,
The hospitals have made a tremendous impact. Vaatsalya opened its
affordable scheme (INR 450 for an APL family of five members and
“The first centre started with gynaecology, paediatrics, surgery and
sometimes, depending on the unmet needs of the local community,
first NICU unit in Gadag with just two beds some four years back.
INR 150 in the case of BPL family), but adding discounted out-patient
general medicine along with diabetes care and physiotherapy,”
specialized services like dialysis, intensive care units, paediatric
Today, the hospital in Gadag has 10 NICU beds, while there are about
services such as doctor consultations, diagnostics and drugs.
offers. In fact, in many centres it offers similar core services that other hospitals in that area provide.
70 NICU beds in the entire network, which are nearly full all the time.
This proposal was one of 10 finalists (only one of two from India) out
charted out an ambitious plan to spread its tentacles.
Prior to Vaatsalya, only a mission hospital in Gadag that had a few
of 100 proposals submitted internationally to the Microinsurance
So, was the expansion plan finalized before the first centre rolled out?
NICU beds served the entire district of one million population. People
Innovation Facility, ILO. With Vaatsalya failing to get the grant from
“We had put together a rough plan of establishing a network of
had to take their ailing newborns to Hubli for treatment. In addition
ILO, it plans to find other resources to launch this product.
hospitals and we did plan for growth, both within the state and
to the cost of transportation, the NICU charges in Hubli were high,
The courage to reform coupled with ambitious plans and innovative
outside, from the very beginning,” says Dr. Naik. However, zeroing in
and more importantly, the time lost in transport is critical. The first 24
ideas could surely change the healthcare landscape of rural India.
on the business model for expansion was crucial. It explored a slew of
hours of a neonate are critical, particularly when they are pre-
informs Dr. Naik. Once the first unit was commissioned, the group
models in the beginning, ranging from a daycare, OPD centre to a 25-
mature. Vaatsalya’s NICU in Gadag has saved many newborns.
The author is an expert in Quality Management and Clinical Trial
bed hospital. Eventually, it settled on the 25-40 bed hospital, which it
Similarly in Bijapur, the group started its first multi-specialty hospital
Audits. She can be reached at madhuriumeshchandra@gmail.com.
scaled up and now focuses on 70 beds in each hospital.
of the district with a dialysis centre. Prior to it, people had to travel to
To expand its network, it soon received funding from social venture
Solapur, which is 120 km from Bijapur.
capital fund ‘Aavishkaar’. Thus, it established two more units in quick
“Our charges are 25% less than Solapur and, in addition, patients save
succession. Subsequently, it raised money from Seedfund and Oasis
on other incidental expenses than when seeking care in Solapur,” says
Capital.
Dr. Renganathan.
“The initial round was to expand the concept from one location to
The Edge
two, two to three locations, and later rounds were to expand outside
7
Diabetes Day at Vaatsalya, Hubli
Vaatsalya - Hubli Hospital
Vaatsalya’s largest hospital (with 122 beds) is located at
8
rural areas? Not many! And that’s why the two doctor friends from
the state of Karnataka,” says Dr. Naik.
Vizianagarama in Andhra Pradesh. Vaatsalya's efforts to take
Karnataka Medical College (KMC), Hubli have come in the limelight
As of now, it has built 10 hospitals spread across Hubli, Gadag,
healthcare to the rural hinterland has received acclaim and it has
for pioneering Vaatsalya Healthcare Solutions.
Bijapur, Mandya, Hassan, Mysore, Gulbarga and Shimoga in
been bestowed with a slew of awards ranging from the Frost &
Explains Dr. Ashwin Naik, Founder and CEO of Vaatsalya, “While 70%
Karnataka; Vizianagaram and Narasannapetta in Andhra Pradesh.
Sullivan, India’s Excellence In Healthcare Award, 2010; Rashtriya
of India stays in villages, healthcare services are concentrated only in
The centres are similar, mid-sized hospitals with an average bed
Samman Puraskar in 2010 for Outstanding Contribution in the
urban areas. To bridge this gap and make quality healthcare services
strength of about 70. The Vizianagarama centre is the largest centre
Healthcare Sector; Sankalp Award for Social Entrepreneurship in
affordable and accessible in semi-urban and rural areas, we set up
with 122 beds, 95 of which are operational.
2009 for healthcare inclusion; LRAMP award for grassroots
Vaatsalya.”
Model la Revolution
innovation in 2008; and Business In Development Challenge India,
The idea of catering healthcare to tier II and tier III cities did not
One significant aspect of Vaatsalya is its low-cost business model,
2007.
engender immediately after graduating from KMC. Dr. Naik went to
which aims at providing high quality medical services at an affordable
According to the founders, the reason Vaatsalya has been a
the US for his Master’s degree from the University of Houston, Texas,
price. It attains its low-cost model by controlling cost to the
resounding success is not because of the range of services that it
followed by working in a leading genomics company in the US, while
maximum and by optimum utilization of resources. It uses a ‘no frills’
Dr. Hiremath graduated with a degree in Hospital Administration
approach and invests only in high quality medical equipment
from P.D. Hinduja Hospital and was working in Malaysia.
relevant to its specialties — obstretics, paediatrics, surgery and
surgery, diabetology and neuro-surgery are added to the service
“The differentiator is that we are assuredly customer centric
“In early 2004, when we both met after coming back to India, I
medicine. Moreover, it does not invest in land and building, since
portfolio. The doctors range from full-timers to visiting consultants.
compared to other hospitals. We overlay these services with a few
proposed the plan to Hiremath. He believed in it and we got started
they are provided on lease for a long-term basis or partnership with
All of them are local. Currently, all 10 centres put together witness
specialized services such as Neonatal ICU (NICU), ICU, and dialysis
with Vaatsalya,” says Dr. Naik. By the end of 2004, Vaatsalya was
existing nursing homes.
three lakh foot falls in their OPDs, annually.
centres. We don’t overcharge just because we have captive
registered.
“On the operational front, we have very high utilization of our
Marketing Strategies
customers who have nowhere else to go,” adds Dr. Madhuri, Project
Rolling out the First Centre
services which further helps reduce the cost of providing care,”
Since it is frugal with its budget for marketing, it does not engage in
Cordinator.
Setting up low-cost hospitals in semi-urban and rural areas entailed
explains Dr. Naik.
print or TV media. “In fact, we don’t have a separate marketing
Exploring Newer Business Models
multiple hurdles. Initially, the challenges were financing, seeking
The cost of setting up a new centre comes to INR two crore. Vaatsalya
department. The business development team assumes the role of
With an endeavour to reduce maternal mortality and, at the same
good clinical staff and establishing the proof of concept. For
uses two strategies for expansion: green field and brown field. The
marketing when needed. We rely on word-of-mouth and spend our
time, decrease the overall cost of pregnancy care in villages, the
financing, the duo was not sure of getting access to traditional means
ratio of green field to brown field is the same.
money wisely on health camps in and outside the hospital. We think
group is foraying into birthing centres. As of now, two centres are in
— venture capital or bank debt. “We tapped into our network of NRI
In a green field strategy, Vaatsalya rents a space suitable for a
of innovative ways to serve the community, even if it does not have
the pipeline, costing INR 10 lakh - 12 lakh per centre. The first birthing
contacts, who were from small towns and believed in the potential of
hospital, remodels it for hospital purpose, recruits doctors, and starts
any direct gains for us. Basically all our marketing activities are about
centre is coming up at Kotumachigein Gadag district and is located
Vaatsalya. They provided the initial capital to set up our first unit,”
operating. In the brown field project, it partners with an existing
gaining or reinforcing the trust customers have in us,” says Dr.
around 20 km from the Gadag town. The birthing centre is spread
informs Dr. Naik. Getting local doctors to join a start-up and the first
hospital, usually has one or more star medicos having a good practice
Renganathan.
over about 1,500 sq. ft. and will have a labour room for two
privately organized entity in that region was also an uphill task. The
and the building is owned by the doctor(s). As part of partnering, the
Vaatsalya has partnered with the Deshpande Foundation in their
deliveries. The delivery will be attended by a midwife. There is also an
duo had to initially tap into their personal networks to slowly build
hospital is rebranded as a Vaatsalya Hospital.
quest to improve healthcare in and around the Dharwad district of
antenatal programme consisting of consultations, diagnostics, and
the team. Based on this initial funding from NRIs, the first centre was
“It took Vaatsalya three years to attain breakeven for its first centre in
Karnataka. It is also coalesced with nursing homes, wherein their
medicines. The first centre is slated to be operational in the next two
rolled out in the outskirts of Hubli in 2005.
Hubli, primarily because it was still in the learning phase. Today, a
doctors join Vaatsalya’s team and help expand the services offered.
months.
What was the reason for choosing Hubli, a regional town and one of
new centre could breakeven in about eighteen months,” asserts Dr.
“This helps the doctors to focus on their clinical practice, while we
Vaatsalya has also devised a micro-insurance scheme, for which it
the fastest developing industrial hubs in Karnataka? The group felt
Renganathan.
take care of the administration part,” says Dr. Naik.
was seeking grant from the Microinsurance Innovation Facility, ILO,
that Hubli, which was devoid of good healthcare facilities, could be an
While all Vaatsalya hospitals focus on the core specialities of
The Impact
Switzerland. This insurance scheme leverages the Government’s
ideal testing ground for the innovative business model.
gynaecology, paediatrics, general surgery and general medicine,
The hospitals have made a tremendous impact. Vaatsalya opened its
affordable scheme (INR 450 for an APL family of five members and
“The first centre started with gynaecology, paediatrics, surgery and
sometimes, depending on the unmet needs of the local community,
first NICU unit in Gadag with just two beds some four years back.
INR 150 in the case of BPL family), but adding discounted out-patient
general medicine along with diabetes care and physiotherapy,”
specialized services like dialysis, intensive care units, paediatric
Today, the hospital in Gadag has 10 NICU beds, while there are about
services such as doctor consultations, diagnostics and drugs.
offers. In fact, in many centres it offers similar core services that other hospitals in that area provide.
70 NICU beds in the entire network, which are nearly full all the time.
This proposal was one of 10 finalists (only one of two from India) out
charted out an ambitious plan to spread its tentacles.
Prior to Vaatsalya, only a mission hospital in Gadag that had a few
of 100 proposals submitted internationally to the Microinsurance
So, was the expansion plan finalized before the first centre rolled out?
NICU beds served the entire district of one million population. People
Innovation Facility, ILO. With Vaatsalya failing to get the grant from
“We had put together a rough plan of establishing a network of
had to take their ailing newborns to Hubli for treatment. In addition
ILO, it plans to find other resources to launch this product.
hospitals and we did plan for growth, both within the state and
to the cost of transportation, the NICU charges in Hubli were high,
The courage to reform coupled with ambitious plans and innovative
outside, from the very beginning,” says Dr. Naik. However, zeroing in
and more importantly, the time lost in transport is critical. The first 24
ideas could surely change the healthcare landscape of rural India.
on the business model for expansion was crucial. It explored a slew of
hours of a neonate are critical, particularly when they are pre-
informs Dr. Naik. Once the first unit was commissioned, the group
models in the beginning, ranging from a daycare, OPD centre to a 25-
mature. Vaatsalya’s NICU in Gadag has saved many newborns.
The author is an expert in Quality Management and Clinical Trial
bed hospital. Eventually, it settled on the 25-40 bed hospital, which it
Similarly in Bijapur, the group started its first multi-specialty hospital
Audits. She can be reached at madhuriumeshchandra@gmail.com.
scaled up and now focuses on 70 beds in each hospital.
of the district with a dialysis centre. Prior to it, people had to travel to
To expand its network, it soon received funding from social venture
Solapur, which is 120 km from Bijapur.
capital fund ‘Aavishkaar’. Thus, it established two more units in quick
“Our charges are 25% less than Solapur and, in addition, patients save
succession. Subsequently, it raised money from Seedfund and Oasis
on other incidental expenses than when seeking care in Solapur,” says
Capital.
Dr. Renganathan.
“The initial round was to expand the concept from one location to
The Edge
two, two to three locations, and later rounds were to expand outside
7
Diabetes Day at Vaatsalya, Hubli
Vaatsalya - Hubli Hospital
Vaatsalya’s largest hospital (with 122 beds) is located at
8
Telehealth: The Reinvention of Healthcare TeleHealth:
Dr. K. Ganapathy, President Elect — Indian Society of Stereotactic and Functional Neurosurgery, envisions a future Reinvention of Healthcare where The new age technology and traditional medical practices join hands to meet India's unique healthcare needs.
even have to piggy back, we can leap frog! Today there are about 575 telemedicine units located in suburban and rural India and about
interactivity of a conventional person-to-person meeting are all there
seventy five telemedicine units functioning in tertiary care hospitals.
– excepting that the patient and doctor are hundreds (or even
However, about 20 units have contributed to 80% of the 700,000
thousands) of miles away. Issues can be addressed and multiple
teleconsults that have now taken place. With 70% of the population
opinions can be obtained from all around the globe quickly. High-
residing in rural areas and having access to less than 20% of the
speed networks and multimedia servers allow medical professionals
available doctors, which itself is only 1:2000, telehealth appears to
to exchange many types of healthcare information
be the only way to bridge the urban-rural health divide. The India of
The necessity of home telecare systems is growing due to an increase
tomorrow will be different economically, socially and culturally.
in chronic diseases, aged population (living alone) and medical
Tomorrow’s slogan may even be ‘Roti, kapada, makan aur
expenses; a video visit to the patient’s home will be more cost
bandwidth!’ Today the teledensity of India is almost 62% (103% in
effective. Tabletop sensors can monitor blood pressure, cardiac
metros and 20% even in rural India). Obviously it is easier to set up an
rhythms, blood sugar, and other parameters – signs that can provide
excellent telecommunication infrastructure, than to place thousands
an immediate objective assessment. A homebound patient could use
of medical specialists in suburban and rural India.
a digital camera to take a picture of his post operative wound or bed
Telemedicine can bridge the gap only when telediagnosis is followed
sore and upload the photo directly to his medical record via e-mail for
up by appropriate referrals for investigations and subsequent
his surgeon to see. Intelligent telephones will monitor vital functions
management. To achieve this, universal insurance is an absolute
from thousands of miles away. A video surveillance unit can watch an
necessity. Telemedicine patients can ensure that the care they get is
old man take his pills, look at his bed sore, and even ensure that the
the care they want. Empowered patients will embrace location-
refrigerator and pantry are adequately stocked. Implanted devices
independent care, thus imposing global standards
will directly relay vital parameters through satellite telephones,
One also has to accept the fact that if it was a choice between having
enabling monitoring from a distance. The author has personally
one’s illness cured through a remote teleconsultation versus having
directed 17 electronic house visits where non-medical personnel
your hand held by an extremely sympathetic but ignorant doctor,
have taken a webcam enabled laptop with a high speed wireless data
most would prefer the former. The ideal scenario is where the urban
card and connected a patient from their house to a specialist via video
elitist super specialist virtually wipes a tear of his rural patient. Many
conferencing.
countries have started addressing these issues by starting courses on
Technology differentiates the victors from the vanquished, and the
ethics and humanism in conjunction with the use of hi-tech gizmos.
“Mr. Watson, come here – I want to see you.” said Alexander Graham
What is the relevance of telehealth in India? Well, the Indian
Bell on March 20, 1876, when he inadvertently spilled battery acid on
healthcare industry is one of the biggest industries in the world, with
haves from the have-nots. A good image doesn’t do much good if it
Indian doctors all over the world excel because of their innate ability
himself, while making the world’s first telephone call. Little did Bell
every sixth individual on the planet being a consumer. To expect a
exists in only one place. If a picture is worth a thousand words, then a
to combine professionalism with compassion. Pastoral as well as
realize that this was also the world’s first telemedical consultation.
fledgling, different method of healthcare delivery (i.e. telemedicine)
picture accompanied with hypertext links and a sound file (e.g. a
technical skills, and art as well as science is required. This has to be
We have come a long way since then.
to have a significant effective impact on the healthcare scenario very
good web page) must be worth several thousand. Telemedicine gives
taught in medical school now so that when telemedicine is
Telemedicine is a method, by which patients can be examined,
soon is to turn a Nelson’s eye to the stark realities. In the last eleven
equal education opportunities to doctors in big cities or small towns.
commonplace, it will not be forgotten.
investigated, monitored and treated with the patient and the doctor
years, thanks to the relentless work done by several groups of
Web-based medical education will become one of the most
Issues in implementing telemedicine include acceptance of the
physically located in different places. ‘Tele’ is a Greek word meaning
committed champions of telemedicine spearheaded by Apollo
successful and visible forms of telemedicine. It will affect every
modality by society, patients, family physicians, specialists,
‘distance’ and ‘mederi’ is a Latin word meaning ‘to heal’. In
Hospitals, a beginning has been made.
dimension of the relationship between doctors, patients, hospitals,
administrators and the government; designing cost effective
Telemedicine one transfers the expertise, not the patient. A major
The Indian Space Research Organization (ISRO), SGPGI in Lucknow,
goal of telemedicine is to eliminate unnecessary travelling of patients
SRMC in Chennai, AIMS in Kochi, and Narayana Hrudayalaya, among
and their escorts. Image acquisition, storage, display and processing,
others, have all contributed to this.
and image transfer form the basis of telemedicine. While
The effective delivery of telehealth services will require
telemedicine has been developing for the last two decades, in the last
establishment of standards in clinical practice, privacy,
ten years this growth has been exponential. High quality medical
confidentiality, telecommunications, record keeping and ethical
services can be brought to the patient, rather than transporting the
behaviour. Telehealth technical standards should be assessed on
patient to distant and expensive tertiary care centres. Images are
requirements covering access to patient data, availability,
acquired, stored and forwarded to the specialist centre in a
encryption, guaranteed reliability, interpretability, legal obligations,
health plans, employers, the government and other entities involved
appropriate technology, connectivity, hardware and software,
in healthcare.
standardising, certifying, authenticating and registering
India, though considered a developing country, is a paradox. We
telemedicine units so that minimum safe standards are uniformly
produce and launch our own satellites; there has been an
adopted; running short term courses to train the trainers and the
unprecedented growth and development in Information Technology
users, passing a telehealth act for India, payment to teleconsultants
in India; we no longer has to follow the advanced countries, nor do we
to make the scheme attractive and viable; getting grants, subsidies and waivers to introduce telemedicine in suburban and rural areas, getting Indian telemedicine units recognized by other countries so that we can provide overseas teleconsults for revenue generation, which can be used to subsidize rural telemedicine; and introducing
compressed format and digital manipulation can be done by the
limiting access to authorised users, multimedia applications,
teleconsultant at the remote end. Immediate electronic access to
performance levels and security, and must be an ongoing process.
specialists saves time, costs and reduces the enormous physical effort
Interoperability of systems, compatibility and scalability are an
Questions are often raised – and rightly so – whether telemedicine is
normally required of a patient in travelling long distances. Text,
absolute must. All equipment should meet international DICOM
the result of a technology push rather than clinical pull. Information
reports, voice data, images and video can be transferred. Through
standards. Privacy, authentication, authorization, certification,
Technology has changed, is changing, and will continue to change the
cost effective video tele-conferencing, expertise available in the cities
digital signature standardization, equipment liability, digital
delivery of healthcare, worldwide. Humankind is witnessing a
can be transferred to rural areas. Ultimately standards of healthcare
compression and constant benchmarking is required.
in rural areas will be increased, and costs reduced. Preliminary trials
Today’s video conferencing systems are so sophisticated that even
with telemedicine have revealed high levels of satisfaction among
four different groups of people can be viewed simultaneously on a
patients, general practitioners, specialists and technologists.
9
unbelievable clarity. Participants remain in view at all times making it literally a face-to-face meeting. The spontaneity, naturalness, and
giant screen. Minute facial expressions can be discerned with
telemedicine in the medical/IT curriculum.
growth in technology unprecedented in the annals of history. Hospitals of the future will draw patients from all over the world, without geographical limitations. Telemedicine’s champions will have to work hard to make sure that
10
Telehealth: The Reinvention of Healthcare TeleHealth:
Dr. K. Ganapathy, President Elect — Indian Society of Stereotactic and Functional Neurosurgery, envisions a future Reinvention of Healthcare where The new age technology and traditional medical practices join hands to meet India's unique healthcare needs.
even have to piggy back, we can leap frog! Today there are about 575 telemedicine units located in suburban and rural India and about
interactivity of a conventional person-to-person meeting are all there
seventy five telemedicine units functioning in tertiary care hospitals.
– excepting that the patient and doctor are hundreds (or even
However, about 20 units have contributed to 80% of the 700,000
thousands) of miles away. Issues can be addressed and multiple
teleconsults that have now taken place. With 70% of the population
opinions can be obtained from all around the globe quickly. High-
residing in rural areas and having access to less than 20% of the
speed networks and multimedia servers allow medical professionals
available doctors, which itself is only 1:2000, telehealth appears to
to exchange many types of healthcare information
be the only way to bridge the urban-rural health divide. The India of
The necessity of home telecare systems is growing due to an increase
tomorrow will be different economically, socially and culturally.
in chronic diseases, aged population (living alone) and medical
Tomorrow’s slogan may even be ‘Roti, kapada, makan aur
expenses; a video visit to the patient’s home will be more cost
bandwidth!’ Today the teledensity of India is almost 62% (103% in
effective. Tabletop sensors can monitor blood pressure, cardiac
metros and 20% even in rural India). Obviously it is easier to set up an
rhythms, blood sugar, and other parameters – signs that can provide
excellent telecommunication infrastructure, than to place thousands
an immediate objective assessment. A homebound patient could use
of medical specialists in suburban and rural India.
a digital camera to take a picture of his post operative wound or bed
Telemedicine can bridge the gap only when telediagnosis is followed
sore and upload the photo directly to his medical record via e-mail for
up by appropriate referrals for investigations and subsequent
his surgeon to see. Intelligent telephones will monitor vital functions
management. To achieve this, universal insurance is an absolute
from thousands of miles away. A video surveillance unit can watch an
necessity. Telemedicine patients can ensure that the care they get is
old man take his pills, look at his bed sore, and even ensure that the
the care they want. Empowered patients will embrace location-
refrigerator and pantry are adequately stocked. Implanted devices
independent care, thus imposing global standards
will directly relay vital parameters through satellite telephones,
One also has to accept the fact that if it was a choice between having
enabling monitoring from a distance. The author has personally
one’s illness cured through a remote teleconsultation versus having
directed 17 electronic house visits where non-medical personnel
your hand held by an extremely sympathetic but ignorant doctor,
have taken a webcam enabled laptop with a high speed wireless data
most would prefer the former. The ideal scenario is where the urban
card and connected a patient from their house to a specialist via video
elitist super specialist virtually wipes a tear of his rural patient. Many
conferencing.
countries have started addressing these issues by starting courses on
Technology differentiates the victors from the vanquished, and the
ethics and humanism in conjunction with the use of hi-tech gizmos.
“Mr. Watson, come here – I want to see you.” said Alexander Graham
What is the relevance of telehealth in India? Well, the Indian
Bell on March 20, 1876, when he inadvertently spilled battery acid on
healthcare industry is one of the biggest industries in the world, with
haves from the have-nots. A good image doesn’t do much good if it
Indian doctors all over the world excel because of their innate ability
himself, while making the world’s first telephone call. Little did Bell
every sixth individual on the planet being a consumer. To expect a
exists in only one place. If a picture is worth a thousand words, then a
to combine professionalism with compassion. Pastoral as well as
realize that this was also the world’s first telemedical consultation.
fledgling, different method of healthcare delivery (i.e. telemedicine)
picture accompanied with hypertext links and a sound file (e.g. a
technical skills, and art as well as science is required. This has to be
We have come a long way since then.
to have a significant effective impact on the healthcare scenario very
good web page) must be worth several thousand. Telemedicine gives
taught in medical school now so that when telemedicine is
Telemedicine is a method, by which patients can be examined,
soon is to turn a Nelson’s eye to the stark realities. In the last eleven
equal education opportunities to doctors in big cities or small towns.
commonplace, it will not be forgotten.
investigated, monitored and treated with the patient and the doctor
years, thanks to the relentless work done by several groups of
Web-based medical education will become one of the most
Issues in implementing telemedicine include acceptance of the
physically located in different places. ‘Tele’ is a Greek word meaning
committed champions of telemedicine spearheaded by Apollo
successful and visible forms of telemedicine. It will affect every
modality by society, patients, family physicians, specialists,
‘distance’ and ‘mederi’ is a Latin word meaning ‘to heal’. In
Hospitals, a beginning has been made.
dimension of the relationship between doctors, patients, hospitals,
administrators and the government; designing cost effective
Telemedicine one transfers the expertise, not the patient. A major
The Indian Space Research Organization (ISRO), SGPGI in Lucknow,
goal of telemedicine is to eliminate unnecessary travelling of patients
SRMC in Chennai, AIMS in Kochi, and Narayana Hrudayalaya, among
and their escorts. Image acquisition, storage, display and processing,
others, have all contributed to this.
and image transfer form the basis of telemedicine. While
The effective delivery of telehealth services will require
telemedicine has been developing for the last two decades, in the last
establishment of standards in clinical practice, privacy,
ten years this growth has been exponential. High quality medical
confidentiality, telecommunications, record keeping and ethical
services can be brought to the patient, rather than transporting the
behaviour. Telehealth technical standards should be assessed on
patient to distant and expensive tertiary care centres. Images are
requirements covering access to patient data, availability,
acquired, stored and forwarded to the specialist centre in a
encryption, guaranteed reliability, interpretability, legal obligations,
health plans, employers, the government and other entities involved
appropriate technology, connectivity, hardware and software,
in healthcare.
standardising, certifying, authenticating and registering
India, though considered a developing country, is a paradox. We
telemedicine units so that minimum safe standards are uniformly
produce and launch our own satellites; there has been an
adopted; running short term courses to train the trainers and the
unprecedented growth and development in Information Technology
users, passing a telehealth act for India, payment to teleconsultants
in India; we no longer has to follow the advanced countries, nor do we
to make the scheme attractive and viable; getting grants, subsidies and waivers to introduce telemedicine in suburban and rural areas, getting Indian telemedicine units recognized by other countries so that we can provide overseas teleconsults for revenue generation, which can be used to subsidize rural telemedicine; and introducing
compressed format and digital manipulation can be done by the
limiting access to authorised users, multimedia applications,
teleconsultant at the remote end. Immediate electronic access to
performance levels and security, and must be an ongoing process.
specialists saves time, costs and reduces the enormous physical effort
Interoperability of systems, compatibility and scalability are an
Questions are often raised – and rightly so – whether telemedicine is
normally required of a patient in travelling long distances. Text,
absolute must. All equipment should meet international DICOM
the result of a technology push rather than clinical pull. Information
reports, voice data, images and video can be transferred. Through
standards. Privacy, authentication, authorization, certification,
Technology has changed, is changing, and will continue to change the
cost effective video tele-conferencing, expertise available in the cities
digital signature standardization, equipment liability, digital
delivery of healthcare, worldwide. Humankind is witnessing a
can be transferred to rural areas. Ultimately standards of healthcare
compression and constant benchmarking is required.
in rural areas will be increased, and costs reduced. Preliminary trials
Today’s video conferencing systems are so sophisticated that even
with telemedicine have revealed high levels of satisfaction among
four different groups of people can be viewed simultaneously on a
patients, general practitioners, specialists and technologists.
9
unbelievable clarity. Participants remain in view at all times making it literally a face-to-face meeting. The spontaneity, naturalness, and
giant screen. Minute facial expressions can be discerned with
telemedicine in the medical/IT curriculum.
growth in technology unprecedented in the annals of history. Hospitals of the future will draw patients from all over the world, without geographical limitations. Telemedicine’s champions will have to work hard to make sure that
10
investment decisions are made with respect to the future, not the past. ‘Easy to use’ should be a prerequisite in the selection of equipment and systems for telemedicine. User-friendly, it must enhance, not hinder the process of healthcare. Like any revolutionary force, telemedicine will encounter considerable resistance as it moves from the fringe to the mainstream of healthcare over the next decade. Deciding how to pay for it, who is qualified to do it and how to assess its quality are already major issues. Teleconsultation is not a new medical service but a new way of delivering a consultation. Previous generations of physicians will find the new concepts of telemedicine unfathomable – to many it may sound blasphemous. What will happen to the individual doctor-patient relationship considered sacrosanct for centuries? Is it not sacrilegious and
world order a drastic change toward a better world of health. Major
bordering on heresy to treat a patient in another continent without
paradigm shifts will emerge from ‘hospital-centred healthcare’ to
knowing his family and cultural background? Yes, say the diehards.
‘citizen-centred health’ and from ‘treatment’ to ‘prevention’.
No, say the technology enthusiasts. The first generation of
However, it must be stressed that the ultimate success or failure of
telemedicine enthusiasts should not forget that technology should
implementation of telemedicine will not be due to technological
be used as a support to treat patients, not viewed as the goal itself.
glitches, or lack of funding, or even red tapism. It will be due to
The challenge today is not confined to overcoming technological
human inertia, lack of involvement, commitment and the passionate
barriers, insurmountable though they may appear; it is true that
burning desire so necessary to break traditional barriers. To
available technology still has scope for improvement. Rather, the
paraphrase Don Quixote in ‘The Man of La Mancha’: “To reach the
challenge is why, where and how to implement which technology and
unreachable star. This is my quest – To follow that star, no matter how
at what cost. A needs assessment is critical. However, technology can
hopeless, no matter how far.” History has shown time and again that
only treat diseases. To treat sick people, empathy and understanding
what is unreachable today is reachable tomorrow.
is needed.
Though I do not wish to conclude on a cynical note, eleven years of
The takeoff problems facing telemedicine are legion. It is our dream
involvement with telehealth has taught me that we will never ever achieve that critical mass essential for a successful takeoff unless we have an answer to the question ‘WiiiFM’? It is not Wi Max or Wi-Fi but ‘WiiiFM’ that will ultimately determine whether telemedicine will be incorporated. ‘What is in it For Me?’ – when every stakeholder understands the WiiiFM quotient, only then will there be an involvement, a dedication and a passion which alone will further the growth of telemedicine. It is not technology, nor regulations (or the lack of it), nor even paucity of funds, but purely human inertia which is now standing in the way. The author is the former Secretary and President of the Neurological Society of India, and former Secretary General of the Asian
and hope that within the next few years there will be telemedicine
Australasian Society of Neurological Surgery. He may be contacted at
units in most parts of suburban and rural India. Eventually, no Indian
drganapathy@apollohospitals.com.
will be deprived of a specialist consultation wherever he or she is – consultation will soon be only a mouse click away! For this to happen, a critical mass must be reached. What is required is not implementing better technology and getting funds, but changing the mindset of the people involved. Awareness should permeate throughout society. Real growth will take place only when society realizes that distance is meaningless today, and that telemedicine can bridge the gap between the haves and the have nots, at least insofar as access to healthcare is concerned. There are critics who believe telemedicine is a waste of precious resources that are needed urgently for higher health priorities. Telemedicine, however, is a part of the wider phenomenon of information, and information is arguably the strongest change agent. Telemedicine is a part of this great change. Information brings to the
11
investment decisions are made with respect to the future, not the past. ‘Easy to use’ should be a prerequisite in the selection of equipment and systems for telemedicine. User-friendly, it must enhance, not hinder the process of healthcare. Like any revolutionary force, telemedicine will encounter considerable resistance as it moves from the fringe to the mainstream of healthcare over the next decade. Deciding how to pay for it, who is qualified to do it and how to assess its quality are already major issues. Teleconsultation is not a new medical service but a new way of delivering a consultation. Previous generations of physicians will find the new concepts of telemedicine unfathomable – to many it may sound blasphemous. What will happen to the individual doctor-patient relationship considered sacrosanct for centuries? Is it not sacrilegious and
world order a drastic change toward a better world of health. Major
bordering on heresy to treat a patient in another continent without
paradigm shifts will emerge from ‘hospital-centred healthcare’ to
knowing his family and cultural background? Yes, say the diehards.
‘citizen-centred health’ and from ‘treatment’ to ‘prevention’.
No, say the technology enthusiasts. The first generation of
However, it must be stressed that the ultimate success or failure of
telemedicine enthusiasts should not forget that technology should
implementation of telemedicine will not be due to technological
be used as a support to treat patients, not viewed as the goal itself.
glitches, or lack of funding, or even red tapism. It will be due to
The challenge today is not confined to overcoming technological
human inertia, lack of involvement, commitment and the passionate
barriers, insurmountable though they may appear; it is true that
burning desire so necessary to break traditional barriers. To
available technology still has scope for improvement. Rather, the
paraphrase Don Quixote in ‘The Man of La Mancha’: “To reach the
challenge is why, where and how to implement which technology and
unreachable star. This is my quest – To follow that star, no matter how
at what cost. A needs assessment is critical. However, technology can
hopeless, no matter how far.” History has shown time and again that
only treat diseases. To treat sick people, empathy and understanding
what is unreachable today is reachable tomorrow.
is needed.
Though I do not wish to conclude on a cynical note, eleven years of
The takeoff problems facing telemedicine are legion. It is our dream
involvement with telehealth has taught me that we will never ever achieve that critical mass essential for a successful takeoff unless we have an answer to the question ‘WiiiFM’? It is not Wi Max or Wi-Fi but ‘WiiiFM’ that will ultimately determine whether telemedicine will be incorporated. ‘What is in it For Me?’ – when every stakeholder understands the WiiiFM quotient, only then will there be an involvement, a dedication and a passion which alone will further the growth of telemedicine. It is not technology, nor regulations (or the lack of it), nor even paucity of funds, but purely human inertia which is now standing in the way. The author is the former Secretary and President of the Neurological Society of India, and former Secretary General of the Asian
and hope that within the next few years there will be telemedicine
Australasian Society of Neurological Surgery. He may be contacted at
units in most parts of suburban and rural India. Eventually, no Indian
drganapathy@apollohospitals.com.
will be deprived of a specialist consultation wherever he or she is – consultation will soon be only a mouse click away! For this to happen, a critical mass must be reached. What is required is not implementing better technology and getting funds, but changing the mindset of the people involved. Awareness should permeate throughout society. Real growth will take place only when society realizes that distance is meaningless today, and that telemedicine can bridge the gap between the haves and the have nots, at least insofar as access to healthcare is concerned. There are critics who believe telemedicine is a waste of precious resources that are needed urgently for higher health priorities. Telemedicine, however, is a part of the wider phenomenon of information, and information is arguably the strongest change agent. Telemedicine is a part of this great change. Information brings to the
11
Our villages lie both ignored and untapped.
Taking Healthcare Taking Healthcare beyond the Metros
Dr. Divya Pottath we've gone wrong, beyond theignored Metros Our villages lie both and untapped. Dr. Divya Pottath maps maps where where we've gone wrong, and gives us solutions to make amends. and gives us solutions to make amends.
consumables etc.
from secondary care hospitals whereas those in the metros are
·
Government incentives
mainly from tertiary care hospitals.
·
Lower cost of living
Apart from this, there are other growth impetuses available in the
These basic criteria served as the first impetus for IT companies and
metros that make them a more favoured investment ground for
manufacturing industries to set up their units in tier II and III cities.
healthcare; some of which are listed below:
High paying IT jobs and the volume of jobs available in manufacturing
·
Denser population
industries led to migration of people from the bigger cities to these
·
Greater paying capacity
smaller, lesser developed areas. But to retain this population and to
·
Easily and economically available advanced technology
incentivise highly skilled personnel, it was important to create a self
·
Easily available manpower (both skilled and unskilled)
sustaining society with good education, healthcare and recreational
·
Better organized healthcare delivery system
facilities. Thus healthcare in these cities saw a new dimension beyond
·
Better insurance penetration
secondary care with the entry of tertiary care healthcare facilities and corporate hospital groups providing quality healthcare services comparable to those provided in the metropolitan cities. A city thus fortified with industries and these support amenities will progress towards overall development and growth and become attractive grounds for investment (national and foreign investors); thus making it a self sustaining growth cycle which was incentivised by the visionaries from the public and private sectors of all industries, including healthcare. Although the wheel of fortune for tier II and III cities has begun to turn, the challenge still remains to bridge the gap between the metropolitans and these cities with respect to the portfolio and quality of services being provided. The Indian President recently announced that, “A strong and
the tier II cities. This has currently become the target market for big
The table below shows the difference between healthcare resources
prosperous nation needs healthy and educated citizens.” With 71% of
(Apollo Group, Fortis Healthcare, Manipal Group, CARE Hospitals
available in the metros as compared to the rest of India:
India’s citizens residing in rural areas, the most obvious approach is to
etc.) and medium sized (targeting particular states e.g. Kamineni
The global standard for number of hospital beds per 1000 population
redistribute the concentrated resources from the remaining 29% and
Hospital in Andhra Pradesh) healthcare players. The market also saw
is 4 (As per the WHO) and India falls far behind this standard at 0.9.
to create region-specific opportunities for new means of
the inception and rapid growth of a novel healthcare model
Some of the metropolitan cities, however, come considerably close to
development. Good health and education go hand in hand, where
consisting of a chain of hospitals; called ‘Vaatsalya Healthcare’,
this number with Hyderabad being the closest at 3.17; followed
one cannot increase its expanse without the help of the other. The
catering only to the Tier II and III cities with an aim to bridge the
closely by Bangalore at 3, which is comparable to China's average of 3.
term ‘functional literacy’ is fast gaining popularity because of its
disparity between the services provided in these cities and the
practical and effective approach in making an individual self reliant,
metros. Their mission is to bring ‘Affordable, Accessible and
progressive and aware.
Appropriate’ healthcare services to under-served areas of the
Indian
Total Hospital Beds
Beds per 1000 pop
1,063,271
0.9 2.13
NCR
37,602
Bangalore and Hyderabad. Another city that is fast catching up to
This market penetration distal to the metropolitans has been
Mumbai
35,595
1.75
Hyderabad Bangalore
23,993 23.,419
3.17 3
make it to this list is Pune. According to the classification by Knight
manoeuvred by the development in other sectors such as electricity,
Frank, India; which is based primarily on information technology (IT)
water, sanitation, education, connectivity, infrastructure and
Kolkata
20,938
1.29
progress and real estate market growth , these are the tier I cities as
technology. The parallel growth in these sectors not only form the
Chnnai
20,508
2.52
they are most favoured by investors in all industry sectors, especially
support pillars to bring healthcare services as close to people's
Total Metropolitan
162,055
2.3
Rest of India
901,216
0.8
IT and Real Estate (occupying 60% of the total real estate space). The
doorsteps as possible, but also helps in attaining basic quality
tier II cities are those which have seen a significant and steep growth
standards of healthcare delivery. For example, preventive healthcare
in IT and real estate space in the past few years, while tier III are those
initiatives will be successful and effective only when people are
The other metros are also above the Indian average of 0.9 beds/1000
that are trying to emerge as IT hubs. Similar trends of growth have
provided with clean drinking water, adequate nutritious food and
population, with the total average of the metropolitan cities being 2.3
been observed in the healthcare industry too. The liberalisation of
sanitation facilities.
investors has seen a saturation of the market (in terms of services and
become more lucrative than tier I. The reasons for the
This disparity between the distribution of hospital beds shows that
same have been attributed to the following:
15% of the beds are available among 6% of the population. This also
tax holidays for hospitals with more than 100 beds) in the tier II and
·
Affordability of space
tier III cities, a steep rise of such projects was observed, specifically in
·
Cheaper Resources – manpower, materials,
premises
contention here is the distribution of sub-optimal resources and citizens of a country and should be distributed as equally as possible. The need for channelizing healthcare services towards the tier II and III cities is further detailed below: ·
Self reliance Healthcare services, both basic and specialized, should be made available and accessible for the population living in cities capable of providing quality services in order to render them self reliant.
·
Double burden of disease Non-communicable – mostly the population working in the corporate sector who may be migrants or original inhabitants Therefore it will be challenging for the existing secondary care institutions to serve the requirements of the entire
beds/1000 population as against the rest of India at 0.8 beds/1000
In the past decade or so, the tier II and III cities have
Availability of space in terms of land or ready commercial
essence however, these cities too need to strengthen their healthcare system to match global standards. But the point of
population (lower than the Indian average).
policies to make investments in healthcare more lucrative for private
projects (allocation of Socio-Economic Zones for healthcare projects,
13
Region
country.
·
Saturation of healthcare services in the metros is only relative because of the polarity between them and the rest of India. In
Communicable – mainly the lower socioeconomic strata
The metropolitan cities in India are Mumbai, Chennai, Kolkata, Delhi,
government further incentivised the penetration of healthcare
The Need – Tier II & III
basic healthcare; where the latter is considered to be the right of the
The Gap between Metros and Tier II & III
space) with respect to the metros. Once this was achieved and the
A metro’s advantages also serve as challenges to improve penetration of healthcare delivery in the tier II and III cities.
implies that investments in the healthcare industry as a whole (including diagnostics, day care, medical insurance, medical technology etc.) are concentrated or directed more towards the same 6% metropolitan population. Also, the total beds in the tier II and III cities mainly comprise of those
14
Our villages lie both ignored and untapped.
Taking Healthcare Taking Healthcare beyond the Metros
Dr. Divya Pottath we've gone wrong, beyond theignored Metros Our villages lie both and untapped. Dr. Divya Pottath maps maps where where we've gone wrong, and gives us solutions to make amends. and gives us solutions to make amends.
consumables etc.
from secondary care hospitals whereas those in the metros are
·
Government incentives
mainly from tertiary care hospitals.
·
Lower cost of living
Apart from this, there are other growth impetuses available in the
These basic criteria served as the first impetus for IT companies and
metros that make them a more favoured investment ground for
manufacturing industries to set up their units in tier II and III cities.
healthcare; some of which are listed below:
High paying IT jobs and the volume of jobs available in manufacturing
·
Denser population
industries led to migration of people from the bigger cities to these
·
Greater paying capacity
smaller, lesser developed areas. But to retain this population and to
·
Easily and economically available advanced technology
incentivise highly skilled personnel, it was important to create a self
·
Easily available manpower (both skilled and unskilled)
sustaining society with good education, healthcare and recreational
·
Better organized healthcare delivery system
facilities. Thus healthcare in these cities saw a new dimension beyond
·
Better insurance penetration
secondary care with the entry of tertiary care healthcare facilities and corporate hospital groups providing quality healthcare services comparable to those provided in the metropolitan cities. A city thus fortified with industries and these support amenities will progress towards overall development and growth and become attractive grounds for investment (national and foreign investors); thus making it a self sustaining growth cycle which was incentivised by the visionaries from the public and private sectors of all industries, including healthcare. Although the wheel of fortune for tier II and III cities has begun to turn, the challenge still remains to bridge the gap between the metropolitans and these cities with respect to the portfolio and quality of services being provided. The Indian President recently announced that, “A strong and
the tier II cities. This has currently become the target market for big
The table below shows the difference between healthcare resources
prosperous nation needs healthy and educated citizens.” With 71% of
(Apollo Group, Fortis Healthcare, Manipal Group, CARE Hospitals
available in the metros as compared to the rest of India:
India’s citizens residing in rural areas, the most obvious approach is to
etc.) and medium sized (targeting particular states e.g. Kamineni
The global standard for number of hospital beds per 1000 population
redistribute the concentrated resources from the remaining 29% and
Hospital in Andhra Pradesh) healthcare players. The market also saw
is 4 (As per the WHO) and India falls far behind this standard at 0.9.
to create region-specific opportunities for new means of
the inception and rapid growth of a novel healthcare model
Some of the metropolitan cities, however, come considerably close to
development. Good health and education go hand in hand, where
consisting of a chain of hospitals; called ‘Vaatsalya Healthcare’,
this number with Hyderabad being the closest at 3.17; followed
one cannot increase its expanse without the help of the other. The
catering only to the Tier II and III cities with an aim to bridge the
closely by Bangalore at 3, which is comparable to China's average of 3.
term ‘functional literacy’ is fast gaining popularity because of its
disparity between the services provided in these cities and the
practical and effective approach in making an individual self reliant,
metros. Their mission is to bring ‘Affordable, Accessible and
progressive and aware.
Appropriate’ healthcare services to under-served areas of the
Indian
Total Hospital Beds
Beds per 1000 pop
1,063,271
0.9 2.13
NCR
37,602
Bangalore and Hyderabad. Another city that is fast catching up to
This market penetration distal to the metropolitans has been
Mumbai
35,595
1.75
Hyderabad Bangalore
23,993 23.,419
3.17 3
make it to this list is Pune. According to the classification by Knight
manoeuvred by the development in other sectors such as electricity,
Frank, India; which is based primarily on information technology (IT)
water, sanitation, education, connectivity, infrastructure and
Kolkata
20,938
1.29
progress and real estate market growth , these are the tier I cities as
technology. The parallel growth in these sectors not only form the
Chnnai
20,508
2.52
they are most favoured by investors in all industry sectors, especially
support pillars to bring healthcare services as close to people's
Total Metropolitan
162,055
2.3
Rest of India
901,216
0.8
IT and Real Estate (occupying 60% of the total real estate space). The
doorsteps as possible, but also helps in attaining basic quality
tier II cities are those which have seen a significant and steep growth
standards of healthcare delivery. For example, preventive healthcare
in IT and real estate space in the past few years, while tier III are those
initiatives will be successful and effective only when people are
The other metros are also above the Indian average of 0.9 beds/1000
that are trying to emerge as IT hubs. Similar trends of growth have
provided with clean drinking water, adequate nutritious food and
population, with the total average of the metropolitan cities being 2.3
been observed in the healthcare industry too. The liberalisation of
sanitation facilities.
investors has seen a saturation of the market (in terms of services and
become more lucrative than tier I. The reasons for the
This disparity between the distribution of hospital beds shows that
same have been attributed to the following:
15% of the beds are available among 6% of the population. This also
tax holidays for hospitals with more than 100 beds) in the tier II and
·
Affordability of space
tier III cities, a steep rise of such projects was observed, specifically in
·
Cheaper Resources – manpower, materials,
premises
contention here is the distribution of sub-optimal resources and citizens of a country and should be distributed as equally as possible. The need for channelizing healthcare services towards the tier II and III cities is further detailed below: ·
Self reliance Healthcare services, both basic and specialized, should be made available and accessible for the population living in cities capable of providing quality services in order to render them self reliant.
·
Double burden of disease Non-communicable – mostly the population working in the corporate sector who may be migrants or original inhabitants Therefore it will be challenging for the existing secondary care institutions to serve the requirements of the entire
beds/1000 population as against the rest of India at 0.8 beds/1000
In the past decade or so, the tier II and III cities have
Availability of space in terms of land or ready commercial
essence however, these cities too need to strengthen their healthcare system to match global standards. But the point of
population (lower than the Indian average).
policies to make investments in healthcare more lucrative for private
projects (allocation of Socio-Economic Zones for healthcare projects,
13
Region
country.
·
Saturation of healthcare services in the metros is only relative because of the polarity between them and the rest of India. In
Communicable – mainly the lower socioeconomic strata
The metropolitan cities in India are Mumbai, Chennai, Kolkata, Delhi,
government further incentivised the penetration of healthcare
The Need – Tier II & III
basic healthcare; where the latter is considered to be the right of the
The Gap between Metros and Tier II & III
space) with respect to the metros. Once this was achieved and the
A metro’s advantages also serve as challenges to improve penetration of healthcare delivery in the tier II and III cities.
implies that investments in the healthcare industry as a whole (including diagnostics, day care, medical insurance, medical technology etc.) are concentrated or directed more towards the same 6% metropolitan population. Also, the total beds in the tier II and III cities mainly comprise of those
14
·
population ·
Lesser risk in experimenting with new healthcare models
Reduce costs
and therefore act as a additional deterrent for investors. ·
Bringing in advanced technology
Travel costs – Many families spend a considerable amount of
·
Lesser competition
money in travelling to the metros to avail specialized
·
Word of mouth spreads faster and is more important.
manpower required to run the advanced technology
Therefore extensive marketing budgets are not required
systems/machines becomes a challenge with the limited
healthcare services. Lost man days – Of the patients and their relatives (mostly
Challenges – bringing healthcare to Tier II & III ·
more than one relative per patient)
Providing the support infrastructure and the skilled
Different healthcare dynamics
resources available. ·
Very low health insurance penetration
To nullify/neutralize the monopoly of small hospitals in
The referral system is general practitioner (GP) driven. The
these cities to ensure competitive pricing of services and
population first approaches these GPs and the footfalls in
non metro regions. The people belonging to non metros also
efforts to deliver promised quality.
the hospitals are dependent on how many patients they
tend to have lesser dispensable income hence unable to pay
The out of pocket spending on healthcare is very high in the
Advantage – Tier II & Tier III
direct to the hospitals. The GPs also tend to keep the
that extra premium for better quality services. Value of
·
Huge Unexplored potential market
patients for longer time with them to continue receiving
money weighs heavier than quality services as long as basic
Two thirds of India's middle class population lies outside the
their consultation fees.
healthcare needs are met. Low penetration of private
top tier cities Economies of scale works to reduce costs and
The population is not aware of the gamut of healthcare
insurance because of high premium and limited success of
increase profit margins.
services that are available for them at these hospitals and
social/micro insurance schemes either by the Government or the private players has made it further difficult to reduce
·
Economic Growth Potential
their significance in faster recovery. The image of hospitals
India's total consumption is primarily spearheaded by the
still remains of an institution where people go when they
middle class population and is expected to hit $1.5 trillion by
are seriously or chronically ill.
2025. This is further supported by the statistics that 10.7
·
Strengthen Primary and Preventive Healthcare
the burden of healthcare expenses on the population. Overcome Challenges ·
Seize growing connectivity advantage
million of the total population, earning up to about INR 10
This has been a major challenge for our government ever
Transportation — Better roads, new railway lines with
lakh per annum, live in smaller cities such as Nagpur,
since the time our healthcare delivery system was
improved frequency, airline connectivity between smaller
Vadodara, Ahmedabad, Vijaywada etc.
structured. Problems range from lack of infrastructure,
cities and the metros and more affordable travel.
An ASSOCHAM study report stated that the major
technology, skilled manpower to basic support amenities
All this can be used to encourage visits/consultations by
beneficiaries of the current 9% Indian economy growth
like electricity, water, sanitation etc.
specialist doctors and transport materials (medical
Availability of skilled manpower
equipments and consumables; both Indian and imported)
them was calculated to be about INR 2.8 crores, with a
Skilled medical professionals either receive their training
Network connectivity — In terms of telecom, radio,
curve are the tier II cities, where the total credit availed by
·
environment contaminants/pollution. ·
Standardize operating procedures
growth rate of 23.7%, with Lucknow and Vishakapatnam
from bigger metro cities or migrate to such cities in search of
television, internet accessibility and availability.
·
Local tie ups for procuring consumables and drugs
topping the list respectively. It is however observed that the
better economic value. Another possible deterrent in
It helps in creating awareness among the population about
·
Strategies for greater footfalls- Camps (in the hospital
conversion of money deposited to credit is much lower in
retaining them in the smaller tier cities may be the lack of
the services available in other parts of the country or the
premises and neighbouring drainage areas), direct
the tier III than the tier II cities (92%). This is mainly because
support infrastructure and limited career growth potential.
world. This empowers them to make informed choices
marketing, clinical seminars in the premises etc.
Investments
independent of the local practitioner's guidance. This in fact
of the nature of the industries in tier III cities which mainly
·
·
Empower local manpower
comprises of small entrepreneurs, small scale industries,
Private Investors and funding institutions require
will also help the local practitioners be aware of the
Train the local population on a continual basis with
unorganized retail etc.
convincing about the commercial feasibility of a project.
developments and options available in healthcare services
competitive incentives for retention .
· Healthcare delivery advantages ·
Lower capital and operational costs
The healthcare industry in general has a longer gestation
across the country giving them options to either replicate
period, which may be further intensified in smaller towns
such models or import such services.
The vision of self sustained cities and towns is not complete unless it
Increased options for advertising healthcare services and
includes its healthcare facilities among other sectors such as
·
·
infrastructure and technology. This approach is also critical for the
strategies. This also helps to overcome the strong GP driven
sustenance of the big metros and to curb the effects of migration
referral system prevalent in the smaller tier cities.
leading to overcrowding and therefore struggle for limited resources
Take advantage of economies of scale
leading to inflated prices, poor hygiene, unemployment, rise in crime
The factors that work towards turning the wheels of
rate, corruption etc.
economies of scale are:
Some strategies that may help improve the healthcare system in the
Reduce costs
tier II and III cities are as folllows: ·
The Hub and Spoke model
nonprofit sectors to encourage capital investments in tier II
The Hub is the big hospital that may be in the metros or the
and III cities. But the key to the success of such projects is the
bigger tier II cities where all the high end tertiary care
sustenance of these facilities. Therefore it is equally if not
specialty services are provided whereas the spokes are the
more important to curb the operating costs of these
outreach primary or secondary care centers, set up in the
facilities.
neighbouring smaller cities or towns; where preventive and
The strategies that can be adopted for the same are:
curative care is provided. These also serve as feeding centers
· Growing Economies
The Way Ahead
hence help target a greater audience using direct marketing
Many initiatives have been taken by the government and
15
non metros from going the metro way with respect to
Green initiatives – Help save expenses on power, water
for the hub to avail its high end medical services.
etc. Environment friendly operations to prevent the
This model works better than providing tertiary level care at
16
·
population ·
Lesser risk in experimenting with new healthcare models
Reduce costs
and therefore act as a additional deterrent for investors. ·
Bringing in advanced technology
Travel costs – Many families spend a considerable amount of
·
Lesser competition
money in travelling to the metros to avail specialized
·
Word of mouth spreads faster and is more important.
manpower required to run the advanced technology
Therefore extensive marketing budgets are not required
systems/machines becomes a challenge with the limited
healthcare services. Lost man days – Of the patients and their relatives (mostly
Challenges – bringing healthcare to Tier II & III ·
more than one relative per patient)
Providing the support infrastructure and the skilled
Different healthcare dynamics
resources available. ·
Very low health insurance penetration
To nullify/neutralize the monopoly of small hospitals in
The referral system is general practitioner (GP) driven. The
these cities to ensure competitive pricing of services and
population first approaches these GPs and the footfalls in
non metro regions. The people belonging to non metros also
efforts to deliver promised quality.
the hospitals are dependent on how many patients they
tend to have lesser dispensable income hence unable to pay
The out of pocket spending on healthcare is very high in the
Advantage – Tier II & Tier III
direct to the hospitals. The GPs also tend to keep the
that extra premium for better quality services. Value of
·
Huge Unexplored potential market
patients for longer time with them to continue receiving
money weighs heavier than quality services as long as basic
Two thirds of India's middle class population lies outside the
their consultation fees.
healthcare needs are met. Low penetration of private
top tier cities Economies of scale works to reduce costs and
The population is not aware of the gamut of healthcare
insurance because of high premium and limited success of
increase profit margins.
services that are available for them at these hospitals and
social/micro insurance schemes either by the Government or the private players has made it further difficult to reduce
·
Economic Growth Potential
their significance in faster recovery. The image of hospitals
India's total consumption is primarily spearheaded by the
still remains of an institution where people go when they
middle class population and is expected to hit $1.5 trillion by
are seriously or chronically ill.
2025. This is further supported by the statistics that 10.7
·
Strengthen Primary and Preventive Healthcare
the burden of healthcare expenses on the population. Overcome Challenges ·
Seize growing connectivity advantage
million of the total population, earning up to about INR 10
This has been a major challenge for our government ever
Transportation — Better roads, new railway lines with
lakh per annum, live in smaller cities such as Nagpur,
since the time our healthcare delivery system was
improved frequency, airline connectivity between smaller
Vadodara, Ahmedabad, Vijaywada etc.
structured. Problems range from lack of infrastructure,
cities and the metros and more affordable travel.
An ASSOCHAM study report stated that the major
technology, skilled manpower to basic support amenities
All this can be used to encourage visits/consultations by
beneficiaries of the current 9% Indian economy growth
like electricity, water, sanitation etc.
specialist doctors and transport materials (medical
Availability of skilled manpower
equipments and consumables; both Indian and imported)
them was calculated to be about INR 2.8 crores, with a
Skilled medical professionals either receive their training
Network connectivity — In terms of telecom, radio,
curve are the tier II cities, where the total credit availed by
·
environment contaminants/pollution. ·
Standardize operating procedures
growth rate of 23.7%, with Lucknow and Vishakapatnam
from bigger metro cities or migrate to such cities in search of
television, internet accessibility and availability.
·
Local tie ups for procuring consumables and drugs
topping the list respectively. It is however observed that the
better economic value. Another possible deterrent in
It helps in creating awareness among the population about
·
Strategies for greater footfalls- Camps (in the hospital
conversion of money deposited to credit is much lower in
retaining them in the smaller tier cities may be the lack of
the services available in other parts of the country or the
premises and neighbouring drainage areas), direct
the tier III than the tier II cities (92%). This is mainly because
support infrastructure and limited career growth potential.
world. This empowers them to make informed choices
marketing, clinical seminars in the premises etc.
Investments
independent of the local practitioner's guidance. This in fact
of the nature of the industries in tier III cities which mainly
·
·
Empower local manpower
comprises of small entrepreneurs, small scale industries,
Private Investors and funding institutions require
will also help the local practitioners be aware of the
Train the local population on a continual basis with
unorganized retail etc.
convincing about the commercial feasibility of a project.
developments and options available in healthcare services
competitive incentives for retention .
· Healthcare delivery advantages ·
Lower capital and operational costs
The healthcare industry in general has a longer gestation
across the country giving them options to either replicate
period, which may be further intensified in smaller towns
such models or import such services.
The vision of self sustained cities and towns is not complete unless it
Increased options for advertising healthcare services and
includes its healthcare facilities among other sectors such as
·
·
infrastructure and technology. This approach is also critical for the
strategies. This also helps to overcome the strong GP driven
sustenance of the big metros and to curb the effects of migration
referral system prevalent in the smaller tier cities.
leading to overcrowding and therefore struggle for limited resources
Take advantage of economies of scale
leading to inflated prices, poor hygiene, unemployment, rise in crime
The factors that work towards turning the wheels of
rate, corruption etc.
economies of scale are:
Some strategies that may help improve the healthcare system in the
Reduce costs
tier II and III cities are as folllows: ·
The Hub and Spoke model
nonprofit sectors to encourage capital investments in tier II
The Hub is the big hospital that may be in the metros or the
and III cities. But the key to the success of such projects is the
bigger tier II cities where all the high end tertiary care
sustenance of these facilities. Therefore it is equally if not
specialty services are provided whereas the spokes are the
more important to curb the operating costs of these
outreach primary or secondary care centers, set up in the
facilities.
neighbouring smaller cities or towns; where preventive and
The strategies that can be adopted for the same are:
curative care is provided. These also serve as feeding centers
· Growing Economies
The Way Ahead
hence help target a greater audience using direct marketing
Many initiatives have been taken by the government and
15
non metros from going the metro way with respect to
Green initiatives – Help save expenses on power, water
for the hub to avail its high end medical services.
etc. Environment friendly operations to prevent the
This model works better than providing tertiary level care at
16
the smaller cities/towns since most medical conditions may
care institutions to serve the requirements of the entire
be treated and prevented from becoming critical if taken
population
care of at the primary stages. ·
Steps by the Government
The author is a physiotherapist with an MBA in Hospital and
Incentivize Indian and Foreign investments in smaller cities
Healthcare from Symbiosis International University. She was
by providing tax incentives.
formerly working with HOSMAC as a Management Consultant and
Encourage funding from Global not for profit organizations
can be reached at divya.pottath@gmail.com.
and private investors for private healthcare projects. Encourage health insurance schemes for ensuring better penetration. ·
Telemedicine projects With India becoming the second largest wireless network in the world (overtaking USA); the implementation of telemedicine facilities, especially mobile telemedicine will become easier and more affordable.
·
Public-Private Partnerships For projects concerned with healthcare infrastructure, high end medical technology, medical or social insurance schemes etc
·
Capital flow (public and private) Public — Greater allocation of funds to healthcare and ensure efficient utilization Private — Incentives such as tax holidays, lower interest rates, incentives for foreign direct investments
· ·
Efficient implementation of National Health Programs Education & Training A literate population is more aware of its healthcare needs and more capable of making informed decisions. A functional literacy program should be planned and implemented especially among the lower socio economic strata of the society. Training of local manpower to become skilled healthcare professionals should be further encouraged by the Education Councils especially with respect to Nursing, Paramedics, primary healthcare workers etc.
·
Create a Competitive Market More healthcare providers will make the market competitive and hence ensure competitive pricing and quality services
17
the smaller cities/towns since most medical conditions may
care institutions to serve the requirements of the entire
be treated and prevented from becoming critical if taken
population
care of at the primary stages. ·
Steps by the Government
The author is a physiotherapist with an MBA in Hospital and
Incentivize Indian and Foreign investments in smaller cities
Healthcare from Symbiosis International University. She was
by providing tax incentives.
formerly working with HOSMAC as a Management Consultant and
Encourage funding from Global not for profit organizations
can be reached at divya.pottath@gmail.com.
and private investors for private healthcare projects. Encourage health insurance schemes for ensuring better penetration. ·
Telemedicine projects With India becoming the second largest wireless network in the world (overtaking USA); the implementation of telemedicine facilities, especially mobile telemedicine will become easier and more affordable.
·
Public-Private Partnerships For projects concerned with healthcare infrastructure, high end medical technology, medical or social insurance schemes etc
·
Capital flow (public and private) Public — Greater allocation of funds to healthcare and ensure efficient utilization Private — Incentives such as tax holidays, lower interest rates, incentives for foreign direct investments
· ·
Efficient implementation of National Health Programs Education & Training A literate population is more aware of its healthcare needs and more capable of making informed decisions. A functional literacy program should be planned and implemented especially among the lower socio economic strata of the society. Training of local manpower to become skilled healthcare professionals should be further encouraged by the Education Councils especially with respect to Nursing, Paramedics, primary healthcare workers etc.
·
Create a Competitive Market More healthcare providers will make the market competitive and hence ensure competitive pricing and quality services
17
General Hospital, Ernakulum is one of the largest governmental facilities in Southeast Asia with 748 beds and 1000 hospital staff. Isha Khanolkar – Asst. Manager Operations – Hosmac, interviews Dr. Beena K.V. To be or not to be — Accredited Isha Khanolkar, Asst. Manager Operations – Hosmac, interviews Dr. Beena K.V., District Program – District Program Manager – NRHM on her journey to facilitate the Manager – NRHM, on her journey to facilitate the NABH accreditation of General Hospital, Ernakulum. NABH accreditation of the first large hospital in India.
What did they entail? BKV: The hospital lies in the heart of Cochin, set on six acres of land. The major renovations that took place were with the inpatient ward, administration office, outpatient department and operation theatres. Since only additions were made to the existing facilities, the construction activity did not hinder the operations of the hospital. IK: Cost of implementing changes would have been quite high considering the fact that the hospital was run like a governmental setup. What quarters were chosen to accumulate funds? BKV: General Hospital, Ernakulum has a Hospital Development Committee which was given the responsibility to liaise with various agencies and raise funds for the infrastructural needs. Our District Dr. Beena receiving NABH accreditation from QCI
Collector also contacted several government, public sector units to seek sponsorship of individual blocks in the hospital campus. We
our patients once quote, ‘Receiving private hospital like-care at a
were heartened by the support of agencies like GAIL, Lions Club,
governmental hospital for subsidized rates is extraordinary!’
Manaseva Trust and others. Our personal acquaintances and networking also facilitated the receipt of funds for further development. IK: What indicators in the hospital showed major improvements after the implementation of NABH standards? BKV: The most important indicators of improvement in healthcare delivery were found to be in the infection control practices of the hospital. We monitored parameters like needlestick injuries to keep a watch on the safety methods in use. The average length of a patient’s stay decreased; conversely, there was an increase in patient
19
IK: When and why did you decide that an NABH accreditation would
not perceive how NABH would help improve the quality levels and
be suitable for your hospital?
make a difference to their current working style. They also had
satisfaction levels. Bed occupancy rates increased and resulted in an increase in turnover. IK: Quality is ultimately to serve the customer. What has been the
BKV: The current trend with regard to healthcare in Kerala is that
apprehensions about the increased workload and tedious
consumers demand quality in care, irrespective of their economic
documentation which would ensue. However, six months into the
status. All strata of society are willing to pay out of their pockets to
program, we were able to gather complete support from our staff as
BKV: We have implemented several programs to make our hospital
receive the best treatment from private hospitals, where the
the results of implementation were evident.
patient friendly. Project ‘Hunger Free’ was conceptualized to ensure
atmosphere is conceived to be pleasant. Furthermore, the mission
IK: What were the major gaps that were discovered after the gap
statement of NRHM emphasizes on the provision of quality
analysis was conducted? What strategies did you employ to bridge
healthcare through public healthcare facilities for the masses. The
them?
directive for applying of accreditation came from NRHM in January,
BKV: After conducting a gap analysis study in assistance of technical
reaction of patients from Ernakulum to the improvement made?
that all food made available to patients and their relatives would be free of cost. Auxiliary services such as X-ray and CT scans are being provided at subsided rates. Several patients were interviewed with regard to our hospital services, and response was gratifying. One of
IK: In your opinion, what measures must be instituted to ensure the success of NABH accreditation? BKV: To catalyse quality improvement in the healthcare delivery system of India, QCI (Quality Council of India) along with the NRHM should take to promoting the accreditation of hospitals and provide adequate support. Though hospitals as well as the government knows that implementing quality is a costly affair, in the long run, it proves quite rewarding. IK: The accreditation journey for the hospital took two long years to reach its conclusion. What motivated you to stay relentless in your effort? BKV: One is only as successful as the team behind you wants you to be. I had the good fortune of having built a good rapport with my hospital team even before NABH came into the picture. My Core Team consisted of people who were willing to strive for even 24 hours straight, when required for the quality effort. Another factor was the relentless support extended by NRHM along with the 5-day NABH training program, where we learned about the process of accreditation. Never taking ‘no’ for an answer, we worked our way
2008 and the process was initiated in August, 2008.
consultants, we discovered that our hospital lacked grades in
IK: The government played a pivotal role in the success of General
infrastructure, waste management, human resources and
IK: What message would you give other government hospitals in the country trying to achieve NABH accreditation?
After
through.
Hospital, Ernakulum receiving accreditation. What kind of support
equipment for use. The way out would be to employ an intensive 8-
was offered and how did it aid you?
step approach, beginning with core team-building and committee
BKV: The key to a successful shot at NABH is to plan the approach in
BKV: We received immense support from all levels of the government
formation, followed by development of SOPs, infrastructure
advance. A vital factor is the Core Team that must consist of 3-5
for the project. What strengthened our purpose even further was the
redevelopment, sensitization of staff and so on.
committed members, willing to work long hours. Identification of the
fact that policy decisions were made with speed and problems
K: Your hospital boasts of a combined strength of 1000 nurses and
gaps and their categorization according to importance is
received immediate response and correction. For instance, one of the
doctors. With such a large manpower to train, how were the
instrumental. The correct personnel must administer the quality
concerns we faced early on was that our hospital did not meet the
training programs designed and assessed later on?
assignments. They must be proficient in the assigned area to achieve
bed space requirement as per NABH standards. The IAS officers-in-
BKV: A training calendar was created; the hospital staff was divided
charge immediately arranged for a sum of INR 2 crore to renovate the
into smaller groups. All chapters of the NABH guidelines were
Before
the desired results. Perseverance is the key!
inpatient ward and expand it to 25,000 sqft. Not only did we receive
covered in this training. A pre-assessment test was conducted to
adequate aid from NRHM, but ministers from the state funded a few
judge the levels of understanding of the staff after which training was
from Rotary Club, Women Achiever Award from Sakhi and Best
of the infrastructure projects as well.
conducted. A post-assessment test was later taken to ensure the
Hospital Award from Indian Red Cross Society. She may be reached at
IK: Once a decision was made to achieve NABH standards, what
effectiveness of the training. Subsequent internal audits further
dpmekm@gmail.com.
challenges did you face when you shared your plan with the
helped in assessing the awareness and learning amongst the staff.
hospital staff?
IK: The hospital space is a 170-year old institution; there must have
BKV: Initially, most of the staff was against our decision. They could
been several infrastructural changes made to meet the standards.
The interviewee is a proud recipient of Vocational Excellence Award
20
General Hospital, Ernakulum is one of the largest governmental facilities in Southeast Asia with 748 beds and 1000 hospital staff. Isha Khanolkar – Asst. Manager Operations – Hosmac, interviews Dr. Beena K.V. To be or not to be — Accredited Isha Khanolkar, Asst. Manager Operations – Hosmac, interviews Dr. Beena K.V., District Program – District Program Manager – NRHM on her journey to facilitate the Manager – NRHM, on her journey to facilitate the NABH accreditation of General Hospital, Ernakulum. NABH accreditation of the first large hospital in India.
What did they entail? BKV: The hospital lies in the heart of Cochin, set on six acres of land. The major renovations that took place were with the inpatient ward, administration office, outpatient department and operation theatres. Since only additions were made to the existing facilities, the construction activity did not hinder the operations of the hospital. IK: Cost of implementing changes would have been quite high considering the fact that the hospital was run like a governmental setup. What quarters were chosen to accumulate funds? BKV: General Hospital, Ernakulum has a Hospital Development Committee which was given the responsibility to liaise with various agencies and raise funds for the infrastructural needs. Our District Dr. Beena receiving NABH accreditation from QCI
Collector also contacted several government, public sector units to seek sponsorship of individual blocks in the hospital campus. We
our patients once quote, ‘Receiving private hospital like-care at a
were heartened by the support of agencies like GAIL, Lions Club,
governmental hospital for subsidized rates is extraordinary!’
Manaseva Trust and others. Our personal acquaintances and networking also facilitated the receipt of funds for further development. IK: What indicators in the hospital showed major improvements after the implementation of NABH standards? BKV: The most important indicators of improvement in healthcare delivery were found to be in the infection control practices of the hospital. We monitored parameters like needlestick injuries to keep a watch on the safety methods in use. The average length of a patient’s stay decreased; conversely, there was an increase in patient
19
IK: When and why did you decide that an NABH accreditation would
not perceive how NABH would help improve the quality levels and
be suitable for your hospital?
make a difference to their current working style. They also had
satisfaction levels. Bed occupancy rates increased and resulted in an increase in turnover. IK: Quality is ultimately to serve the customer. What has been the
BKV: The current trend with regard to healthcare in Kerala is that
apprehensions about the increased workload and tedious
consumers demand quality in care, irrespective of their economic
documentation which would ensue. However, six months into the
status. All strata of society are willing to pay out of their pockets to
program, we were able to gather complete support from our staff as
BKV: We have implemented several programs to make our hospital
receive the best treatment from private hospitals, where the
the results of implementation were evident.
patient friendly. Project ‘Hunger Free’ was conceptualized to ensure
atmosphere is conceived to be pleasant. Furthermore, the mission
IK: What were the major gaps that were discovered after the gap
statement of NRHM emphasizes on the provision of quality
analysis was conducted? What strategies did you employ to bridge
healthcare through public healthcare facilities for the masses. The
them?
directive for applying of accreditation came from NRHM in January,
BKV: After conducting a gap analysis study in assistance of technical
reaction of patients from Ernakulum to the improvement made?
that all food made available to patients and their relatives would be free of cost. Auxiliary services such as X-ray and CT scans are being provided at subsided rates. Several patients were interviewed with regard to our hospital services, and response was gratifying. One of
IK: In your opinion, what measures must be instituted to ensure the success of NABH accreditation? BKV: To catalyse quality improvement in the healthcare delivery system of India, QCI (Quality Council of India) along with the NRHM should take to promoting the accreditation of hospitals and provide adequate support. Though hospitals as well as the government knows that implementing quality is a costly affair, in the long run, it proves quite rewarding. IK: The accreditation journey for the hospital took two long years to reach its conclusion. What motivated you to stay relentless in your effort? BKV: One is only as successful as the team behind you wants you to be. I had the good fortune of having built a good rapport with my hospital team even before NABH came into the picture. My Core Team consisted of people who were willing to strive for even 24 hours straight, when required for the quality effort. Another factor was the relentless support extended by NRHM along with the 5-day NABH training program, where we learned about the process of accreditation. Never taking ‘no’ for an answer, we worked our way
2008 and the process was initiated in August, 2008.
consultants, we discovered that our hospital lacked grades in
IK: The government played a pivotal role in the success of General
infrastructure, waste management, human resources and
IK: What message would you give other government hospitals in the country trying to achieve NABH accreditation?
After
through.
Hospital, Ernakulum receiving accreditation. What kind of support
equipment for use. The way out would be to employ an intensive 8-
was offered and how did it aid you?
step approach, beginning with core team-building and committee
BKV: The key to a successful shot at NABH is to plan the approach in
BKV: We received immense support from all levels of the government
formation, followed by development of SOPs, infrastructure
advance. A vital factor is the Core Team that must consist of 3-5
for the project. What strengthened our purpose even further was the
redevelopment, sensitization of staff and so on.
committed members, willing to work long hours. Identification of the
fact that policy decisions were made with speed and problems
K: Your hospital boasts of a combined strength of 1000 nurses and
gaps and their categorization according to importance is
received immediate response and correction. For instance, one of the
doctors. With such a large manpower to train, how were the
instrumental. The correct personnel must administer the quality
concerns we faced early on was that our hospital did not meet the
training programs designed and assessed later on?
assignments. They must be proficient in the assigned area to achieve
bed space requirement as per NABH standards. The IAS officers-in-
BKV: A training calendar was created; the hospital staff was divided
charge immediately arranged for a sum of INR 2 crore to renovate the
into smaller groups. All chapters of the NABH guidelines were
Before
the desired results. Perseverance is the key!
inpatient ward and expand it to 25,000 sqft. Not only did we receive
covered in this training. A pre-assessment test was conducted to
adequate aid from NRHM, but ministers from the state funded a few
judge the levels of understanding of the staff after which training was
from Rotary Club, Women Achiever Award from Sakhi and Best
of the infrastructure projects as well.
conducted. A post-assessment test was later taken to ensure the
Hospital Award from Indian Red Cross Society. She may be reached at
IK: Once a decision was made to achieve NABH standards, what
effectiveness of the training. Subsequent internal audits further
dpmekm@gmail.com.
challenges did you face when you shared your plan with the
helped in assessing the awareness and learning amongst the staff.
hospital staff?
IK: The hospital space is a 170-year old institution; there must have
BKV: Initially, most of the staff was against our decision. They could
been several infrastructural changes made to meet the standards.
The interviewee is a proud recipient of Vocational Excellence Award
20
Tiny drops fill an ocean –
A Bird's-Eye View A Bird's-Eye View of Microinsurancea c o n c e p t t h a t w e c o u l d Tiny drops fill an ocean – a concept that we could apply to healthcare, of Microinsurance
claims Dr. Rahul Garde.
apply to healthcare, claims Dr. Rahul Garde.
Table 1. Comparison between Traditional and Micro-Insurance Schemes Basis
Traditional Insurance
Microinsurance
Clients
Low risk environment Established insurance culture
High risk exposure/ high vulnerability Weak insurance culture
Distribution model
Sold by licensed intermediaries or by insurance companies directly to wealthy clients or companies that understand insurance
Sold by nontraditional intermediaries to clients with little experience of insurance
Policies
Complex policy documents with many exclusions
Simple language Few, if any exclusion Group policies
Premium calculation
Good statistical data Pricing based on Individual risk
Little historical data Group pricing Very price sensitive market
Premium collection
Monthly/quarterly/semi or annually collection
Frequent or irregular payment adapted to volatile cash flow of clients Often linked with other transaction (e.g. loan repayment
Control of insurance risk (adverse selection, moral hazards, frauds)
Limited eligibility Significant documentation required Screening such as medical test is required
Broad eligibility Limited but effective control Insurance risk included in premium rather than exclusion Linked to other service (like credit)
Claims handling
Complicated process Extensive verification documentation
Simple and fast procedure of small firms Efficient fraud control
Microinsurance Products in India
formation of people's associations and is running various
Although microinsurance seems to have become the buzzword lately,
development programmes through them. In Hyderabad,
India is enjoying rapid growth and benefits from a young population.
hospitalized patients take loans or sell assets to pay for
it has been practiced in India for quite some time now, even before
ASSEFA has started a life insurance scheme that covers
Its middle class is growing rapidly but 70 percent of the population is
hospitalization.
the IRDA’s Microinsurance Regulations came about in 2005. These
natural and accidental death and suicide of the insured
still rural, often very poor, and handicapped by poor health and
Microinsurance, when appropriately designed alongside client
programmes generally offered primary healthcare services delivered
member against an annual premium rate of INR 10 for each
health services, and low literacy rates. Although the type of risks
education, can offer poor families valuable protection against these
by NGOs and other similar natured charitable trusts in a localized
family. The death benefits are a fixed rate of INR 3,000 per
faced by the poor such as that of death, illness, injury and accident
adverse circumstances. It is the protection of low-income
geographical area or community. A few such examples are given
case.
are no different from those faced by others, they are more vulnerable
households against specific perils in exchange for premium
below:
Co-operative Development Foundation (CDF)
to such risks because of their economic circumstance. According to a
payments proportionate to the likelihood and cost of the risk
Action for Community Organization, Rehabilitation and
CDF was formed in 1982, by an association of primary
World Bank study (Peters et al. 2002), about one-fourth of
involved. It is specifically designed for the protection of low-income
Development (ACCORD)
agricultural cooperatives in Andhra Pradesh. As part of its
hospitalized Indians fall below the poverty line because of their stay
people with affordable insurance products to help them cope with
ACCORD has been working among the tribal communities
cooperative development work, CDF promotes and
in hospitals. The same study reports that more than 40 percent of
and recover from common risk.
at Gudalur, a small town, at the area of Nilgiris (bordering
supports thrift cooperatives in the districts of Warangal
The Need for Microinsurance
Kerala and Karnataka) in Tamil Nadu. The programme set
and Karimnagar (both are in the state of Andhra Pradesh),
A key strategy for enhancing economic development and alleviating
up a hospital in 1990 and initiated a ‘composite social
which offer savings and credit services to their members.
poverty is to make financial systems more inclusive, for example by
insurance package’ in partnership with an insurance
By paying an entrance fee of INR 10 and a deposit of
improving access to savings and credit services for un-served and
company. The monthly premium is INR 60 for a family of
minimum INR 50 along with an application form, a member
under-served markets. In part, poverty stems from the fact that low-
five, and it covers the risk of damage to their hut and
or an employee of a thrift cooperative may join the
MAJOR PLAYERS IN MICROINSURANCE §Life Insurance Corporation of India (LIC) §ICICI Prudential Life Insurance Company Ltd. §Birla Sun Life Insurance Company Ltd. §Tata AIG Life Insurance Company Ltd. §SBI Life Insurance Company Limited §ING Vysya Life Insurance Company Private Limited §Allianz Bajaj Life Insurance Company Ltd. §Metlife India Insurance Company Pvt. Ltd. §Aviva Life Insurance Company India Limited §Sahara India life insurance §Shriram life insurance company §IDBI Fortis Life Insurance Company Ltd. §DLF Pramerica Life Insurance Co. Ltd. §Star Union Dai-ichi Life Insurance Co. Ltd.
income households and markets do not have the same opportunities
belongings (up to INR 1,500), death and permanent
to finance investments, accumulate capital or protect assets
disability of the head of family (INR 3,000), and all illnesses
(including human assets).
requiring hospitalisation (up to INR 1,500). This ‘composite
In principle, microinsurance works like any typical insurance
social insurance package’ received an encouraging
business. However, several things differentiate it from normal
response from the tribals but it encounters problems in
insurance. First, group insurance can cover thousands of customers
collecting regular contributions and in insurance renewals.
under one contract. Second, microinsurance requires an
It has been suggested that linking up the insurance
intermediary between the customer and the insurance company.
programme to the credit fund may ensure regular
Preferably, this intermediary is a non-governmental organization
collection of premiums.
(NGO) or microfinance institution, for example a rural bank that can
Association for Sarva Seva Farms (ASSEFA), Hyderabad
handle the whole distribution and most of the administration
It is based in Tamil Nadu and Andhra Pradesh and is working
process. The few differences between traditional insurance and
in five other states. The organization encourages the
microinsurance are in the table, as follows:
21
22
Tiny drops fill an ocean –
A Bird's-Eye View A Bird's-Eye View of Microinsurancea c o n c e p t t h a t w e c o u l d Tiny drops fill an ocean – a concept that we could apply to healthcare, of Microinsurance
claims Dr. Rahul Garde.
apply to healthcare, claims Dr. Rahul Garde.
Table 1. Comparison between Traditional and Micro-Insurance Schemes Basis
Traditional Insurance
Microinsurance
Clients
Low risk environment Established insurance culture
High risk exposure/ high vulnerability Weak insurance culture
Distribution model
Sold by licensed intermediaries or by insurance companies directly to wealthy clients or companies that understand insurance
Sold by nontraditional intermediaries to clients with little experience of insurance
Policies
Complex policy documents with many exclusions
Simple language Few, if any exclusion Group policies
Premium calculation
Good statistical data Pricing based on Individual risk
Little historical data Group pricing Very price sensitive market
Premium collection
Monthly/quarterly/semi or annually collection
Frequent or irregular payment adapted to volatile cash flow of clients Often linked with other transaction (e.g. loan repayment
Control of insurance risk (adverse selection, moral hazards, frauds)
Limited eligibility Significant documentation required Screening such as medical test is required
Broad eligibility Limited but effective control Insurance risk included in premium rather than exclusion Linked to other service (like credit)
Claims handling
Complicated process Extensive verification documentation
Simple and fast procedure of small firms Efficient fraud control
Microinsurance Products in India
formation of people's associations and is running various
Although microinsurance seems to have become the buzzword lately,
development programmes through them. In Hyderabad,
India is enjoying rapid growth and benefits from a young population.
hospitalized patients take loans or sell assets to pay for
it has been practiced in India for quite some time now, even before
ASSEFA has started a life insurance scheme that covers
Its middle class is growing rapidly but 70 percent of the population is
hospitalization.
the IRDA’s Microinsurance Regulations came about in 2005. These
natural and accidental death and suicide of the insured
still rural, often very poor, and handicapped by poor health and
Microinsurance, when appropriately designed alongside client
programmes generally offered primary healthcare services delivered
member against an annual premium rate of INR 10 for each
health services, and low literacy rates. Although the type of risks
education, can offer poor families valuable protection against these
by NGOs and other similar natured charitable trusts in a localized
family. The death benefits are a fixed rate of INR 3,000 per
faced by the poor such as that of death, illness, injury and accident
adverse circumstances. It is the protection of low-income
geographical area or community. A few such examples are given
case.
are no different from those faced by others, they are more vulnerable
households against specific perils in exchange for premium
below:
Co-operative Development Foundation (CDF)
to such risks because of their economic circumstance. According to a
payments proportionate to the likelihood and cost of the risk
Action for Community Organization, Rehabilitation and
CDF was formed in 1982, by an association of primary
World Bank study (Peters et al. 2002), about one-fourth of
involved. It is specifically designed for the protection of low-income
Development (ACCORD)
agricultural cooperatives in Andhra Pradesh. As part of its
hospitalized Indians fall below the poverty line because of their stay
people with affordable insurance products to help them cope with
ACCORD has been working among the tribal communities
cooperative development work, CDF promotes and
in hospitals. The same study reports that more than 40 percent of
and recover from common risk.
at Gudalur, a small town, at the area of Nilgiris (bordering
supports thrift cooperatives in the districts of Warangal
The Need for Microinsurance
Kerala and Karnataka) in Tamil Nadu. The programme set
and Karimnagar (both are in the state of Andhra Pradesh),
A key strategy for enhancing economic development and alleviating
up a hospital in 1990 and initiated a ‘composite social
which offer savings and credit services to their members.
poverty is to make financial systems more inclusive, for example by
insurance package’ in partnership with an insurance
By paying an entrance fee of INR 10 and a deposit of
improving access to savings and credit services for un-served and
company. The monthly premium is INR 60 for a family of
minimum INR 50 along with an application form, a member
under-served markets. In part, poverty stems from the fact that low-
five, and it covers the risk of damage to their hut and
or an employee of a thrift cooperative may join the
MAJOR PLAYERS IN MICROINSURANCE §Life Insurance Corporation of India (LIC) §ICICI Prudential Life Insurance Company Ltd. §Birla Sun Life Insurance Company Ltd. §Tata AIG Life Insurance Company Ltd. §SBI Life Insurance Company Limited §ING Vysya Life Insurance Company Private Limited §Allianz Bajaj Life Insurance Company Ltd. §Metlife India Insurance Company Pvt. Ltd. §Aviva Life Insurance Company India Limited §Sahara India life insurance §Shriram life insurance company §IDBI Fortis Life Insurance Company Ltd. §DLF Pramerica Life Insurance Co. Ltd. §Star Union Dai-ichi Life Insurance Co. Ltd.
income households and markets do not have the same opportunities
belongings (up to INR 1,500), death and permanent
to finance investments, accumulate capital or protect assets
disability of the head of family (INR 3,000), and all illnesses
(including human assets).
requiring hospitalisation (up to INR 1,500). This ‘composite
In principle, microinsurance works like any typical insurance
social insurance package’ received an encouraging
business. However, several things differentiate it from normal
response from the tribals but it encounters problems in
insurance. First, group insurance can cover thousands of customers
collecting regular contributions and in insurance renewals.
under one contract. Second, microinsurance requires an
It has been suggested that linking up the insurance
intermediary between the customer and the insurance company.
programme to the credit fund may ensure regular
Preferably, this intermediary is a non-governmental organization
collection of premiums.
(NGO) or microfinance institution, for example a rural bank that can
Association for Sarva Seva Farms (ASSEFA), Hyderabad
handle the whole distribution and most of the administration
It is based in Tamil Nadu and Andhra Pradesh and is working
process. The few differences between traditional insurance and
in five other states. The organization encourages the
microinsurance are in the table, as follows:
21
22
IRDA (MICROINSURANCE) REGULATIONS, 2005 Regulations on micro insurance were officially gazette by the IRDA on 30 November 2005. Amongst other things it def ines the micro insurance products as:
After the advent of the IRDA’s regulations, the microinsurance
Table 2. Few of the Microinsurance schemes available in the market
market now offers a variety of products that offer a varied range of
Name of Insurer
insurance services. Some of the current ones are:
1.
AVIVA Life Ins. Co. India Pvt. Ltd.
Grameen Suraksha
2.
Bajaj Allianz Life Insurance Co. Ltd
Bajaj Allianz Jana Vikas Yojana Bajaj Allianz Saral Suraksha Yojana Bajaj Allianz Alp Nivesh Yojana
3.
Birla Sun Life Insurance Co. Ltd.
Birla Sun Life Insurance Bima Suraksha Super Birla Sun Life Insurance Bima Dhan Sanchay
4.
DLF Pramerica Life Insurance Co. Ltd
DLF Pramerica Sarv Suraksha
5.
ICICI Prudential Life Insurance Co. Ltd
ICICI Pru Sarv Jana Suraksha
institutions are being set up in India in response to this ailing
6.
IDBI Fortis Life Insurance Co. Ltd.
IDBI Fortis Group Microsurance Plan
healthcare situation. Some of these institutions are very large, yet
7.
ING Vysya Life Insurance Co. Ltd.
ING Vysya Saral Suraksha
8.
Life Insurance Corporation of India
LIC's Jeevan Madhur LIC's Jeevan Mangal
9.
Met Life India
Met Vishwas
Conclusion Providing healthcare in a developing country like ours is a daunting task. The products and services are limited and expensive, the quality is bad, the personnel are under-motivated and there seems
· ‘General micro insurance product’ means any health insurance contract, any contract covering the belongings, such as, hut, livestock or tools or instruments or any personal accident contract, either on individual or gr oup basis, as per terms stated in Schedule-I appended to these regulations. · ‘Life micro insurance product’ means any term insurance contract with or without return of premium, and endowment insurance contract or health insurance contract, with our without an accident benefit rider, either on individual or group basis, as per terms stated in Schedule-II appended to these regulations. · Intermediaries - for selling and servicing various micro-insurance products. The regulation also creates a new intermediary called the micro insurance agent. The regulation clearly defines MI agents and has imposed minima in terms of the number of years of experience (at least 3) of working with low income groups. · Micro-Finance Institutions (MFI) means any institution or entity or association registered under any law for the registration of societies or co-operative societies, as the case may be, interalia, for sanctioning loan/finance to its members.
to be a perpetual shortage of staff and supply of affordable medicines. On top of that, patients are dropping out of the system. To
Name of the Product
put it briefly, the overwhelming majority of people in our country are suffering from the lack of a social protection net. Microinsurance
others count their members in the hundreds. These organisations knit together the local population and make sure that inhabitants cover themselves against the risk of illness. Micro-insurance institutions do more than simply pool the financial resources of local people; they interact with medical personnel or in some cases,
10. Sahara India Life Insurance Co. Ltd.
Sahara Sahayog (Micro Endowment Insurance without profit plan)
11. SBI Life Insurance Co. Ltd.
SBI Life Grameen Shakti SBI Life Grameen Super Suraksha
12. Shriram Life Insurance Co. Ltd.
Shri Sahay Sri Sahay (AP)
13. Star Union Dai-ichi Life Insurance Co
SUD Life Paraspar Suraksha Plan
14. TATA AIG Life Insurance Co. Ltd.
Ayushman Yojana Navkalyan Yojana Sampoorn Bima Yojana Tata AIG Sumangal Bima Yojana
themselves provide medical personnel to improve the quality of the services provided and give their members advice and information to create awareness about these options and help them derive the ‘financial’ benefits of good health.
The author is currently working as a Consultant with Hosmac Consulting Services for the past year and has an overall work experience of 5 years in the healthcare industry in India in both Public and Private sectors. He can be reached at rahul.garde@hosmac.com.
scheme. A member can then make further deposits in multiples of INR 50. The scheme covers the risk of death (natural or accidental, up to 60 years old). The debt relief benefits range from 5 to 20 times the deposits, depending on the age of the member. The maximum debt relief benefit payment is INR 10,000. Integrated Social Security Scheme of SEWA The Self-Employed Women's Association (SEWA) is a union of self-employed, low-income women working in the Indian state of Gujarat. SEWA started as a self-help movement looking after the rights of women in the informal sector and it gradually developed new services such as money lending, education and childcare. In 1992, SEWA introduced an ‘Integrated Social Security Scheme’ that covers several areas including health insurance. This social security system is the largest system in India based on members’ contributions. It has more than 30,000 members now.
23
24
IRDA (MICROINSURANCE) REGULATIONS, 2005 Regulations on micro insurance were officially gazette by the IRDA on 30 November 2005. Amongst other things it def ines the micro insurance products as:
After the advent of the IRDA’s regulations, the microinsurance
Table 2. Few of the Microinsurance schemes available in the market
market now offers a variety of products that offer a varied range of
Name of Insurer
insurance services. Some of the current ones are:
1.
AVIVA Life Ins. Co. India Pvt. Ltd.
Grameen Suraksha
2.
Bajaj Allianz Life Insurance Co. Ltd
Bajaj Allianz Jana Vikas Yojana Bajaj Allianz Saral Suraksha Yojana Bajaj Allianz Alp Nivesh Yojana
3.
Birla Sun Life Insurance Co. Ltd.
Birla Sun Life Insurance Bima Suraksha Super Birla Sun Life Insurance Bima Dhan Sanchay
4.
DLF Pramerica Life Insurance Co. Ltd
DLF Pramerica Sarv Suraksha
5.
ICICI Prudential Life Insurance Co. Ltd
ICICI Pru Sarv Jana Suraksha
institutions are being set up in India in response to this ailing
6.
IDBI Fortis Life Insurance Co. Ltd.
IDBI Fortis Group Microsurance Plan
healthcare situation. Some of these institutions are very large, yet
7.
ING Vysya Life Insurance Co. Ltd.
ING Vysya Saral Suraksha
8.
Life Insurance Corporation of India
LIC's Jeevan Madhur LIC's Jeevan Mangal
9.
Met Life India
Met Vishwas
Conclusion Providing healthcare in a developing country like ours is a daunting task. The products and services are limited and expensive, the quality is bad, the personnel are under-motivated and there seems
· ‘General micro insurance product’ means any health insurance contract, any contract covering the belongings, such as, hut, livestock or tools or instruments or any personal accident contract, either on individual or gr oup basis, as per terms stated in Schedule-I appended to these regulations. · ‘Life micro insurance product’ means any term insurance contract with or without return of premium, and endowment insurance contract or health insurance contract, with our without an accident benefit rider, either on individual or group basis, as per terms stated in Schedule-II appended to these regulations. · Intermediaries - for selling and servicing various micro-insurance products. The regulation also creates a new intermediary called the micro insurance agent. The regulation clearly defines MI agents and has imposed minima in terms of the number of years of experience (at least 3) of working with low income groups. · Micro-Finance Institutions (MFI) means any institution or entity or association registered under any law for the registration of societies or co-operative societies, as the case may be, interalia, for sanctioning loan/finance to its members.
to be a perpetual shortage of staff and supply of affordable medicines. On top of that, patients are dropping out of the system. To
Name of the Product
put it briefly, the overwhelming majority of people in our country are suffering from the lack of a social protection net. Microinsurance
others count their members in the hundreds. These organisations knit together the local population and make sure that inhabitants cover themselves against the risk of illness. Micro-insurance institutions do more than simply pool the financial resources of local people; they interact with medical personnel or in some cases,
10. Sahara India Life Insurance Co. Ltd.
Sahara Sahayog (Micro Endowment Insurance without profit plan)
11. SBI Life Insurance Co. Ltd.
SBI Life Grameen Shakti SBI Life Grameen Super Suraksha
12. Shriram Life Insurance Co. Ltd.
Shri Sahay Sri Sahay (AP)
13. Star Union Dai-ichi Life Insurance Co
SUD Life Paraspar Suraksha Plan
14. TATA AIG Life Insurance Co. Ltd.
Ayushman Yojana Navkalyan Yojana Sampoorn Bima Yojana Tata AIG Sumangal Bima Yojana
themselves provide medical personnel to improve the quality of the services provided and give their members advice and information to create awareness about these options and help them derive the ‘financial’ benefits of good health.
The author is currently working as a Consultant with Hosmac Consulting Services for the past year and has an overall work experience of 5 years in the healthcare industry in India in both Public and Private sectors. He can be reached at rahul.garde@hosmac.com.
scheme. A member can then make further deposits in multiples of INR 50. The scheme covers the risk of death (natural or accidental, up to 60 years old). The debt relief benefits range from 5 to 20 times the deposits, depending on the age of the member. The maximum debt relief benefit payment is INR 10,000. Integrated Social Security Scheme of SEWA The Self-Employed Women's Association (SEWA) is a union of self-employed, low-income women working in the Indian state of Gujarat. SEWA started as a self-help movement looking after the rights of women in the informal sector and it gradually developed new services such as money lending, education and childcare. In 1992, SEWA introduced an ‘Integrated Social Security Scheme’ that covers several areas including health insurance. This social security system is the largest system in India based on members’ contributions. It has more than 30,000 members now.
23
24
Effective Cost Treatment Dr. A.M. Joglekar, CEO - Godrej Memorial Hospital, delineates on how Godrej has overcome the challenge to provide quality service at an affordable cost through better hospital management strategies.
The thrust of healthcare delivery in cities is through the system of
providing emergency medical services – for accidents or sudden
Public, Corporate and Charitable (Trust) Hospitals — each of which
serious illness. Mobile high-end emergency medical services at low
has its strengths and weaknesses. The primary stakeholders in all the
or no cost to medically needy victims could save lives and limbs, and
systems include the community of patients, medical professionals,
also serve the purpose of charity.
especially, senior consultant doctors, hospital employees and, most
Given the scenario of public hospitals being over burdened and
importantly, funding agencies such as the government or
unable to provide for all, and corporate hospitals providing
corporations, corporate investors and philanthropic donors.
seemingly high quality services at costs affordable only to few, and
A Public-Private Philanthropic Perspective
charitable hospitals becoming unviable, a ‘sustainable charity’
The public hospital system provides an excellent front end for
model was created at Godrej Memorial Hospital.
healthcare policy implementation by the state. However, while the
The Model
vision and policies are very adequate, implementation perhaps falls
Fundamentally, the model in effect provides better services at lesser
short of expectations. Corporate-style hospitals as well as nursing
cost to patients. The system harnesses the strengths of the public
homes are largely financial ventures; success or failure is measurable
hospitals with the virtues of the competitive corporate system,
in terms of profits or losses, and the system is usually target-driven.
amalgamated with the values of a charitable trust.
Ethics, rationality and transparency are not prominently visible.
The approach is overwhelmingly educative rather than
Corporate hospitals are often perceived as providing quality at high
authoritarian, the system works on incentives rather than targets.
cost (five star services at seven star prices).
‘Charity’ clearly distinguishes between patient ‘needs’ and ‘wants’. It
A renewed sense of charity
operates on mutual trust between all the stakeholders. The vision is
Charitable trust hospitals are looked upon as an ideal system for
supported by policies that are smoothly implemented through well
patients to obtain quality healthcare at an affordable cost. However,
set processes and procedures, guided by constantly improving forms
in present times of spiraling costs, the charitable trust system is under
and formats. It grows by meeting aspirations of people, namely
intense pressure to deliver. It is not feasible to provide donations for
patients, medical professionals and hospital employees, thus
setting up as well as meeting costs for running the hospital
enabling them to grow in turn; it offers unlimited opportunities
indefinitely. Most charitable hospitals today have metamorphosed to
rather than careers. The system is robust as a business model; it
resembling either the public or corporate hospitals. The solution lies
rejects the less deserving and ejects the unethical, thus keeping itself
in creating a system of ‘Sustainable Charity’.
lean, mean and clean. It draws further strength from the weaknesses
Sustainable charity is required to be distinguished from mere charity.
of public and corporate healthcare systems. These strategic concepts
The redefinition in terms of urban needs, for example, could be
form the operating base for Godrej Memorial Hospital.
26
Effective Cost Treatment Dr. A.M. Joglekar, CEO - Godrej Memorial Hospital, delineates on how Godrej has overcome the challenge to provide quality service at an affordable cost through better hospital management strategies.
The thrust of healthcare delivery in cities is through the system of
providing emergency medical services – for accidents or sudden
Public, Corporate and Charitable (Trust) Hospitals — each of which
serious illness. Mobile high-end emergency medical services at low
has its strengths and weaknesses. The primary stakeholders in all the
or no cost to medically needy victims could save lives and limbs, and
systems include the community of patients, medical professionals,
also serve the purpose of charity.
especially, senior consultant doctors, hospital employees and, most
Given the scenario of public hospitals being over burdened and
importantly, funding agencies such as the government or
unable to provide for all, and corporate hospitals providing
corporations, corporate investors and philanthropic donors.
seemingly high quality services at costs affordable only to few, and
A Public-Private Philanthropic Perspective
charitable hospitals becoming unviable, a ‘sustainable charity’
The public hospital system provides an excellent front end for
model was created at Godrej Memorial Hospital.
healthcare policy implementation by the state. However, while the
The Model
vision and policies are very adequate, implementation perhaps falls
Fundamentally, the model in effect provides better services at lesser
short of expectations. Corporate-style hospitals as well as nursing
cost to patients. The system harnesses the strengths of the public
homes are largely financial ventures; success or failure is measurable
hospitals with the virtues of the competitive corporate system,
in terms of profits or losses, and the system is usually target-driven.
amalgamated with the values of a charitable trust.
Ethics, rationality and transparency are not prominently visible.
The approach is overwhelmingly educative rather than
Corporate hospitals are often perceived as providing quality at high
authoritarian, the system works on incentives rather than targets.
cost (five star services at seven star prices).
‘Charity’ clearly distinguishes between patient ‘needs’ and ‘wants’. It
A renewed sense of charity
operates on mutual trust between all the stakeholders. The vision is
Charitable trust hospitals are looked upon as an ideal system for
supported by policies that are smoothly implemented through well
patients to obtain quality healthcare at an affordable cost. However,
set processes and procedures, guided by constantly improving forms
in present times of spiraling costs, the charitable trust system is under
and formats. It grows by meeting aspirations of people, namely
intense pressure to deliver. It is not feasible to provide donations for
patients, medical professionals and hospital employees, thus
setting up as well as meeting costs for running the hospital
enabling them to grow in turn; it offers unlimited opportunities
indefinitely. Most charitable hospitals today have metamorphosed to
rather than careers. The system is robust as a business model; it
resembling either the public or corporate hospitals. The solution lies
rejects the less deserving and ejects the unethical, thus keeping itself
in creating a system of ‘Sustainable Charity’.
lean, mean and clean. It draws further strength from the weaknesses
Sustainable charity is required to be distinguished from mere charity.
of public and corporate healthcare systems. These strategic concepts
The redefinition in terms of urban needs, for example, could be
form the operating base for Godrej Memorial Hospital.
26
Welfare of employees The hospital has employed younger age groups and policies are growth oriented. The employees are groomed and trained but no special moves are made to retain them if they intend on moving on to seemingly greener pastures. Those who take more responsibility automatically get more authority, leading to a better position and returns. Small, subsidized housing is provided by the Godrej Memorial trust for helping needy staff. Better education for children by priority admission at Godrej School with concessional fees,
How do patients benefit? The hospital's location provides ready accessibility, especially during medical emergencies. The advanced mobile emergency medical service is provided free of cost to the community living around the hospital (around-the-clock). There are no barriers by way of advance payment for inpatient treatment, greatly facilitating patients, especially in emergency situations. There is concessional tariff for all, being 40-60% cheaper in comparison to any other accredited private hospitals in urban locations. Continuous improvement and rationality of services offered is driven by patient feedback, and monitoring of indicators and audits. All this provides quality services at affordable costs helping a patient centric approach. The medical professional has much to gain The hospital provides an opportunity to doctors with excellent academic records who are in need of a support platform to grow as professionals. It synergises with good doctors and encourages them to meet their aspirations. Concessional fees for a high standard of
medical treatment through group insurance, etc. all build up towards
service make patients flock to GMH doctors, increasing their practice
a brighter future for employees and their families.
steadily. Sophisticated instruments and facilities provide a high-
Making quality happen
standard, professional environment without any personal monetary
At Godrej Memorial Hospital, quality is made-to-happen via a well
investment. No restriction on respectable places of practice or in-
planned approach. It is conceptualized, defined, implemented,
house competition from full-time employed doctors gives an
monitored, measured, reinforced, and constantly improved. All this
accelerated growth prospect. A rational revenue sharing system
has enabled the hospital to achieve and maintain accreditations such
based on mutual trust and incentives allows genuinely deserving
as NABH and NABL.
doctors to prosper. The freedom to give concessions to needy
The Godrej Memorial Hospital model, in a larger sense, is a direct
patients provides authority, whilst medico-legal support from the
private-public partnership and could perhaps be replicated under
hospital, gives reassurance to good practitioners.
the leadership of like minded people in any urban centre. The author has served Dinanath Mangeshkar Hospital, Pune and Lilavati Hospital and Research Center, Mumbai after a 25-year long stint with the defence services. He has been associated with building, commissioning and operating Godrej Memorial Hospital since 2003. He may be contacted at hospital@godrej.com.
Smile Train — An initiative of Godrej Memorial
27
28
Welfare of employees The hospital has employed younger age groups and policies are growth oriented. The employees are groomed and trained but no special moves are made to retain them if they intend on moving on to seemingly greener pastures. Those who take more responsibility automatically get more authority, leading to a better position and returns. Small, subsidized housing is provided by the Godrej Memorial trust for helping needy staff. Better education for children by priority admission at Godrej School with concessional fees,
How do patients benefit? The hospital's location provides ready accessibility, especially during medical emergencies. The advanced mobile emergency medical service is provided free of cost to the community living around the hospital (around-the-clock). There are no barriers by way of advance payment for inpatient treatment, greatly facilitating patients, especially in emergency situations. There is concessional tariff for all, being 40-60% cheaper in comparison to any other accredited private hospitals in urban locations. Continuous improvement and rationality of services offered is driven by patient feedback, and monitoring of indicators and audits. All this provides quality services at affordable costs helping a patient centric approach. The medical professional has much to gain The hospital provides an opportunity to doctors with excellent academic records who are in need of a support platform to grow as professionals. It synergises with good doctors and encourages them to meet their aspirations. Concessional fees for a high standard of
medical treatment through group insurance, etc. all build up towards
service make patients flock to GMH doctors, increasing their practice
a brighter future for employees and their families.
steadily. Sophisticated instruments and facilities provide a high-
Making quality happen
standard, professional environment without any personal monetary
At Godrej Memorial Hospital, quality is made-to-happen via a well
investment. No restriction on respectable places of practice or in-
planned approach. It is conceptualized, defined, implemented,
house competition from full-time employed doctors gives an
monitored, measured, reinforced, and constantly improved. All this
accelerated growth prospect. A rational revenue sharing system
has enabled the hospital to achieve and maintain accreditations such
based on mutual trust and incentives allows genuinely deserving
as NABH and NABL.
doctors to prosper. The freedom to give concessions to needy
The Godrej Memorial Hospital model, in a larger sense, is a direct
patients provides authority, whilst medico-legal support from the
private-public partnership and could perhaps be replicated under
hospital, gives reassurance to good practitioners.
the leadership of like minded people in any urban centre. The author has served Dinanath Mangeshkar Hospital, Pune and Lilavati Hospital and Research Center, Mumbai after a 25-year long stint with the defence services. He has been associated with building, commissioning and operating Godrej Memorial Hospital since 2003. He may be contacted at hospital@godrej.com.
Smile Train — An initiative of Godrej Memorial
27
28
PPP: Is it really the Solution?
the hospital CEO and other hospital managers such as the finance
patients to PPP directly as s/he considers the PPP as his/her ‘own’
PPPs have been regarded as the way out for the healthcare delivery system in India but there's more to it, Dr. Rajiv Boudhankar, Vice President – Kohinoor Hospital, sheds light.
manager and PPP coordinator. But friction is encountered when the
hospital. The most important aspect is the tariff that has to be clearly
numbers are equal on both sides. Subjects in discussion arrive at an
defined in the HMIS master; this has to be signed by both parties.
even number of votes from either side launching the issues up in the
Since tariff is concessional for diagnostics, drugs, consumables etc., a
air. Whereas, sometimes carried forward without a final decision but
daily interim bill must be issued to the referral patients; the entire
not without kickbacks.
hospital stay would otherwise be considered free by them. To steer
Gradually, as the MOU is drafted, the challenge is to get it endorsed
clear of such situations, the most prudent step would be to counsel
by the general body of the elected representative. Since PPP is
patients before admission and clearly define the charges, albeit at
mooted by the ruling party, the opposition picks up loopholes in the
concessional rates. Though this practice is followed, patients
draft MOU. Ergo, a lot of political maneuvering is required to get it
principally demand free services and often refuse to pay even the
passed.
concessional rates. To add to this, elected representatives
Furthermore, since today’s opposition can become tomorrow's
sometimes ‘advocate’ the case of the patient by writing off these
ruling party, utmost care has to be taken to be affable with all political
charges. The ‘advocate’ may even go to the extent of using violent
parties, which in itself, is a mammoth task since the opposition
and undemocratic means to force their point of view on hospital
parties see you as a friend of the ruling party. To make their
management.
opposition public, the press and electronic media are fed, sometimes controversial, stories about the PPP by the opposition party. This calls for preemptive good relations with the press and media. The help of a good PR agency should be sought to keep the press and electronic media on the side of the PPP. Care should be taken that our approach is transparent, and all clauses of the draft MOU are put across factually and with proper reasoning to them, so that unnecessary ammunition is not provided to the press. This again becomes a difficult task because certain sections of the press and media are actually owned by opposition parties. PPP models have now become the new mantra for politicians,
free beds for the community and the private entrepreneur trying his
bureaucrats and private entrepreneurs alike. A politician earns
maximum to reduce this number. Generally such MOUs have the
recognition for his social commitments, whereas a private
following features:
entrepreneur finds route to express his corporate social responsibility
·
to the community. Even though PPP models were recently unleashed as an expedient solution to India's scarce healthcare resources, the
patients at no charge ·
Cost of diagnostics and investigations available at the
mindset of the politician still does not accommodate PPP as a role
hospital for free or at concessional rates; for diagnostics
model. Besides, the private entrepreneur is yet to change his
and investigations sent outside the hospital, special rates
mindset. Therein lays the real challenge in running a PPP healthcare model.
be negotiated for ·
The ‘battle’ begins right from drafting the MOU for the proposed PPP. The Goverment and the private player both want to take a ‘win-win’ position at this stage itself. Though on paper, this is a partnership in the interest of the community, it is an entirely different picture in
Cost of drugs, medicines and consumables either free or at concessional rates
·
Similarly, implants, stents, ambulance service, food etc. at free or concessional rates
Since both parties want to extract maximum mileage form the MOU,
endorsed by the standing committee of the elected representatives which goes into the final details for the agreement. Here too a lot of
The challenges of a PPP further extend to the references by all and
political maneuvering is required and a good PR agency would
sundry of the public body asking for heavy discounts for patients who
definitely help the purpose. If need be, local political bigwigs should
don’t even fall under the category of poor patients. Thus, besides the
also be approached to ensure smooth sailing through the Standing
officially referred patients that are given discounts and free
Committee. Once across, the final agreement is drafted by the Head
treatment, a big chunk of ‘non-eligible patients’ are also given
of the bureaucracy, in consultation with the legal department of the
discounted rates, thereby hitting the profit of the hospital from the
public body. Here too a lot of back end maneuvering is required with
business entrepreneur’s point of view. The entrepreneurs, in spite of
the concerned HoDs e.g. Engineering Department, Health
all these difficulties, want to ‘break even’ at the earliest; almost in the
Department, Legal Department etc.
same time frame as any other non-PPP hospital, which is a big
At the project stage, the necessary permissions have to be taken from
challenge for the Hospital Administrator. The job of the hospital
the public body so that there are no hiccups during the completion of
administrator is literally a tight rope walk — trying to balance the
the project. The agencies that are to be chased are the Development
demands of the public representatives, opposition parties and
Plan Officer, City Engineering Office, Health Department, Fire
bureaucrats on one hand and his employer on the other. Needless to
reality. The bureaucrats drafting the MOU have to keep their political
a lot of negotiation takes place on the issue of free and concessional
godfathers happy and hence their objective is to see that maximum
Department and the Commissioner’s Office. Nearing completion,
rates. Generally, the acceptable tariff is the one that is charged at the
mention, many PPP projects are frequently in the public news for
the other departments such as the Assessor and Collection
reasons beyond the control of hospital administration.
mileage is in favor of their political bosses. Though the constitution
Government or municipal hospitals for all investigations, diagnostics,
gives bureaucracy an independent stature, in reality, the political
Department for Property Tax and the Ward Office for local issues
drugs and consumables. However, since most Government hospitals
For a PPP to pay off, the private entrepreneur must ideally view it as a
must be followed up with.
true CSR activity, and the elected representatives must not demand
wing drives the real agenda. Hence, PPP is more of a tool for the
also order many drugs and implants from outside, this issue becomes
politician to gain popularity and, thereby, more votes in the next
a bone of contention with the bureaucrats asking for concessional
election. For the private entrepreneur, PPP is a shortcut to enter new
rates and the private entrepreneur asking for the MRP. More often
markets at a very minimal cost or, in some cases, enter an absolutely
than not, a fair amount of discount is passed out on all such drugs,
virgin market where he has no foothold. With profit as the primary objective for a private entrepreneur, it becomes difficult for him to grasp the ‘public interest’ of a PPP model.
consumables, implants etc. to close the issue. In due course, when the MOU is drafted, the logistics have to be structured. For this, a committee is appointed jointly by both sides to
In view of the above, drafting an MOU becomes almost a battle
oversee the implementation of the project as well as its operation.
wherein both parties try their level best to gain an upper hand. The
Predominantly, the public body is represented by a bureaucrat and a
classic example is the politician trying to get maximum number of
29
About 10-15% of total no. of beds are reserved for poor
Once the actual MOU is passed by the General Body, it has also to be
few elected representatives, whereas the private entrepreneur by
Once the hospital starts operations, the bigger challenge is the SOPs
unrealistic deliverables from the undertaking. If a pragmatic sense is
that are formulated for the referral patients. The SOP should clearly
adopted by India’s public and private players, PPPs can assuredly be
mention the process flow, eligibility of patients, the signatory for
an answer to enhance and evolve our pre-eminent healthcare sector.
reference, documents to be carried by patients, reference for particular specialty etc.
The author has over 24 years of healthcare experience in Hospitals &
In many cases, the elected representative refers the patients straight
Health Systems management. He is recipient to several awards and
to the PPP on their respective letterheads without any endorsement
has published several papers on healthcare. He is also a guide and
or signature from the public body authorized signatory. This is very
faculty member at several esteemed healthcare institutions. He may
common as the elected representative feels it his right to refer
be reached at rajeev.boudhankar@kohinoorhospitals.in.
30
PPP: Is it really the Solution?
the hospital CEO and other hospital managers such as the finance
patients to PPP directly as s/he considers the PPP as his/her ‘own’
PPPs have been regarded as the way out for the healthcare delivery system in India but there's more to it, Dr. Rajiv Boudhankar, Vice President – Kohinoor Hospital, sheds light.
manager and PPP coordinator. But friction is encountered when the
hospital. The most important aspect is the tariff that has to be clearly
numbers are equal on both sides. Subjects in discussion arrive at an
defined in the HMIS master; this has to be signed by both parties.
even number of votes from either side launching the issues up in the
Since tariff is concessional for diagnostics, drugs, consumables etc., a
air. Whereas, sometimes carried forward without a final decision but
daily interim bill must be issued to the referral patients; the entire
not without kickbacks.
hospital stay would otherwise be considered free by them. To steer
Gradually, as the MOU is drafted, the challenge is to get it endorsed
clear of such situations, the most prudent step would be to counsel
by the general body of the elected representative. Since PPP is
patients before admission and clearly define the charges, albeit at
mooted by the ruling party, the opposition picks up loopholes in the
concessional rates. Though this practice is followed, patients
draft MOU. Ergo, a lot of political maneuvering is required to get it
principally demand free services and often refuse to pay even the
passed.
concessional rates. To add to this, elected representatives
Furthermore, since today’s opposition can become tomorrow's
sometimes ‘advocate’ the case of the patient by writing off these
ruling party, utmost care has to be taken to be affable with all political
charges. The ‘advocate’ may even go to the extent of using violent
parties, which in itself, is a mammoth task since the opposition
and undemocratic means to force their point of view on hospital
parties see you as a friend of the ruling party. To make their
management.
opposition public, the press and electronic media are fed, sometimes controversial, stories about the PPP by the opposition party. This calls for preemptive good relations with the press and media. The help of a good PR agency should be sought to keep the press and electronic media on the side of the PPP. Care should be taken that our approach is transparent, and all clauses of the draft MOU are put across factually and with proper reasoning to them, so that unnecessary ammunition is not provided to the press. This again becomes a difficult task because certain sections of the press and media are actually owned by opposition parties. PPP models have now become the new mantra for politicians,
free beds for the community and the private entrepreneur trying his
bureaucrats and private entrepreneurs alike. A politician earns
maximum to reduce this number. Generally such MOUs have the
recognition for his social commitments, whereas a private
following features:
entrepreneur finds route to express his corporate social responsibility
·
to the community. Even though PPP models were recently unleashed as an expedient solution to India's scarce healthcare resources, the
patients at no charge ·
Cost of diagnostics and investigations available at the
mindset of the politician still does not accommodate PPP as a role
hospital for free or at concessional rates; for diagnostics
model. Besides, the private entrepreneur is yet to change his
and investigations sent outside the hospital, special rates
mindset. Therein lays the real challenge in running a PPP healthcare model.
be negotiated for ·
The ‘battle’ begins right from drafting the MOU for the proposed PPP. The Goverment and the private player both want to take a ‘win-win’ position at this stage itself. Though on paper, this is a partnership in the interest of the community, it is an entirely different picture in
Cost of drugs, medicines and consumables either free or at concessional rates
·
Similarly, implants, stents, ambulance service, food etc. at free or concessional rates
Since both parties want to extract maximum mileage form the MOU,
endorsed by the standing committee of the elected representatives which goes into the final details for the agreement. Here too a lot of
The challenges of a PPP further extend to the references by all and
political maneuvering is required and a good PR agency would
sundry of the public body asking for heavy discounts for patients who
definitely help the purpose. If need be, local political bigwigs should
don’t even fall under the category of poor patients. Thus, besides the
also be approached to ensure smooth sailing through the Standing
officially referred patients that are given discounts and free
Committee. Once across, the final agreement is drafted by the Head
treatment, a big chunk of ‘non-eligible patients’ are also given
of the bureaucracy, in consultation with the legal department of the
discounted rates, thereby hitting the profit of the hospital from the
public body. Here too a lot of back end maneuvering is required with
business entrepreneur’s point of view. The entrepreneurs, in spite of
the concerned HoDs e.g. Engineering Department, Health
all these difficulties, want to ‘break even’ at the earliest; almost in the
Department, Legal Department etc.
same time frame as any other non-PPP hospital, which is a big
At the project stage, the necessary permissions have to be taken from
challenge for the Hospital Administrator. The job of the hospital
the public body so that there are no hiccups during the completion of
administrator is literally a tight rope walk — trying to balance the
the project. The agencies that are to be chased are the Development
demands of the public representatives, opposition parties and
Plan Officer, City Engineering Office, Health Department, Fire
bureaucrats on one hand and his employer on the other. Needless to
reality. The bureaucrats drafting the MOU have to keep their political
a lot of negotiation takes place on the issue of free and concessional
godfathers happy and hence their objective is to see that maximum
Department and the Commissioner’s Office. Nearing completion,
rates. Generally, the acceptable tariff is the one that is charged at the
mention, many PPP projects are frequently in the public news for
the other departments such as the Assessor and Collection
reasons beyond the control of hospital administration.
mileage is in favor of their political bosses. Though the constitution
Government or municipal hospitals for all investigations, diagnostics,
gives bureaucracy an independent stature, in reality, the political
Department for Property Tax and the Ward Office for local issues
drugs and consumables. However, since most Government hospitals
For a PPP to pay off, the private entrepreneur must ideally view it as a
must be followed up with.
true CSR activity, and the elected representatives must not demand
wing drives the real agenda. Hence, PPP is more of a tool for the
also order many drugs and implants from outside, this issue becomes
politician to gain popularity and, thereby, more votes in the next
a bone of contention with the bureaucrats asking for concessional
election. For the private entrepreneur, PPP is a shortcut to enter new
rates and the private entrepreneur asking for the MRP. More often
markets at a very minimal cost or, in some cases, enter an absolutely
than not, a fair amount of discount is passed out on all such drugs,
virgin market where he has no foothold. With profit as the primary objective for a private entrepreneur, it becomes difficult for him to grasp the ‘public interest’ of a PPP model.
consumables, implants etc. to close the issue. In due course, when the MOU is drafted, the logistics have to be structured. For this, a committee is appointed jointly by both sides to
In view of the above, drafting an MOU becomes almost a battle
oversee the implementation of the project as well as its operation.
wherein both parties try their level best to gain an upper hand. The
Predominantly, the public body is represented by a bureaucrat and a
classic example is the politician trying to get maximum number of
29
About 10-15% of total no. of beds are reserved for poor
Once the actual MOU is passed by the General Body, it has also to be
few elected representatives, whereas the private entrepreneur by
Once the hospital starts operations, the bigger challenge is the SOPs
unrealistic deliverables from the undertaking. If a pragmatic sense is
that are formulated for the referral patients. The SOP should clearly
adopted by India’s public and private players, PPPs can assuredly be
mention the process flow, eligibility of patients, the signatory for
an answer to enhance and evolve our pre-eminent healthcare sector.
reference, documents to be carried by patients, reference for particular specialty etc.
The author has over 24 years of healthcare experience in Hospitals &
In many cases, the elected representative refers the patients straight
Health Systems management. He is recipient to several awards and
to the PPP on their respective letterheads without any endorsement
has published several papers on healthcare. He is also a guide and
or signature from the public body authorized signatory. This is very
faculty member at several esteemed healthcare institutions. He may
common as the elected representative feels it his right to refer
be reached at rajeev.boudhankar@kohinoorhospitals.in.
30
Just What the Future Ordered Just What the Future Ordered Marketing to India's rural population has to be as distinct as the population that it approaches. Alvin Saldanha, Chief Creative Officer — Idea Domain, makes a point.
financing from the government.
risk the possibility of looking foolish.
Private pharmaceutical companies have shown initiative in this area.
Another learning is that when communicating to people who,
Recognising the very long term potential of providing diagnostic,
unfortunately, cannot read or write, merely giving them
preventive and medical services to the poorest of the poor, they have
communication to look at doesn’t suffice. Getting them to cotton on
long since begun a variety of imaginative and effective exercises in
is crucial; hence the imagination with which the communication
reaching out to impoverished Indians in benighted internal areas,
depicts people, illnesses, and manifestations of disease is important.
thus laying the foundations of good health. From the openly visible
The key here is that positive imagery draws people into a
population control exercises by NGOs to a variety of programs that
communication and negative imagery (pictures of disease of inflicted
deal with women’s issues, vision problems, TB and diarrhoea, good
people) repels them, so it should be placed either inside the location
nutrition and vaccination exercises, companies are deploying armies
or should be in the hands of medical personnel, to take away the
of doctors, medical workers, and organising camps… all ensuring that
repulsion factor.
a fresh wave of ‘inclusive’ medical possibility touches the lives of
Wherever the communication is being displayed, a recognition of the
Indians who would otherwise have no hope for it.
local folk aesthetic also plays a make or break factor. Idiom, colour,
Herein lays another challenge: communication. This kind of
local folk arts are key elements. Because many communications need
communication has proven to present some of the most unique
to be centrally produced to ensure economy and accuracy, they can
challenges and each campaign results in fresh learnings that must be
be strangely off-putting when they appear in their final intended
shared.
location. An extra effort to add a layer of ‘localising’ can make all the
The most important thing to remember is that any communication
difference. For example, ‘city’-esque pictures don’t go far with
faces ‘competition’ from erroneous beliefs, erroneous practices, and
villagers when you want them to change a lifelong unhygienic habit
insecure village doctors. Indeed, as in the WHO’s case, it was the
because they seem to think that this kind of ‘cleanliness luxury’ is for
religious authorities that presented the problem. As in the case of all
the city folk, who have the time and money to indulge in these things!
such groups, their yen for exercising their power, however
Above all, go bearing gifts. It’s not just the thought (or the campaign)
capriciously, and their need to show and feel that they still wield
that counts. To touch their hearts shows a smidgen of affection and generosity. To get your communication ready and shining is all good and dandy, but if you want people to look at it with favour and co-
Some years ago, the WHO’s polio vaccine drive to dispense a critical
encourage people to visit the medical camps and assure them that
multi-state polio vaccination in India faced a particularly vexing
the vaccine had no ‘side effects’ to fear.
challenge: Muslim religious leaders in two states prohibited the
However, a strategic decision was taken: while Aamir’s beaming,
faithful from administering their infants with the polio vaccine
welcoming, reassuring face appeared on each and every
because, as they had told the trusting folk, the polio vaccine was ‘an
communication, the perverse issue that had stymied the program
evil plot by the West to destroy the reproductive system of their
was ignored completely. Aamir’s fabulous star power was pressed
infants from developing correctly, and prevent them from having
into play, and it worked like a charm. Thousands of Indians flocked to
children when they grow up’.
the camps, they arrived grinning at the Aamir overdose all around
Fortunately, we were in close contact with Indian film star Aamir
them, whooping and laughing, they took pictures next to the giant
Khan, being as we were in the middle of the giant ‘Thanda Matlab
Aamir cutouts dotted all over the camp, and had their babies
Coca-Cola’ campaign. Aamir instantly agreed to help, gratis, with
confidently vaccinated.
anything and everything we could do to encourage these parents to
It is an interesting episode to relate to in the challenge of caring for
have their infants vaccinated. With reference to his suggestions, we
Indians who have been marginalised in India’s Great Leap Forward.
developed a campaign to respond to this bizarre challenge; to
And it is an interesting learning we can bring to bear in solving what is
operation, remember that you have to earn their pleasure. The author began his career in 1982 at JWT as a copywriter, and has been Creative Director with Rediffusion DY&R, Vice President and Executive Creative Director with the McCann Worldgroup. He can be reached at alvinsaldanha@gmail.com.
not just one of the most pressing needs of the country, but one of the most promising growth segments for the many providers of India’s infrastructure. And one of the most important dynamics in this emerging new sector is health. In fact, India’s health universe, central to powering and sustaining India’s leap into the fraternity of first world nations, needs to be communicated, understood and appreciated accurately by all its constituencies. At the top end, the knowing constituencies need no persuasion: seeped in market and profit realities, they can easily see the road ahead. The challenge here lies in convincing market-oriented businesses and organisations to commit to setting up health facilities in places where the profit margin is not so high, or the initial set-up financing and revenue possibility is linked to the capriciousness of
31
some clout, all play a part. One learning is, paradoxically, to present an overwhelming distraction to a false issue. As with Aamir Khan, the positive assurance of Aamir’s star power overrode not just any hesitation but gave people the gumption to defy the religious leaders. To the religious leaders, Aamir Khan is a checkmate issue and they cannot
32
Just What the Future Ordered Just What the Future Ordered Marketing to India's rural population has to be as distinct as the population that it approaches. Alvin Saldanha, Chief Creative Officer — Idea Domain, makes a point.
financing from the government.
risk the possibility of looking foolish.
Private pharmaceutical companies have shown initiative in this area.
Another learning is that when communicating to people who,
Recognising the very long term potential of providing diagnostic,
unfortunately, cannot read or write, merely giving them
preventive and medical services to the poorest of the poor, they have
communication to look at doesn’t suffice. Getting them to cotton on
long since begun a variety of imaginative and effective exercises in
is crucial; hence the imagination with which the communication
reaching out to impoverished Indians in benighted internal areas,
depicts people, illnesses, and manifestations of disease is important.
thus laying the foundations of good health. From the openly visible
The key here is that positive imagery draws people into a
population control exercises by NGOs to a variety of programs that
communication and negative imagery (pictures of disease of inflicted
deal with women’s issues, vision problems, TB and diarrhoea, good
people) repels them, so it should be placed either inside the location
nutrition and vaccination exercises, companies are deploying armies
or should be in the hands of medical personnel, to take away the
of doctors, medical workers, and organising camps… all ensuring that
repulsion factor.
a fresh wave of ‘inclusive’ medical possibility touches the lives of
Wherever the communication is being displayed, a recognition of the
Indians who would otherwise have no hope for it.
local folk aesthetic also plays a make or break factor. Idiom, colour,
Herein lays another challenge: communication. This kind of
local folk arts are key elements. Because many communications need
communication has proven to present some of the most unique
to be centrally produced to ensure economy and accuracy, they can
challenges and each campaign results in fresh learnings that must be
be strangely off-putting when they appear in their final intended
shared.
location. An extra effort to add a layer of ‘localising’ can make all the
The most important thing to remember is that any communication
difference. For example, ‘city’-esque pictures don’t go far with
faces ‘competition’ from erroneous beliefs, erroneous practices, and
villagers when you want them to change a lifelong unhygienic habit
insecure village doctors. Indeed, as in the WHO’s case, it was the
because they seem to think that this kind of ‘cleanliness luxury’ is for
religious authorities that presented the problem. As in the case of all
the city folk, who have the time and money to indulge in these things!
such groups, their yen for exercising their power, however
Above all, go bearing gifts. It’s not just the thought (or the campaign)
capriciously, and their need to show and feel that they still wield
that counts. To touch their hearts shows a smidgen of affection and generosity. To get your communication ready and shining is all good and dandy, but if you want people to look at it with favour and co-
Some years ago, the WHO’s polio vaccine drive to dispense a critical
encourage people to visit the medical camps and assure them that
multi-state polio vaccination in India faced a particularly vexing
the vaccine had no ‘side effects’ to fear.
challenge: Muslim religious leaders in two states prohibited the
However, a strategic decision was taken: while Aamir’s beaming,
faithful from administering their infants with the polio vaccine
welcoming, reassuring face appeared on each and every
because, as they had told the trusting folk, the polio vaccine was ‘an
communication, the perverse issue that had stymied the program
evil plot by the West to destroy the reproductive system of their
was ignored completely. Aamir’s fabulous star power was pressed
infants from developing correctly, and prevent them from having
into play, and it worked like a charm. Thousands of Indians flocked to
children when they grow up’.
the camps, they arrived grinning at the Aamir overdose all around
Fortunately, we were in close contact with Indian film star Aamir
them, whooping and laughing, they took pictures next to the giant
Khan, being as we were in the middle of the giant ‘Thanda Matlab
Aamir cutouts dotted all over the camp, and had their babies
Coca-Cola’ campaign. Aamir instantly agreed to help, gratis, with
confidently vaccinated.
anything and everything we could do to encourage these parents to
It is an interesting episode to relate to in the challenge of caring for
have their infants vaccinated. With reference to his suggestions, we
Indians who have been marginalised in India’s Great Leap Forward.
developed a campaign to respond to this bizarre challenge; to
And it is an interesting learning we can bring to bear in solving what is
operation, remember that you have to earn their pleasure. The author began his career in 1982 at JWT as a copywriter, and has been Creative Director with Rediffusion DY&R, Vice President and Executive Creative Director with the McCann Worldgroup. He can be reached at alvinsaldanha@gmail.com.
not just one of the most pressing needs of the country, but one of the most promising growth segments for the many providers of India’s infrastructure. And one of the most important dynamics in this emerging new sector is health. In fact, India’s health universe, central to powering and sustaining India’s leap into the fraternity of first world nations, needs to be communicated, understood and appreciated accurately by all its constituencies. At the top end, the knowing constituencies need no persuasion: seeped in market and profit realities, they can easily see the road ahead. The challenge here lies in convincing market-oriented businesses and organisations to commit to setting up health facilities in places where the profit margin is not so high, or the initial set-up financing and revenue possibility is linked to the capriciousness of
31
some clout, all play a part. One learning is, paradoxically, to present an overwhelming distraction to a false issue. As with Aamir Khan, the positive assurance of Aamir’s star power overrode not just any hesitation but gave people the gumption to defy the religious leaders. To the religious leaders, Aamir Khan is a checkmate issue and they cannot
32
medical centres. Europe, the major hub of air traffic in the transport
Hands-on Nuclear Medicine Dr. Shanmuga Sundaram, Amrita Institute of Medical Sciences, talks about the problems faced by nuclear medicine providers.
of these weekly generators to India, has, in recent times, faced
The flip side of PET CT imaging is the high cost of a PET CT scanner and
natural calamities like snowfall, volcanic ash and the shutting down of
the short half-life of almost all PET isotopes.
airports. The situation is beginning to stabilise, but we are not out of
These PET isotopes are produced in a cyclotron (Cyclotrons
the woods yet.
Nuclear medical departments are functioning
accelerate charged particles using high frequency alternating
overtime when isotopes are available and trying to use positron
voltages and bombard targets, producing desired PET isotopes).
emitting isotopes as substitutes to tide over the crisis.
Many short lived radionuclides can be produced, like 11Carbon,
Problem faced by the Indian Nuclear medicine society with
15
patients. Glass or resin impregnated 90Yttrium is indicated for liver
Nuclear medicine is a sub-specialty of medicine, which uses minute
carcinoma management and Erbium / Yttrium radioactive colloids
amounts of radioisotopes to image various organs of the human body
for the treatment of arthritis like Rheumatoid.
and to treat specific disease conditions.
Technetium-99m (99mTc)
In fact, nuclear medicine imaging's superiority is marked by its physiological basis and ability to identify diseases at an early stage, much before anatomical imaging modalities like ultrasound, CT and MRI. However, the very name ‘nuclear’ has negative connotations with the general public. Attempts to minimise this have led to the introduction in recent years of the term ‘molecular imaging’. 131
contribution in therapy as well. For example, Radioactive Iodine ( I) is used in the treatment of differentiated thyroid cancer and also hyperthyroidism.
Strontium,
32
Phosphorus and
153
Samarium are
other isotopes used to alleviate bone pains in terminally ill cancer
Tc Technetium is the most extensively used diagnostic medical
isotope (over 30 million medical imaging procedures a year). Its use is seen growing by 3-5% annually. It provides doctors high-quality image mapping e.g. blood flow to the heart or the spread of cancer to bones, while delivering only low radiation doses to patients.
99m
Tc is
an artificially produced radioisotope i.e. a decay product of another
Nuclear medicine is not only used in diagnosis but has an important
89
99m
reactor produced radioactive element Molybdenum 99Mo. Given its rapid rate of radioactive decay, 99Mo is produced and supplied as a 99
Molybdenum -
99m
Tc generator on a weekly basis to satisfy the
worldwide demand of 99mTc. Present status of
Oxygen, 82Rubidium, but 18Fluorine is only transportable due to its
reference to general Nuclear medicine imaging and therapy, and
'longer half-life' (110 minutes vs. less than 20 minutes) compared to
probable solutions for the same
the other mentioned isotopes.
It appears that this 99Mo 99mTc generator crisis may not be completely
Establishing and maintaining a cyclotron is a financially challenging
solved even if existing nuclear reactors restart their production. It is
and daunting task. This is exemplified by the limited number of
high time for a nuclear empowered country like India to have its own
cyclotrons (located mainly in metro cities like New Delhi, Mumbai,
nuclear reactor capable of producing not only 99Mo Molybdenum but
Bangalore, Hyderabad and Chennai) in India.
also other medically useful isotopes like 67Gallium,
201
Thallium etc.
It is a prerequisite to ensure an uninterrupted supply of PET isotopes
India can take the lead of supplying these medically useful
(primarily 18F labelled FDG) to have a successful PET CT centre in a
radioisotopes to many other developing countries like Sri Lanka,
peripheral city like Cochin. As FDG has a half-life of 110 minutes, it is
Bangladesh etc.
possible to transport FDG from a remote cyclotron either by road or
Also, it will be desirable to have regional radiopharmacy centres (the
by air. PET CT centres in cities with a cyclotron in them or in their
existing BRIT- Board of Radiation and Isotope Technology, Mumbai,
vicinity (within 150kms) are served better by land transport but a
an Indian Government organisation can have regional centres or it
centre like ours has to depend on efficient air transport.
can also be in the Private Public Sector). This will ensure the easy,
FDG transport is a logistical nightmare based on the following
affordable and uninterrupted supply of radiopharmaceuticals and
constraints
isotopes for nuclear medicine.
Brief outline about Nuclear Medicine
Deoxy Glucose (FDG), with a half-life of only 110 minutes.
Being a radioactive material, FDG containers needs to be
PET CT Imaging
transported on large aircraft with exclusive cargo carriage
An exciting, newer imaging modality called PET CT (Positron Emitting
sections (i.e. not on smaller ATR flights)
Tomography with Computed Tomography) has been added to the
Also, being categorized under ‘Dangerous Goods
powerful armamentarium of existing nuclear medicine imaging
Regulations (DGR)’, FDG can be transported only if both
techniques. Hailed as the ‘Investigation of this Century’, the PET CT
pilots of the transporting carrier are ‘DGR certified’. If even
modality has revolutionized cancer care by its ability to detect early
one has not undergone a DGR renewal course, the
malignancy. It is also extremely useful for cancer staging its response
consignment would be offloaded.
to therapy and for radiation therapy planning etc. PET CT is also found
FDG has a mandatory cooling period in the cargo area of
to be useful in diagnosing several non-oncological conditions in
the airport before being moved into the aircraft. Precious
cardiology and neurology. Ours is the first and only centre in the state
time can be lost in this process.
of Kerala performing PET CT studies.
There needs to be a smooth workflow within the FDG
By tagging a Glucose molecule (the basic substrate of any rapidly
production team
dividing cell) with a positron isotope (in this case an 18F Fluorine
At the cyclotron facility (need to ensure the right
isotope), it is possible to localize the malignant lesion. The most
quantity of FDG is produced, quality controlled and
commonly used radiopharmaceutical in PET CT imaging is 18F Flouro
packed),
99m
Tc generators in India
Today, the most widely used diagnostic radioisotope, 99mTc, is in short supply because it relies on an unsustainably low number of production nuclear reactors. Most of the world's supply of 99Mo is obtained from only five ageing nuclear reactors and availability has been much reduced in recent times owing to problems at the largest reactors in Chalk River, Canada and Petten, in the Netherlands. 70% of world’s
99m
Tc need is met by these two reactors. A few other
reactors have been decommissioned and not replaced. This situation has improved recently, but it can still be jeopardized when there is an emergency shutdown of any of the presently working reactors. This worldwide 99mTc resource crunch and subsequent increase in the price of
99
Mo
99m
Tc generators (a 300% increase per weekly
consignment) has put a lot of financial strain on Indian nuclear-
33
34
medical centres. Europe, the major hub of air traffic in the transport
Hands-on Nuclear Medicine Dr. Shanmuga Sundaram, Amrita Institute of Medical Sciences, talks about the problems faced by nuclear medicine providers.
of these weekly generators to India, has, in recent times, faced
The flip side of PET CT imaging is the high cost of a PET CT scanner and
natural calamities like snowfall, volcanic ash and the shutting down of
the short half-life of almost all PET isotopes.
airports. The situation is beginning to stabilise, but we are not out of
These PET isotopes are produced in a cyclotron (Cyclotrons
the woods yet.
Nuclear medical departments are functioning
accelerate charged particles using high frequency alternating
overtime when isotopes are available and trying to use positron
voltages and bombard targets, producing desired PET isotopes).
emitting isotopes as substitutes to tide over the crisis.
Many short lived radionuclides can be produced, like 11Carbon,
Problem faced by the Indian Nuclear medicine society with
15
patients. Glass or resin impregnated 90Yttrium is indicated for liver
Nuclear medicine is a sub-specialty of medicine, which uses minute
carcinoma management and Erbium / Yttrium radioactive colloids
amounts of radioisotopes to image various organs of the human body
for the treatment of arthritis like Rheumatoid.
and to treat specific disease conditions.
Technetium-99m (99mTc)
In fact, nuclear medicine imaging's superiority is marked by its physiological basis and ability to identify diseases at an early stage, much before anatomical imaging modalities like ultrasound, CT and MRI. However, the very name ‘nuclear’ has negative connotations with the general public. Attempts to minimise this have led to the introduction in recent years of the term ‘molecular imaging’. 131
contribution in therapy as well. For example, Radioactive Iodine ( I) is used in the treatment of differentiated thyroid cancer and also hyperthyroidism.
Strontium,
32
Phosphorus and
153
Samarium are
other isotopes used to alleviate bone pains in terminally ill cancer
Tc Technetium is the most extensively used diagnostic medical
isotope (over 30 million medical imaging procedures a year). Its use is seen growing by 3-5% annually. It provides doctors high-quality image mapping e.g. blood flow to the heart or the spread of cancer to bones, while delivering only low radiation doses to patients.
99m
Tc is
an artificially produced radioisotope i.e. a decay product of another
Nuclear medicine is not only used in diagnosis but has an important
89
99m
reactor produced radioactive element Molybdenum 99Mo. Given its rapid rate of radioactive decay, 99Mo is produced and supplied as a 99
Molybdenum -
99m
Tc generator on a weekly basis to satisfy the
worldwide demand of 99mTc. Present status of
Oxygen, 82Rubidium, but 18Fluorine is only transportable due to its
reference to general Nuclear medicine imaging and therapy, and
'longer half-life' (110 minutes vs. less than 20 minutes) compared to
probable solutions for the same
the other mentioned isotopes.
It appears that this 99Mo 99mTc generator crisis may not be completely
Establishing and maintaining a cyclotron is a financially challenging
solved even if existing nuclear reactors restart their production. It is
and daunting task. This is exemplified by the limited number of
high time for a nuclear empowered country like India to have its own
cyclotrons (located mainly in metro cities like New Delhi, Mumbai,
nuclear reactor capable of producing not only 99Mo Molybdenum but
Bangalore, Hyderabad and Chennai) in India.
also other medically useful isotopes like 67Gallium,
201
Thallium etc.
It is a prerequisite to ensure an uninterrupted supply of PET isotopes
India can take the lead of supplying these medically useful
(primarily 18F labelled FDG) to have a successful PET CT centre in a
radioisotopes to many other developing countries like Sri Lanka,
peripheral city like Cochin. As FDG has a half-life of 110 minutes, it is
Bangladesh etc.
possible to transport FDG from a remote cyclotron either by road or
Also, it will be desirable to have regional radiopharmacy centres (the
by air. PET CT centres in cities with a cyclotron in them or in their
existing BRIT- Board of Radiation and Isotope Technology, Mumbai,
vicinity (within 150kms) are served better by land transport but a
an Indian Government organisation can have regional centres or it
centre like ours has to depend on efficient air transport.
can also be in the Private Public Sector). This will ensure the easy,
FDG transport is a logistical nightmare based on the following
affordable and uninterrupted supply of radiopharmaceuticals and
constraints
isotopes for nuclear medicine.
Brief outline about Nuclear Medicine
Deoxy Glucose (FDG), with a half-life of only 110 minutes.
Being a radioactive material, FDG containers needs to be
PET CT Imaging
transported on large aircraft with exclusive cargo carriage
An exciting, newer imaging modality called PET CT (Positron Emitting
sections (i.e. not on smaller ATR flights)
Tomography with Computed Tomography) has been added to the
Also, being categorized under ‘Dangerous Goods
powerful armamentarium of existing nuclear medicine imaging
Regulations (DGR)’, FDG can be transported only if both
techniques. Hailed as the ‘Investigation of this Century’, the PET CT
pilots of the transporting carrier are ‘DGR certified’. If even
modality has revolutionized cancer care by its ability to detect early
one has not undergone a DGR renewal course, the
malignancy. It is also extremely useful for cancer staging its response
consignment would be offloaded.
to therapy and for radiation therapy planning etc. PET CT is also found
FDG has a mandatory cooling period in the cargo area of
to be useful in diagnosing several non-oncological conditions in
the airport before being moved into the aircraft. Precious
cardiology and neurology. Ours is the first and only centre in the state
time can be lost in this process.
of Kerala performing PET CT studies.
There needs to be a smooth workflow within the FDG
By tagging a Glucose molecule (the basic substrate of any rapidly
production team
dividing cell) with a positron isotope (in this case an 18F Fluorine
At the cyclotron facility (need to ensure the right
isotope), it is possible to localize the malignant lesion. The most
quantity of FDG is produced, quality controlled and
commonly used radiopharmaceutical in PET CT imaging is 18F Flouro
packed),
99m
Tc generators in India
Today, the most widely used diagnostic radioisotope, 99mTc, is in short supply because it relies on an unsustainably low number of production nuclear reactors. Most of the world's supply of 99Mo is obtained from only five ageing nuclear reactors and availability has been much reduced in recent times owing to problems at the largest reactors in Chalk River, Canada and Petten, in the Netherlands. 70% of world’s
99m
Tc need is met by these two reactors. A few other
reactors have been decommissioned and not replaced. This situation has improved recently, but it can still be jeopardized when there is an emergency shutdown of any of the presently working reactors. This worldwide 99mTc resource crunch and subsequent increase in the price of
99
Mo
99m
Tc generators (a 300% increase per weekly
consignment) has put a lot of financial strain on Indian nuclear-
33
34
Time chart of our FDG consignment production and transport: 1-3 AM
Production, quality control and Packaging of FDG
3-4 AM
Local transport from cyclotron facility to airport cargo terminal
4-5 AM
Cooling time
5-5.30 AM
Aircraft loading
5.30-7.20 AM
In flight
7.20-7.40AM
Clearance and handing over of FDG consignment to hospital staff waiting at Cochin airport
7.40-8.15 AM
Road transport of FDG from Cochin airport to PET CT Centre
8.15-11.15 AM
Injection of FDG to patients in batches
Although Hyderabad, Chennai and Bangalore are nearby, there is no ideal air connectivity in terms of aircraft size, departure time etc. To add to these limitations, only a couple of air carriers are interested in carrying these radioactive consignments classified under ‘Dangerous Local transport team (ensuring the prompt transport of FDG from the cyclotron facility to airport cargo section), Air cargo ground staff (they need to ensure that it is handed over to the aircraft); and Once the consignment arrives at the destination (i.e. Cochin), the ground cargo handling staff has to ensure the fast tracking of this consignment after mandatory security clearances are completed. There is also a greater responsibility from the end user to ensure that this consignment is received and immediately checked for any damage. An exclusive vehicle should be used for prompt transport of FDG to the PET CT centre. At the user department also, it is to be ensured that all planned patients are prepared for the procedure (we need to ensure a normal fasting blood sugar range so that there is an optimum FDG uptake in the malignant tissue) and, needless to say, there should be a clear-cut idea for the nuclear medicine physician regarding the number of patients undergoing the PET procedure on that day. Let us look into the logistics of this air transport from Mumbai’s cyclotron to our centre It is possible to transport FDG from Chennai and Bangalore, provided we have ideal connectivity. However, Mumbai is preferred by us for its better air connectivity to Cochin. Preferably, an early morning flight is favoured for FDG transport as patients fast overnight and FDG production at a cyclotron facility is conventionally in the early morning (between 1-3 AM). It is also easy to transport the consignment from the cyclotron facility to Mumbai domestic airport by road at this time of the day due to there being lesser traffic on the streets.
Goods’. Even though the DGCA has accorded a blanket permission to all, only Air India and Jet carry radioactive material. Effectively, these limitations have made us depend on one FDG supplier, thus attributing a monopoly status to Mumbai’s cyclotron and creating an unlevel playing field for nearby facilities. An encumbrance in the production and transport logistics (i.e. cyclotron breakdown, quality control failure, late arrival at Mumbai airport, non availability of a DGR certified pilot on the flight, any security alert etc.) ultimately leads to postponement of scheduled patients for the day. Possible Solutions We need to have regional cyclotrons in Government and Public-Private sectors so that FDG is supplied at an affordable price. All carrier aircraft should carry radioisotopes routinely with commitment. On specific routes and specific flights carrying radioactive substances, it should be ensured that DGR certified pilots are available. There should be a better understanding and awareness of this precious consignment’s transport by ground handling and other airport authorities so that there are no unwarranted hassles in its smooth transport. Conclusion With newer radiopharmaceuticals and advancements in instrumentation like PET MR, Molecular Imaging is looking to be the future of oncology imaging. In spite of all these existing problems, we must strive to make nuclear medicine services available and affordable to all our patients.
Problems faced by our PET CT centre in FDG supply and transport The author is the Clinical Professor and Head of the Department of
logistics Only one cyclotron facility is ideally located and able to supply FDG through air, not only to us but to other peripheral cities.
35
Nuclear Medicine and PET CT at the Amrita Institute of Medical Sciences in Cochin, Kerala. He can be reached at ssundaram@aims.amrita.edu.
36
Time chart of our FDG consignment production and transport: 1-3 AM
Production, quality control and Packaging of FDG
3-4 AM
Local transport from cyclotron facility to airport cargo terminal
4-5 AM
Cooling time
5-5.30 AM
Aircraft loading
5.30-7.20 AM
In flight
7.20-7.40AM
Clearance and handing over of FDG consignment to hospital staff waiting at Cochin airport
7.40-8.15 AM
Road transport of FDG from Cochin airport to PET CT Centre
8.15-11.15 AM
Injection of FDG to patients in batches
Although Hyderabad, Chennai and Bangalore are nearby, there is no ideal air connectivity in terms of aircraft size, departure time etc. To add to these limitations, only a couple of air carriers are interested in carrying these radioactive consignments classified under ‘Dangerous Local transport team (ensuring the prompt transport of FDG from the cyclotron facility to airport cargo section), Air cargo ground staff (they need to ensure that it is handed over to the aircraft); and Once the consignment arrives at the destination (i.e. Cochin), the ground cargo handling staff has to ensure the fast tracking of this consignment after mandatory security clearances are completed. There is also a greater responsibility from the end user to ensure that this consignment is received and immediately checked for any damage. An exclusive vehicle should be used for prompt transport of FDG to the PET CT centre. At the user department also, it is to be ensured that all planned patients are prepared for the procedure (we need to ensure a normal fasting blood sugar range so that there is an optimum FDG uptake in the malignant tissue) and, needless to say, there should be a clear-cut idea for the nuclear medicine physician regarding the number of patients undergoing the PET procedure on that day. Let us look into the logistics of this air transport from Mumbai’s cyclotron to our centre It is possible to transport FDG from Chennai and Bangalore, provided we have ideal connectivity. However, Mumbai is preferred by us for its better air connectivity to Cochin. Preferably, an early morning flight is favoured for FDG transport as patients fast overnight and FDG production at a cyclotron facility is conventionally in the early morning (between 1-3 AM). It is also easy to transport the consignment from the cyclotron facility to Mumbai domestic airport by road at this time of the day due to there being lesser traffic on the streets.
Goods’. Even though the DGCA has accorded a blanket permission to all, only Air India and Jet carry radioactive material. Effectively, these limitations have made us depend on one FDG supplier, thus attributing a monopoly status to Mumbai’s cyclotron and creating an unlevel playing field for nearby facilities. An encumbrance in the production and transport logistics (i.e. cyclotron breakdown, quality control failure, late arrival at Mumbai airport, non availability of a DGR certified pilot on the flight, any security alert etc.) ultimately leads to postponement of scheduled patients for the day. Possible Solutions We need to have regional cyclotrons in Government and Public-Private sectors so that FDG is supplied at an affordable price. All carrier aircraft should carry radioisotopes routinely with commitment. On specific routes and specific flights carrying radioactive substances, it should be ensured that DGR certified pilots are available. There should be a better understanding and awareness of this precious consignment’s transport by ground handling and other airport authorities so that there are no unwarranted hassles in its smooth transport. Conclusion With newer radiopharmaceuticals and advancements in instrumentation like PET MR, Molecular Imaging is looking to be the future of oncology imaging. In spite of all these existing problems, we must strive to make nuclear medicine services available and affordable to all our patients.
Problems faced by our PET CT centre in FDG supply and transport The author is the Clinical Professor and Head of the Department of
logistics Only one cyclotron facility is ideally located and able to supply FDG through air, not only to us but to other peripheral cities.
35
Nuclear Medicine and PET CT at the Amrita Institute of Medical Sciences in Cochin, Kerala. He can be reached at ssundaram@aims.amrita.edu.
36
Vertically Integrated Facility Design In what way is architecture impacted? Mr. Hussain Varawalla, Design Mentor — Architecture Services — Hosmac, finds out.
We do not need more echoing green painted hallways with harsh,
We all have an idea about the complexity of the functional needs of a
unforgiving fluorescent lights. Controlling noise, using pleasant
modern hospital, and the specialized knowledge needed by its
colors, sufficient and comfortable waiting spaces, clarity in way
designer with respect to its engineering services and the needs of the
finding, using natural light and greenery judiciously are just some of
medical equipment it houses. So we can see how a hospital,
the imperatives in ‘patient-friendly design’. Polite and helpful staff,
especially one being built in the 2000’s, could well be considered to
the ready availability of information about the status of the patient to
be ‘a machine for healing in’.
their family and friends and concern about the patient’s mental state
In fact, many (if not most) hospitals built in India during the latter part
are just some of the imperatives in ‘patient-focused care’.
of the last century seem to have been designed to provide a roof over
Healthcare Providers and their Social Conscience
the increasingly complex medical procedures being performed
Many successful new healthcare projects are taking shape
within, with their architects being little more than ‘doctor’s
throughout the developed Western world today, calling into question
draftsmen’, translators of medical and technological requirements
the performance levels of more typical healthcare construction
into built form. The result: grim and cheerless buildings that cannot
endeavors, both in the West and in India. This prompts us to ask just
be dignified with the word ‘architecture’.
how far our conventional healthcare buildings are falling short of the
What has changed in recent times is the very definition of the word
mark, judged by the standards of ‘green’ architecture, the popular
‘healing’, moving away from medical interventions to embrace a
name given to environmentally responsive and ecologically
more holistic meaning, the focus moving away from treating ‘illness’
sustainable building.
to creating ‘wellness’.
What we are discussing here is the social responsibility that
When healthcare designers now conceptualize hospitals, they need
healthcare providers need to feel for the community that houses
to think of them as buildings designed to promote the ‘wellness’ of
their facility and provides them with their patients/profits. At the
not only the ‘patient’ (replace with: ‘healthcare consumer’), but also
stage of conceptualization of the proposed facility, thought needs to
of his/her family, and friends who visit, and the staff who provide the
be given to the environmental effects the proposal will have on its
care.
surroundings. Architects have always been taught that the buildings
In conceptualizing hospitals today, we need to take our cue from the
they design need to be ‘good neighbors’, but their clients, the
hospitality industry. The patient needs to be treated as a guest,
healthcare providers or individual doctors at a smaller scale, need to
opening a Pandora’s Box of medical, architectural, engineering,
someone who is to be informed about what he/she will undergo
understand this in the macro and micro sense.
expanding, reaching out from beyond the metro cities and
social, emotional and moral issues. How all of us professionals in
during his/her stay in the hospital, and should be enabled to take an
Healthcare institutions’ core mission of protecting human health
mushrooming in smaller cities and towns across the country, it seems
HOSMAC India with varying academic backgrounds and skill sets go
active and meaningful part in taking decisions about his/her
provides the basis for them to speak with their words and actions on
appropriate to ask a question that any architect commissioned to
about chasing all these creepy-crawlies, trying to catch them and
treatment. In metro’s today, doctors are no longer seen to be the
the health implications of building construction and operation. The
design a healthcare facility would be interested in mooting:
stuff them back into their box is what I am going to go on to discuss.
demi-gods that they were in the past. It is not at all unusual for
healthcare industry has a leadership opportunity to move the larger
In a healthcare facility design consulting firm that offers vertically
Hopefully during the course of this discussion I will be able to give
patients to enter the doctors consulting rooms armed with an inch-
building industry to a healthier approach by demonstrating the best
integrated consulting services ranging from surveying the potential
some definition to my viewpoint on the subject and to the positive
thick file of internet downloads pertaining to their problem. The net
in healthy, sustainable design, construction, operations and maintenance practices in its own facilities.
At a time in India when the provision of healthcare is rapidly
37
have talked about designing hospitals as ‘machines for healing in’.
market for the project through architectural design consulting till
impact that I know it has on the architectural design of healthcare
has been the great leveler between quality of information available in
advising on standard operating procedures and recruitment of staff,
facilities, large or small, across the country, in the new millennium.
even remote areas of the country. As the general public becomes
This approach to design is known as ‘green’ architecture. This design
is the physical facility design (the architecture) positively impacted?
If you were to ask an architect in India today what is the single most
more aware of the world that surrounds them, healthcare providers
approach addresses concerns such as energy efficiency, the use of
In my experience in our firm, HOSMAC India, which offers such
important design factor he/she would consider while designing a
need to sit up and take note.
clean energy resources, an improved indoor environment through
vertically integrated services, described by us as a ‘one-stop shop’ for
hospital, the chances are the reply you would get would be ‘the
‘Form’ could still follow ‘function’, providing we redefine the function
usage of green building materials and maximizing the use of
healthcare facility design, there seems little doubt that it is.
functional requirements’. They well might say that the ‘form’ of their
of a hospital as an institution built to create a more holistic ‘wellness’,
controlled daylighting, encouraging recycling and waste
Immediately I hear the cry from my fraternity (fellow architects),
design solution would be derived from an analysis of
to consider the dignity, emotional needs and mental state of our
prevention/management strategies and designing in ways that
what do you mean by ‘architecture’, define your terms! How can a
medical/technical requirements of the hospital, that is, the
‘patient/guest’ to be every bit as important as his/her physical health.
medical doctor add value to architectural design; how would a profit
‘function’.
and loss statement for the proposed hospital projected into the
Form follows Function?
healthy parts of a healthy regional ecosystem. The full range of
foreseeable future help you (me!) to achieve Commodity, Firmness
‘Form follows Function’ is an architectural dictum laid down by one
practices to be followed in the pursuit of these socially responsible
promote good building operations practices. Healthcare architects need to redefine the facilities they design as
and (especially!) Delight?
of the Modern Movement in Architecture’s most well known
goals are beyond the scope of this article. HOSMAC works closely
Bob Dylan sang about it years back (albeit nasally): …the times they
practitioners, Ludwig Mies van der Rohe. He was born in Aachen,
with an NGO named Hosmac Foundation on promoting this ‘green’
are a-changin’…Is it possible for us architects to accept that Vitruvius
Germany in 1886. A little simplistically put, he means that a building
initiative in healthcare delivery as a whole.
may not have much value to add to the design of an allopathic
should be designed taking as the starting point for its design the
Hosmac Foundation is networked with a global movement called
healthcare delivery facility in 2011?
activities that that building is meant to house. Hence the final shape
Healthcare Without Harm, involving more than 300 NGOs and
This would bring us back to our aggrieved cry: how then would I
(or ‘form’) of the building would be directly derived from its intended
professional organizations spread over 50 countries, working
define ‘architecture’ in this context? Am I disposing of ‘Delight’ in my
use (or ‘function’).
towards establishing environmentally sound healthcare practices
proposed hospital’s proposed incinerator? This would be, to my
Le Corbusier, another famous Modernist architect, talked of a house
and healthcare facility design and construction.
mind, a simplistic way of viewing the problem solving process related
as a ‘machine for living in’.
Moral Issues in Healthcare Facility Design
to the design of this building type; the issue is complex and involves
If Le Corbusier had been a healthcare architect, maybe he would
Every sensitive designer of buildings knows that during this process
38
Vertically Integrated Facility Design In what way is architecture impacted? Mr. Hussain Varawalla, Design Mentor — Architecture Services — Hosmac, finds out.
We do not need more echoing green painted hallways with harsh,
We all have an idea about the complexity of the functional needs of a
unforgiving fluorescent lights. Controlling noise, using pleasant
modern hospital, and the specialized knowledge needed by its
colors, sufficient and comfortable waiting spaces, clarity in way
designer with respect to its engineering services and the needs of the
finding, using natural light and greenery judiciously are just some of
medical equipment it houses. So we can see how a hospital,
the imperatives in ‘patient-friendly design’. Polite and helpful staff,
especially one being built in the 2000’s, could well be considered to
the ready availability of information about the status of the patient to
be ‘a machine for healing in’.
their family and friends and concern about the patient’s mental state
In fact, many (if not most) hospitals built in India during the latter part
are just some of the imperatives in ‘patient-focused care’.
of the last century seem to have been designed to provide a roof over
Healthcare Providers and their Social Conscience
the increasingly complex medical procedures being performed
Many successful new healthcare projects are taking shape
within, with their architects being little more than ‘doctor’s
throughout the developed Western world today, calling into question
draftsmen’, translators of medical and technological requirements
the performance levels of more typical healthcare construction
into built form. The result: grim and cheerless buildings that cannot
endeavors, both in the West and in India. This prompts us to ask just
be dignified with the word ‘architecture’.
how far our conventional healthcare buildings are falling short of the
What has changed in recent times is the very definition of the word
mark, judged by the standards of ‘green’ architecture, the popular
‘healing’, moving away from medical interventions to embrace a
name given to environmentally responsive and ecologically
more holistic meaning, the focus moving away from treating ‘illness’
sustainable building.
to creating ‘wellness’.
What we are discussing here is the social responsibility that
When healthcare designers now conceptualize hospitals, they need
healthcare providers need to feel for the community that houses
to think of them as buildings designed to promote the ‘wellness’ of
their facility and provides them with their patients/profits. At the
not only the ‘patient’ (replace with: ‘healthcare consumer’), but also
stage of conceptualization of the proposed facility, thought needs to
of his/her family, and friends who visit, and the staff who provide the
be given to the environmental effects the proposal will have on its
care.
surroundings. Architects have always been taught that the buildings
In conceptualizing hospitals today, we need to take our cue from the
they design need to be ‘good neighbors’, but their clients, the
hospitality industry. The patient needs to be treated as a guest,
healthcare providers or individual doctors at a smaller scale, need to
opening a Pandora’s Box of medical, architectural, engineering,
someone who is to be informed about what he/she will undergo
understand this in the macro and micro sense.
expanding, reaching out from beyond the metro cities and
social, emotional and moral issues. How all of us professionals in
during his/her stay in the hospital, and should be enabled to take an
Healthcare institutions’ core mission of protecting human health
mushrooming in smaller cities and towns across the country, it seems
HOSMAC India with varying academic backgrounds and skill sets go
active and meaningful part in taking decisions about his/her
provides the basis for them to speak with their words and actions on
appropriate to ask a question that any architect commissioned to
about chasing all these creepy-crawlies, trying to catch them and
treatment. In metro’s today, doctors are no longer seen to be the
the health implications of building construction and operation. The
design a healthcare facility would be interested in mooting:
stuff them back into their box is what I am going to go on to discuss.
demi-gods that they were in the past. It is not at all unusual for
healthcare industry has a leadership opportunity to move the larger
In a healthcare facility design consulting firm that offers vertically
Hopefully during the course of this discussion I will be able to give
patients to enter the doctors consulting rooms armed with an inch-
building industry to a healthier approach by demonstrating the best
integrated consulting services ranging from surveying the potential
some definition to my viewpoint on the subject and to the positive
thick file of internet downloads pertaining to their problem. The net
in healthy, sustainable design, construction, operations and maintenance practices in its own facilities.
At a time in India when the provision of healthcare is rapidly
37
have talked about designing hospitals as ‘machines for healing in’.
market for the project through architectural design consulting till
impact that I know it has on the architectural design of healthcare
has been the great leveler between quality of information available in
advising on standard operating procedures and recruitment of staff,
facilities, large or small, across the country, in the new millennium.
even remote areas of the country. As the general public becomes
This approach to design is known as ‘green’ architecture. This design
is the physical facility design (the architecture) positively impacted?
If you were to ask an architect in India today what is the single most
more aware of the world that surrounds them, healthcare providers
approach addresses concerns such as energy efficiency, the use of
In my experience in our firm, HOSMAC India, which offers such
important design factor he/she would consider while designing a
need to sit up and take note.
clean energy resources, an improved indoor environment through
vertically integrated services, described by us as a ‘one-stop shop’ for
hospital, the chances are the reply you would get would be ‘the
‘Form’ could still follow ‘function’, providing we redefine the function
usage of green building materials and maximizing the use of
healthcare facility design, there seems little doubt that it is.
functional requirements’. They well might say that the ‘form’ of their
of a hospital as an institution built to create a more holistic ‘wellness’,
controlled daylighting, encouraging recycling and waste
Immediately I hear the cry from my fraternity (fellow architects),
design solution would be derived from an analysis of
to consider the dignity, emotional needs and mental state of our
prevention/management strategies and designing in ways that
what do you mean by ‘architecture’, define your terms! How can a
medical/technical requirements of the hospital, that is, the
‘patient/guest’ to be every bit as important as his/her physical health.
medical doctor add value to architectural design; how would a profit
‘function’.
and loss statement for the proposed hospital projected into the
Form follows Function?
healthy parts of a healthy regional ecosystem. The full range of
foreseeable future help you (me!) to achieve Commodity, Firmness
‘Form follows Function’ is an architectural dictum laid down by one
practices to be followed in the pursuit of these socially responsible
promote good building operations practices. Healthcare architects need to redefine the facilities they design as
and (especially!) Delight?
of the Modern Movement in Architecture’s most well known
goals are beyond the scope of this article. HOSMAC works closely
Bob Dylan sang about it years back (albeit nasally): …the times they
practitioners, Ludwig Mies van der Rohe. He was born in Aachen,
with an NGO named Hosmac Foundation on promoting this ‘green’
are a-changin’…Is it possible for us architects to accept that Vitruvius
Germany in 1886. A little simplistically put, he means that a building
initiative in healthcare delivery as a whole.
may not have much value to add to the design of an allopathic
should be designed taking as the starting point for its design the
Hosmac Foundation is networked with a global movement called
healthcare delivery facility in 2011?
activities that that building is meant to house. Hence the final shape
Healthcare Without Harm, involving more than 300 NGOs and
This would bring us back to our aggrieved cry: how then would I
(or ‘form’) of the building would be directly derived from its intended
professional organizations spread over 50 countries, working
define ‘architecture’ in this context? Am I disposing of ‘Delight’ in my
use (or ‘function’).
towards establishing environmentally sound healthcare practices
proposed hospital’s proposed incinerator? This would be, to my
Le Corbusier, another famous Modernist architect, talked of a house
and healthcare facility design and construction.
mind, a simplistic way of viewing the problem solving process related
as a ‘machine for living in’.
Moral Issues in Healthcare Facility Design
to the design of this building type; the issue is complex and involves
If Le Corbusier had been a healthcare architect, maybe he would
Every sensitive designer of buildings knows that during this process
38
they are constantly called upon to lay their values on the line. This
context of overall conceptualization of the entire project, in which
anyway sticky issue becomes positively gooey when designing
the architect is but a team member rather than being in his/her
healthcare facilities.
traditional role as team leader, he may be called upon to contribute
For example: A disquieting trend in the future of healthcare delivery
to a discussion on trade-offs in allocation of usually limited funds in
systems – healthcare on a cost-versus-benefit equation. The
which the above issue will very much play on the mind of the client,
physician’s Hippocratic Oath prevents them from putting any kind of
though it may remain unarticulated. It would be time then, for that
price on human life. Until some time back, to do ‘everything possible’
architect, to search his conscience for the right answer. His calculator
for a patient cost very little more than to do nothing at all, simply
may not be of much help to him in that situation. Doctors constantly
because there was not much that could be done.
make decisions involving life and death, many times with a very
To be sure, the ambition to do all one could to save a life is a noble
practical basis, like on a battlefield. The healthcare architect too has
one. In the past, it was also economically feasible. Today, however,
to realize that he is right there too on the front line; he has to make
there is much, much more that can be done for any given patient –
tough calls without the crutch of a dramatic situation. Moral issues
and each of these procedures, drugs and interventions comes with a
are to be resolved between an individual and his conscience; no
price tag, which the individual and ultimately society must pay.
article in a magazine can help you do that. All the best! Hopefully
Indiscriminately paying ‘for it all’ has already become crippling to
there will be no more than one sleepless night per tougher decision.
society, and insurance providers and government agencies are now
I hope there is some better understanding of the medical,
acknowledging that it is not merely crippling, but fatal. Outside the
architectural, engineering, social, emotional and moral issues, and
metros the ability of patients’ families to pay these costs is limited,
that this understanding is helping you to define ‘architecture’ as I
and we have all heard stories of people selling their land to pay
experience it day after day in our office. (Engineering issues, of
doctors bills.
course, I have not discussed, best left to those specialists in the
Diagnosis Related Groups (DRGs) are already expressions of
know.) There is a complex web of interactions between all of these,
judgment about the effectiveness of procedures. Insurance providers
and the idea is that a positive change or contribution in one strand of
and government agencies are saying that they will pay for procedures
this web should send a ripple effect of positive changes throughout.
proven to be effective, but they will not pay for unproven or
The task is to create an understanding within the organization of
H OSPITAL MANAGEMENT CONFERENCE 27 - 28 May 2011 • Hotel The Westin • Mumbai
27 - 28 May 2011 • Hotel The Westin • Mumbai Hospital Management Conference (HMC) is a research based content driven conference program that is specially designed in a unique twoday format to bring up-to-date worldwide hospital management thinking and experience to senior hospital and healthcare managers in India. This conference will feature senior levels experts from the hospital and healthcare industry sharing their experiences and insights on steps taken to improve patient flow, safety and workflow processes. There will be case studies; interactive panel discussions on trends, challenges, solutions and
marginally effective treatments. Such cost-versus-benefit judgments
individual responsibilities and how these impact their colleagues’
will play a greater role in the delivery of healthcare, no matter who is
work within this mesh of causes and effects. Ideally the whole team
Some Keynote potential Speakers include:
paying for the treatment. No longer will healthcare providers have
should work seamlessly, the project when built being the end result
?
Enterprises Limited
Mr. Vishal Bali, CEO, Fortis Hospital
?
Mr. Amitabh Saxena, CEO, Anexas Consultancy (India)
?
Mr . Anupam Sibal, Group Medical Director, Indraprastha Apollo Hospitals
?
Dr. Vivek Desai, MD, HOSMAC India Pvt Ltd.
?
There are forces at work in society today which seek to reduce all
?
Dr . A M Joglekar, CEO, Godrej Memorial Hospital
things to the marketplace in which the cheapest objects and services
?
Dr. Pervez Ahmed, CEO, Max Healthcare Institute Limited
Mr. Rajendra Prasad Gupta, International Healthcare Policy E x p e r t & Founding President - DMAI
are assumed to offer the best value. My experience in this
?
Mr. Joy Chakraborty, Director, Administration and Materials, H i n d u j a H o s p i t a l and Medical Research Centre
sacrosanct license to do ‘whatever is necessary’ in each and every
of a smooth, cohesive effort. We at HOSMAC strive towards this goal.
case.
The Consulting Services Marketplace
marketplace gives me little reason to support the view that the cheapest and quickest design process is necessarily the best. Our byline in HOSMAC’s design team is ‘value addition through specialized
?
Dr. B S. Ajaikumar, Founder & Chairman, H C G - Healthcare G l o b a l
In two days of HOSPITAL MANAGEMENT CONFERENCE 2011 all attendees will: ?
Gain insights to the key success factors of Hospital Operations
?
Understand the patient satisfaction through Lean and Six Sigma implementation in Hospital
knowledge’, and I mean ‘value’ as in ‘VALUE!’ We are involved in a search for continuously adding to this ‘specialized knowledge’
PLUS - gain tips from leading Hospitals via case studies and networking sessions
through a process of solving other people’s problems. It can be painful and often frustrating, but it is ultimately an extremely
Registration Fees Details:
satisfying process involving substantial intellectual commitment on our part. It flourishes best when there is an equal commitment from
Category
The cost-versus-benefit goes beyond rupees and paise. Healthcare consumers will increasingly weigh the prospective benefit of a given treatment against the quality of life they may expect as a result of it. It is not only likely that more patients will opt out of treatments that prolong misery in order to merely prolong basic life processes, but that life termination will become a viable medical option. Passive euthanasia has lately been legalized by none other than the Supreme Court of India itself, a visionary decision in my opinion. No doubt the above is an issue involving medical ethics rather than design. However, if we consider ‘healthcare facility design’ in it’s larger context, beyond physical facility design (architecture), in the
39
The process of designing anything can be likened to a journey. As seasoned travelers will know, many things can go wrong on journeys.
*Standard Rate 1st May 2011 Onwards
Indian Delegate
International Delegate
Indian Delegate
1 Delegate
@ INR 10,000
@ US$ 220
@ INR 12,000
@ US$ 264
2 and More Delegates
@ INR 9,000
@ US$ 198
@ INR 10,800
@ US$ 238
the client and clearly benefits from a close and trusting relationship between client and consultant.
*Early Bird Rate Book and pay before 30th April 2011
International Delegate
4 Easy ways to Register : Website
-
www.hmcindia.in
Telephone
-
+91 22 66122658
-
yogeeta.sant@ubm.com
-
UBM Medica India Pvt. Ltd to 611-617, Sagar Tech Plaza - A , Saki Naka Junction , Andheri -Kurla
Mobile - + 91 99203 34407
* 10.3% Service Tax Applicable, amount mentioned above are per delegate rate.
It helps if the territory is charted, and if you have made similar journeys before, you know what to pack! The relief of arriving is of course, welcome, and much anticipated, but we at HOSMAC agree with Robert Louis Stephenson’s famous assertion that ‘to travel hopefully is a better thing than to arrive, and the true success is to labor’. The author has had 20 years of rich experience in healthcare design building, and has worked with Reliance Healthcare Ventures Ltd. He can be reached at hussain.varawalla@hosmac.com.
Knowledge Partner Produced by
Organised by
H OSPITAL MANAGEMENT CONFERENCE 27 - 28 May 2011 • Hotel The Westin • Mumbai
27 - 28 May 2011 • Hotel The Westin • Mumbai Hospital Management Conference (HMC) is a research based content driven conference program that is specially designed in a unique two-day format to bring up-todate worldwide hospital management thinking and experience to senior hospital and healthcare managers in India. This conference will feature senior levels experts from the hospital and healthcare industry sharing their experiences and insights on steps taken to improve patient flow, safety and workflow processes. There will be case studies; interactive panel discussions on trends, challenges, solutions and technologies that will help keep the industry in line with current and future progress. Some Keynote potential Speakers include:
In two days of HOSPITAL MANAGEMENT CONFERENCE 2011 all attendees will:
Mr. Vishal Bali, CEO, Fortis Hospital
Gain insights to the key success factors of Hospital Operations
Understand the patient satisfaction through Lean and Six Sigma implementation in Hospital
Mr . Anupam Sibal, Group Medical Director, Indraprastha Apollo Hospitals
Dr . A M Joglekar, CEO, Godrej Memorial Hospital
Dr. Pervez Ahmed, CEO, Max Healthcare Institute Limited
Find out the Hyperbaric & Diving Medicine - A frontline Hospital Service
Mr. Joy Chakraborty, Director, Administration and Materials, Hinduja Hospital and Medical Research Centre
Acquire the quality methodologies and applying accreditation
Learn innovative practices to increase patient safety & satisfaction
Dr. B S. Ajaikumar, Founder & Chairman, H C G - Healthcare Global Enterprises Limited
Mr. Amitabh Saxena, CEO, Anexas Consultancy (India)
Dr. Vivek Desai, MD, HOSMAC India Pvt Ltd.
Mr. Rajendra Prasad Gupta, International Healthcare Policy Expert & Founding President - DMAI
Discover the roadmap to an effective healthcare system
Leverage the emerging technologies to build an effective healthcare system
Recognize the change management and other strategic management tools
Successfully identify the quality improvement In healthcare
PLUS - gain tips from leading Hospitals via case studies and networking sessions Hear inside success stories on Best Practices by Indraprastha Apollo, Godrej Memorial, Hinduja, Healthcare Global Enterprises Limited (HCG) and Max Healthcare Registration Fees Details:
Category
*Early Bird Rate
*Standard Rate
Book and pay before 30th April 2011
1st May 2011 Onwards
Indian Delegate
International Delegate
Indian Delegate
International Delegate
1 Delegate
@ INR 10,000
@ US$ 220
@ INR 12,000
@ US$ 264
2 and More Delegates
@ INR 9,000
@ US$ 198
@ INR 10,800
@ US$ 238
4 Easy ways to Register : Website
-
www.hmcindia.in
Telephone
-
+91 22 66122658
-
yogeeta.sant@ubm.com
-
UBM Medica India Pvt. Ltd to 611-617, Sagar Tech Plaza - A , Saki Naka Junction , Andheri -Kurla Road, Andheri East, Mumbai 400 072. Maharashtra (India). Attn: Yogeeta Sant
Mobile - + 91 99203 34407
* 10.3% Service Tax Applicable, amount mentioned above are per delegate rate.
Knowledge Partner Produced by
Organised by
Tapping the Opportunity of MES
1.
Medical Record (MRD) Technician (MED 132)
With inputs from Ms. Sumita Chakravarty, Ms. Punam Sah discusses the Minimum Employable
2.
Central Sterile Supply Department (CSSD) Technician (MED 240)
Skills programme and how it could play a vital role in solving India's healthcare problems. 3.
Dialysis Technologist (MED 238)
4.
Radiology Technician (MED 239)
5.
Nursing Aides (MED 134)
6.
Operation Theatre (OT) Assistant (MED 241)
7.
Infection Control Assistant (Level 1) (MED 135)
These courses can be viewed at http://www.dget.nic.in/mes/curricula/Medical-Nursing.pdf Four members of the subcommittee are hospitals with training Industry Engagement in MES
facilities. They have applied to be registered as VTPs to train their
CII is one of the assessing bodies for all the sectors, pan-India. Its key
existing staff and external candidates. The four prospective VTPs are:
role is to organise assessments in an impartial manner. As an
1.
Sir H. N. Hospital
assessing body, it has set up a panel of assessors who are experts in
2.
Holy Family Hospital
the relevant sectors that they evaluate. Since the thrust of MES is on
3.
Prince Aly Khan Hospital
4.
S. L. Raheja (A Fortis Associate) Hospital
employability, CII has to ensure that industry standards and expectations are met.
If more hospitals came forth to contribute towards strengthening
engagement to ensure employability for the workforce through the
this scheme, training in the healthcare sector could be transformed
MES:
and that too in a short span of time.
·
·
Companies/institutions can become Vocational Training
The MES scheme has been launched by the Directorate General of
Providers to improve the employability of the candidates.
Employment and Training (DGE&T), the Ministry of Labour &
They can utilize their existing training facilities and
Employment (MoLE), the Government of India. Details of the
infrastructure.
programme can be viewed on www.dget.nic.in/mes.
Companies/institutions can sign up as an off-base training
About MES
multi entry and exit.
center by linking up with an existing VTP. Under this model,
The Government of India has launched a unique and elaborate
·
It provides modular training in various levels of
The contributors work with CII Western Region as Deputy Directors.
candidates are registered with the VTP but undergo
competency.
For further information, contact punam.sah@cii.in.
training at the off-base training centre at the company.
scheme for skill development – the Modular Employable Skills (MES) scheme that is being implemented across India. The innovative
·
design of this scheme creates scope to include sections of society that are outside the mainstream of education and vocational training. Thus, school leavers and goers, casual workers, semi-skilled and
·
Terminal competency for every level is achieved by
·
Existing or retired employees can conduct an assessment
focusing on employability through output oriented
by becoming assessors on CII’s panel thereby setting
training.
acceptable standards for their sector.
The scheme has a flexible mechanism for the delivery of
·
The industry can develop courses that are relevant to
skilled labourers get an opportunity to develop and upgrade their
training like part time, full time, weekends etc. offered by
skills. More than 1200 trades in 90 sectors have been designed in a
Vocational Training Providers to suit the needs of various
curriculum. They can also become a member of trade
modular fashion. Accordingly, every trade has a matrix of courses at
target groups.
committees for curriculum development whereby they can
various levels of proficiency. A candidate successfully completes a
·
module to be able to move vertically or laterally to upgrade his or her skills.
·
A key element around which the scheme revolves is ‘employability’. This segregates it from other regular vocational training programmes. Employability is assured through making the training output-oriented. Every course therefore has a terminal competency that the candidate has to achieve. This is ascertained through external assessments of candidates, based on which the certificates are issued to them. This way, unlike other vocational training courses where the trainer, assessor and certifier were all in one, here the three become separate agencies. Other features of the scheme are:
them, which CII can facilitate to integrate with the MES
External assessment of the candidates is conducted by
integrate their own course or suggest and approve new
independent assessing bodies.
ones.
The scheme also provides certification for skills acquired informally.
The essence of the scheme is in the certification, which is recognized
The Opportunity for Healthcare Taking this lead, the CII Healthcare Sub-Committee, developed 7 modular courses for the Medical-Nursing sector which were recently
nationally as well as internationally.
approved by the NCVT, and have now been integrated into the MES
The MES Model
course matrix:
The 3 components of the MES model are: Training, External Assessment, and Certification. Training is provided by existing institutions of the government that are designated as Vocational Training Providers (VTPs) or by private institutions and Industrial Training Centers who apply to register as VTPs with the Directorate General of Education and Training in their respective states.
·
It provides the candidate a ‘minimum skills set’ required for gainful employment in the industry.
They have a panel of assessors who have specific areas of expertise.
·
The scheme equips the candidate with employable skills in
Based on their assessment, successful candidates are certified by the
a short span of time.
National Council for Vocational Training (NCVT)
·
41
There are various avenues for industry
Assessing bodies have been identified for various sectors over India.
The flexibility of the scheme enables lifelong learning with
42
Tapping the Opportunity of MES
1.
Medical Record (MRD) Technician (MED 132)
With inputs from Ms. Sumita Chakravarty, Ms. Punam Sah discusses the Minimum Employable
2.
Central Sterile Supply Department (CSSD) Technician (MED 240)
Skills programme and how it could play a vital role in solving India's healthcare problems. 3.
Dialysis Technologist (MED 238)
4.
Radiology Technician (MED 239)
5.
Nursing Aides (MED 134)
6.
Operation Theatre (OT) Assistant (MED 241)
7.
Infection Control Assistant (Level 1) (MED 135)
These courses can be viewed at http://www.dget.nic.in/mes/curricula/Medical-Nursing.pdf Four members of the subcommittee are hospitals with training Industry Engagement in MES
facilities. They have applied to be registered as VTPs to train their
CII is one of the assessing bodies for all the sectors, pan-India. Its key
existing staff and external candidates. The four prospective VTPs are:
role is to organise assessments in an impartial manner. As an
1.
Sir H. N. Hospital
assessing body, it has set up a panel of assessors who are experts in
2.
Holy Family Hospital
the relevant sectors that they evaluate. Since the thrust of MES is on
3.
Prince Aly Khan Hospital
4.
S. L. Raheja (A Fortis Associate) Hospital
employability, CII has to ensure that industry standards and expectations are met.
If more hospitals came forth to contribute towards strengthening
engagement to ensure employability for the workforce through the
this scheme, training in the healthcare sector could be transformed
MES:
and that too in a short span of time.
·
·
Companies/institutions can become Vocational Training
The MES scheme has been launched by the Directorate General of
Providers to improve the employability of the candidates.
Employment and Training (DGE&T), the Ministry of Labour &
They can utilize their existing training facilities and
Employment (MoLE), the Government of India. Details of the
infrastructure.
programme can be viewed on www.dget.nic.in/mes.
Companies/institutions can sign up as an off-base training
About MES
multi entry and exit.
center by linking up with an existing VTP. Under this model,
The Government of India has launched a unique and elaborate
·
It provides modular training in various levels of
The contributors work with CII Western Region as Deputy Directors.
candidates are registered with the VTP but undergo
competency.
For further information, contact punam.sah@cii.in.
training at the off-base training centre at the company.
scheme for skill development – the Modular Employable Skills (MES) scheme that is being implemented across India. The innovative
·
design of this scheme creates scope to include sections of society that are outside the mainstream of education and vocational training. Thus, school leavers and goers, casual workers, semi-skilled and
·
Terminal competency for every level is achieved by
·
Existing or retired employees can conduct an assessment
focusing on employability through output oriented
by becoming assessors on CII’s panel thereby setting
training.
acceptable standards for their sector.
The scheme has a flexible mechanism for the delivery of
·
The industry can develop courses that are relevant to
skilled labourers get an opportunity to develop and upgrade their
training like part time, full time, weekends etc. offered by
skills. More than 1200 trades in 90 sectors have been designed in a
Vocational Training Providers to suit the needs of various
curriculum. They can also become a member of trade
modular fashion. Accordingly, every trade has a matrix of courses at
target groups.
committees for curriculum development whereby they can
various levels of proficiency. A candidate successfully completes a
·
module to be able to move vertically or laterally to upgrade his or her skills.
·
A key element around which the scheme revolves is ‘employability’. This segregates it from other regular vocational training programmes. Employability is assured through making the training output-oriented. Every course therefore has a terminal competency that the candidate has to achieve. This is ascertained through external assessments of candidates, based on which the certificates are issued to them. This way, unlike other vocational training courses where the trainer, assessor and certifier were all in one, here the three become separate agencies. Other features of the scheme are:
them, which CII can facilitate to integrate with the MES
External assessment of the candidates is conducted by
integrate their own course or suggest and approve new
independent assessing bodies.
ones.
The scheme also provides certification for skills acquired informally.
The essence of the scheme is in the certification, which is recognized
The Opportunity for Healthcare Taking this lead, the CII Healthcare Sub-Committee, developed 7 modular courses for the Medical-Nursing sector which were recently
nationally as well as internationally.
approved by the NCVT, and have now been integrated into the MES
The MES Model
course matrix:
The 3 components of the MES model are: Training, External Assessment, and Certification. Training is provided by existing institutions of the government that are designated as Vocational Training Providers (VTPs) or by private institutions and Industrial Training Centers who apply to register as VTPs with the Directorate General of Education and Training in their respective states.
·
It provides the candidate a ‘minimum skills set’ required for gainful employment in the industry.
They have a panel of assessors who have specific areas of expertise.
·
The scheme equips the candidate with employable skills in
Based on their assessment, successful candidates are certified by the
a short span of time.
National Council for Vocational Training (NCVT)
·
41
There are various avenues for industry
Assessing bodies have been identified for various sectors over India.
The flexibility of the scheme enables lifelong learning with
42
started by the Government in which vouchers are provided to people
Healthcare For All
preventive healthcare demand.
What India needs is a healthcare revolution. Lisha Ruparel finds out how with insights from Mr. Narendra Karkera, Director — Finance — Hosmac.
In order to increase the efficiency and reach of healthcare in all parts
below the poverty line by means of which they can claim medical
of India, the Government could encourage privatisation in the
treatments. This scheme has been started only in few states as of
healthcare sector.
now, and could be implemented in all parts of India. A healthcare cess
Privatisation of Healthcare in India
should be created by which funds for healthcare can be generated.
The Government should bring about more privatisation in the healthcare sector even at the primary and secondary level. As of now,
People above poverty line should also be given health insurance at subsidized rates.
the Government provides primary healthcare in the country, but
Schemes such as the Yeshasvini Health Insurance Scheme were
faces many problems like inadequacy, inefficiency and improper
introduced in rural Karnataka in the year 2003. For a premium
utilization of resources. Studies in other countries have shown that
payment of INR 5 per month or INR 60 per year people could avail for
the cost of primary and secondary medical treatment decreased by
comprehensive coverage of all surgical procedures and outpatient
about 30% when it was managed by the private sector. There was also
care. This scheme was very successful and similar models have been
higher patient satisfaction. The private sector brings about
implemented in parts of Gujarat. Similarly the Arogyasri Community
demonstrable efficiency benefits that can outweigh the higher costs
Health Insurance Scheme was made available in a few districts in
of private capital. Private players are driven by their financial interests
Andhra Pradesh to the population below the poverty line. Under this
to deliver on time, while also meeting budgets and optimising cost
scheme, the Government pays the insurance premium to the private
benefit ratios. The government should encourage privatisation by making new policies that will encourage private players to enter the healthcare industry. The Government can aid by reforming policies in: Taxation New tax laws should be made and implemented in which new, upcoming hospitals in rural areas should be given tax holidays for a decade. The Government can also aid them by providing long term loans at very low interest rates. Providing Land at Subsidized Rates A very famous quote by one of our founding fathers, Mahatma
Even land in rural areas should be provided at subsidized
Gandhi, comes to mind: “India lives in her villages, not in her cities.”
healthcare. This has a direct impact on maternal and child mortality.
rates. Stamp duty and registration fees should also be
The 2001 census tells us that 74.24% of our population lives in rural
Globally, it is estimated that an annual rate of decline of 4.4% is
decreased.
India, while only about 25.73% it lives in urban India. Despite these
needed to reduce deaths of children below 5 years of age by two-
Medical Equipment
statistics, rural India receives only about 15% share of healthcare
thirds by 2015. In India, the annual rate of decline in child mortality
Import taxes on medical equipment should be decreased.
The Rashtriya Swasthya Bima Yojna scheme was launched in 2007 to provide a smart card-based, cashless health insurance cover of INR
resources. According to the review of Healthcare in India, 2005, the
between 1990 and 2008 is 2.25%. As per the 2015 target, the
Other taxes such as VAT, sales tax should also be decreased.
rural population has only 9.85 beds per lakh population, 0.36
required rate of decline from 2009 to 2015 per year must be 6.28%.
Power at Subsidized Rates
hospitals per lakh population, and 1.49 dispensaries per lakh
In the recent union budget, a 5% service tax had been imposed on all
Power supplied to hospitals should be highly subsidized.
population. Studies have shown that about 46% of the rural
services provided by private hospitals with at least 25 beds and
The Government should also help in setting up alternate
population travels to cities for medical treatment.
central air-conditioning and also on all diagnostic tests. However,
sources of energy like solar panels for electricity generation
To link the urban and rural divide, new healthcare models are the
due to a huge outcry from consumers and doctors alike, this tax was
and setting up windmills wherever possible.
need of the hour. India has developed considerably in the last few
later withdrawn. If such taxes are implemented they will have a
All these incentives will encourage doctors, individuals and
years but it has left the development of healthcare in rural areas far
negative impact on the growing healthcare sector. A large number of
corporates to set up more hospitals in rural areas instead of urban
behind. To bridge this gap, new proposals for healthcare
hospitals will be affected and the brunt of taxes imposed on them will
areas, where cost of land and construction is very high.
development should be created; the healthcare industry should
eventually be passed on to the consumer. As a result, patients may
The Government should also encourage more private players to enter
evolve in a new way. Along with education, every individual should
defer their treatments and there may be a drop in the elective and
the healthcare industry in these rural areas. The role of the
have access to quality healthcare in all parts of the country; it should
Government should change from being the provider to the
be a constitutional right of every citizen of India. Under new systems,
moderator. We could also turn to Private-Public Partnerships for
healthcare should be treated as infrastructure and the government
maximum utilization of all resources.
should play a very active role in supporting and aiding upcoming hospitals. This status of ‘infrastructure’ would translate to more private players being encouraged to enter the industry. India spends less than 2% of its GDP on health, compared to a 73% out-of-pocket spending; this is much lower in comparison to many developing and developed countries. Most European countries spend about 9%-11% of their GDP on public health, while the United States of America spends about 18% of their GDP on public health. Government expenditure as a share of the total health expenditure in India is even
43
less than what Asian countries such as China and Indonesia spend on
insurance company.
30,000 per family, for a unit of 5, for below poverty line families in the unorganised sector. The premium is shared by the Central and State Government. As of 31st January 2011 this scheme has been implemented in 25 states and union territories. Such programs have been tried in various states and have been found to be successful and it high time that they be implemented throughout India. To Look After Hospitals in the rural areas should be developed to not only to cater to health needs but also to look after social, mental and physical wellbeing of the individual. They can provide all forms of medicine like Ayurveda, homeopathy, yoga retreats, spas etc. People from cities
Schools, colleges and healthcare institutions should be set up in all villages. This will encourage more people to migrate to villages instead of flocking to cities, large towns or metros. The availability of cheap yet good quality healthcare and education in villages could bring about this ‘reverse migration’. The Effect of Insurance As of now, the penetration of insurance in the healthcare industry is very low. Most of the population is not aware of health insurance, or they feel that they don’t require it. Recently schemes have been
44
started by the Government in which vouchers are provided to people
Healthcare For All
preventive healthcare demand.
What India needs is a healthcare revolution. Lisha Ruparel finds out how with insights from Mr. Narendra Karkera, Director — Finance — Hosmac.
In order to increase the efficiency and reach of healthcare in all parts
below the poverty line by means of which they can claim medical
of India, the Government could encourage privatisation in the
treatments. This scheme has been started only in few states as of
healthcare sector.
now, and could be implemented in all parts of India. A healthcare cess
Privatisation of Healthcare in India
should be created by which funds for healthcare can be generated.
The Government should bring about more privatisation in the healthcare sector even at the primary and secondary level. As of now,
People above poverty line should also be given health insurance at subsidized rates.
the Government provides primary healthcare in the country, but
Schemes such as the Yeshasvini Health Insurance Scheme were
faces many problems like inadequacy, inefficiency and improper
introduced in rural Karnataka in the year 2003. For a premium
utilization of resources. Studies in other countries have shown that
payment of INR 5 per month or INR 60 per year people could avail for
the cost of primary and secondary medical treatment decreased by
comprehensive coverage of all surgical procedures and outpatient
about 30% when it was managed by the private sector. There was also
care. This scheme was very successful and similar models have been
higher patient satisfaction. The private sector brings about
implemented in parts of Gujarat. Similarly the Arogyasri Community
demonstrable efficiency benefits that can outweigh the higher costs
Health Insurance Scheme was made available in a few districts in
of private capital. Private players are driven by their financial interests
Andhra Pradesh to the population below the poverty line. Under this
to deliver on time, while also meeting budgets and optimising cost
scheme, the Government pays the insurance premium to the private
benefit ratios. The government should encourage privatisation by making new policies that will encourage private players to enter the healthcare industry. The Government can aid by reforming policies in: Taxation New tax laws should be made and implemented in which new, upcoming hospitals in rural areas should be given tax holidays for a decade. The Government can also aid them by providing long term loans at very low interest rates. Providing Land at Subsidized Rates A very famous quote by one of our founding fathers, Mahatma
Even land in rural areas should be provided at subsidized
Gandhi, comes to mind: “India lives in her villages, not in her cities.”
healthcare. This has a direct impact on maternal and child mortality.
rates. Stamp duty and registration fees should also be
The 2001 census tells us that 74.24% of our population lives in rural
Globally, it is estimated that an annual rate of decline of 4.4% is
decreased.
India, while only about 25.73% it lives in urban India. Despite these
needed to reduce deaths of children below 5 years of age by two-
Medical Equipment
statistics, rural India receives only about 15% share of healthcare
thirds by 2015. In India, the annual rate of decline in child mortality
Import taxes on medical equipment should be decreased.
The Rashtriya Swasthya Bima Yojna scheme was launched in 2007 to provide a smart card-based, cashless health insurance cover of INR
resources. According to the review of Healthcare in India, 2005, the
between 1990 and 2008 is 2.25%. As per the 2015 target, the
Other taxes such as VAT, sales tax should also be decreased.
rural population has only 9.85 beds per lakh population, 0.36
required rate of decline from 2009 to 2015 per year must be 6.28%.
Power at Subsidized Rates
hospitals per lakh population, and 1.49 dispensaries per lakh
In the recent union budget, a 5% service tax had been imposed on all
Power supplied to hospitals should be highly subsidized.
population. Studies have shown that about 46% of the rural
services provided by private hospitals with at least 25 beds and
The Government should also help in setting up alternate
population travels to cities for medical treatment.
central air-conditioning and also on all diagnostic tests. However,
sources of energy like solar panels for electricity generation
To link the urban and rural divide, new healthcare models are the
due to a huge outcry from consumers and doctors alike, this tax was
and setting up windmills wherever possible.
need of the hour. India has developed considerably in the last few
later withdrawn. If such taxes are implemented they will have a
All these incentives will encourage doctors, individuals and
years but it has left the development of healthcare in rural areas far
negative impact on the growing healthcare sector. A large number of
corporates to set up more hospitals in rural areas instead of urban
behind. To bridge this gap, new proposals for healthcare
hospitals will be affected and the brunt of taxes imposed on them will
areas, where cost of land and construction is very high.
development should be created; the healthcare industry should
eventually be passed on to the consumer. As a result, patients may
The Government should also encourage more private players to enter
evolve in a new way. Along with education, every individual should
defer their treatments and there may be a drop in the elective and
the healthcare industry in these rural areas. The role of the
have access to quality healthcare in all parts of the country; it should
Government should change from being the provider to the
be a constitutional right of every citizen of India. Under new systems,
moderator. We could also turn to Private-Public Partnerships for
healthcare should be treated as infrastructure and the government
maximum utilization of all resources.
should play a very active role in supporting and aiding upcoming hospitals. This status of ‘infrastructure’ would translate to more private players being encouraged to enter the industry. India spends less than 2% of its GDP on health, compared to a 73% out-of-pocket spending; this is much lower in comparison to many developing and developed countries. Most European countries spend about 9%-11% of their GDP on public health, while the United States of America spends about 18% of their GDP on public health. Government expenditure as a share of the total health expenditure in India is even
43
less than what Asian countries such as China and Indonesia spend on
insurance company.
30,000 per family, for a unit of 5, for below poverty line families in the unorganised sector. The premium is shared by the Central and State Government. As of 31st January 2011 this scheme has been implemented in 25 states and union territories. Such programs have been tried in various states and have been found to be successful and it high time that they be implemented throughout India. To Look After Hospitals in the rural areas should be developed to not only to cater to health needs but also to look after social, mental and physical wellbeing of the individual. They can provide all forms of medicine like Ayurveda, homeopathy, yoga retreats, spas etc. People from cities
Schools, colleges and healthcare institutions should be set up in all villages. This will encourage more people to migrate to villages instead of flocking to cities, large towns or metros. The availability of cheap yet good quality healthcare and education in villages could bring about this ‘reverse migration’. The Effect of Insurance As of now, the penetration of insurance in the healthcare industry is very low. Most of the population is not aware of health insurance, or they feel that they don’t require it. Recently schemes have been
44
can visit rural areas for vacations along with attending to their
policies. New centralised policies and reforms should be created and
medical needs; a concept known as ‘medical tourism’.
implemented so there is a penetration of healthcare in all parts of
Alternate forms of treatments like Ayurveda, homeopathy etc. could
India.
be encouraged to look after the primary healthcare needs of the
As a country that has exhibited its prowess and intellectual capability
population at a moderate cost so as to decrease the load on allopathy.
in numerous knowledge-based sectors to emerge as a frontrunner
This way, only patients requiring secondary medical care will be sent
worldwide, we have the unique opportunity to design viable and
to hospitals, thus reducing the burden on them.
sustainable healthcare delivery models. We therefore need
The Government should also set up medical and nursing colleges to
‘Healthcare in India’ to be a priority.
train paramedical staff and nurses, since, according to the McKinsey report, there is a shortage of 1.4 million doctors and 2.8 million
in leading healthcare organizations for over37 years. He can be
Price Control Mechanism
reached at narendra.karkera@hosmac.com.
The cost record rule must be implemented in all hospitals as a statutory requirement. The costs in the hospitals should be subject to cost audits by cost accountants. Hence, this price control mechanism will help in determining the costs for all treatments. Hospitals should declare the rates for all their treatments; this will correspond to the pharmaceutical industry, too. Such measures will help in bringing more quality to the healthcare sector. The Effect on Economy With all the subsidies and help the Government will provide in setting up hospitals, more private players will enter the healthcare industry, thus translating to more profit and cash generation. Thus the role of the Government will change from provider to facilitator. Hence Government funding for running hospitals will decrease. As a result of privatisation, there will be efficiency, profitability and overall growth of the sector. This will also give a boost to the healthcare insurance sector. As of now, healthcare in India is segmented; health is a state matter, so there are very few centralised
45
Mr. Karkera has served the finance and administration departments
nurses in India
can visit rural areas for vacations along with attending to their
policies. New centralised policies and reforms should be created and
medical needs; a concept known as ‘medical tourism’.
implemented so there is a penetration of healthcare in all parts of
Alternate forms of treatments like Ayurveda, homeopathy etc. could
India.
be encouraged to look after the primary healthcare needs of the
As a country that has exhibited its prowess and intellectual capability
population at a moderate cost so as to decrease the load on allopathy.
in numerous knowledge-based sectors to emerge as a frontrunner
This way, only patients requiring secondary medical care will be sent
worldwide, we have the unique opportunity to design viable and
to hospitals, thus reducing the burden on them.
sustainable healthcare delivery models. We therefore need
The Government should also set up medical and nursing colleges to
‘Healthcare in India’ to be a priority.
train paramedical staff and nurses, since, according to the McKinsey report, there is a shortage of 1.4 million doctors and 2.8 million
in leading healthcare organizations for over37 years. He can be
Price Control Mechanism
reached at narendra.karkera@hosmac.com.
The cost record rule must be implemented in all hospitals as a statutory requirement. The costs in the hospitals should be subject to cost audits by cost accountants. Hence, this price control mechanism will help in determining the costs for all treatments. Hospitals should declare the rates for all their treatments; this will correspond to the pharmaceutical industry, too. Such measures will help in bringing more quality to the healthcare sector. The Effect on Economy With all the subsidies and help the Government will provide in setting up hospitals, more private players will enter the healthcare industry, thus translating to more profit and cash generation. Thus the role of the Government will change from provider to facilitator. Hence Government funding for running hospitals will decrease. As a result of privatisation, there will be efficiency, profitability and overall growth of the sector. This will also give a boost to the healthcare insurance sector. As of now, healthcare in India is segmented; health is a state matter, so there are very few centralised
45
Mr. Karkera has served the finance and administration departments
nurses in India
HOSMAC FOUNDATION HOSMAC FOUNDATION
HOSMAC Pulse Vol. 1 No. 5 April, 2011
Head Office 120, Udyog Bhavan, Sonawala Lane, Goregaon East, Mumbai - 400 063, Maharashtra Tel : +91 22 6723 7000, Fax: +91 22 2686 3465
Taking Healthcare Beyond The Metros
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PPP: Is it really the solution? Pg. 29
Cover Story Pg. 11